A Conversation with Liza Mundy
Q: What inspired you to write a book about assisted reproductive technologies (ART)?
A: I have always been interested in reproductive politics and the controversies they inspire in American culture and politics. For years, of course, widely available contraception and safe and legal abortion were the reproductive technologies that inspired controversy; galvanized liberals and conservatives alike; and contributed to enormous changes in American life and politics, for men and women. In the past ten years, though, it has become clear that technologies which enable people to have children, as opposed to helping them forestall or delay having children, are driving enormous changes of their own. Women conceiving later in life: single mothers using sperm donation; gays and lesbians using ART to have children together; heterosexual couples conceiving with the help of an egg donor: all of these parents and would-be parents are changing the way we think about the human family and how it can be composed. I began writing about these issues for The Washington Post, and it became immediately clear to me that issues surrounding assisted reproduction absolutely galvanized the newspaper readership. I also realized how many people I knew, personally, who were affected by these technologies.
Q: What most fascinated you as you researched and wrote EVERYTHING CONCEIVABLE?
A: For me, probably the great revelation of the book was learning more about the science of reproductive biology, and getting to know and spend time with scientists involved in ART. I had already spent many years reporting on reproductive politics, and interviewing individuals about conception and family life, but I did not know a lot about the science involved in ART. I was able to spend two weeks in a laboratory where young scientists were learning cutting-edge assisted reproduction techniques, and it was fascinating to learn about the science and see them react to the techniques they were learning. One of the small revelations I had was assisted reproduction requires not only immense learning but—equally important—excellent fine motor skills. There’s a lot of very, very fine injection and tweezing and snipping, done under a microscope. Some of the great breakthroughs have been made by great scientists who were also great mechanical tinkerers.
Q: What most alarmed you?
A: The explosion in multiple births. No question about it. So many parents conceiving through ART end up with twins, triplets or even more. Many of us—and many ART patients, starting out—have the idea that a lot of very tiny babies, born as a set, are something cute or desirable—an entire family, delivered overnight! In truth, these babies are far more likely to be born premature, and to suffer from lasting and severe medical problems, and they place a great deal of stress on their parents. The industry needs to do much more to eliminate multiple births, and it can do more. I interviewed patients who had suffered so much tragedy and grief as a result of conceiving multiples, and inevitably they had not been adequately warned of the dangers involved.
Q: Where do you see ART and its accompanying complexities in relation to other issues we face today in the United States?
A: Well, it does seem to me that we are in a time, politically and culturally, when the great changes of the 1960s and 1970s—the passage of Roe v. Wade, the coeducation of universities, the influx of women into the workforce, the coming-out of many gays and lesbians—have become mainstream and accepted, and now we are seeing a new wave of cultural changes as a result. People who were on the front line of those changes are ready, now, to settle down and have families, and many are doing so with the help of ART. And thanks to ART, we are having to change our thinking about human life; about parenting; about later childbearing. Just look at the White House: personally and politically, its denizens have felt the full impact of ART and its promise. One of the first domestic policy decisions President Bush had to make was whether to permit federal funding of stem-cell research using excess IVF embryos. Thanks to ART, he—and the American public—are being compelled to wrestle anew with the question of when human life truly begins, and what can be done with the earliest human life forms. Meanwhile, the president and his wife have twin daughters. Meanwhile, the vice-president’s daughter, Mary Cheney, a partnered lesbian, is pregnant via a sperm donor, and her parents are very happy. It’s all there—in my book, in every household, even playing out at the highest levels of government.
Q: Assisted reproductive technology is largely unregulated in the United States. Why? What effect has this had on the industry?
A: It’s unregulated for a lot of reasons. For one thing, we don’t regulate medicine much in the United States, compared to more socialized governments. Our main regulation comes as the result of insurance coverage, and medical malpractice. Well, IVF often is not covered by medical insurance, so there aren’t insurance companies watching what doctors are doing; and so far there has not been much in the way of malpractice, in part because the industry has managed to avoid defining standards of care. It’s also unregulated, in part, because of Roe v. Wade and other Supreme Court decisions establishing an umbrella of reproductive liberty; and it’s also unregulated because doctors want it that way, and many patients do, too. People say they want more regulation, but in fact, in many realms, patients want to preserve individual choice. Many people—women over 45, say, or single women, or gay men and lesbians—are afraid they’ll be excluded from treatment if ART is regulated. And patients groups are very leery of government involvement in fertility medicine, because in this country, reproductive issues are always vulnerable to pro-choice and pro-life ideologies. They’re not wrong; just look at the FDA’s highly politicized treatment of the contraceptive Plan B.
Q: What do you think will finally drive the government to step in, assuming they do?
A: I really don’t know that it will. Perhaps, if a Democrat is elected president in 2008 and a Democratic Congress is in place, and federal funding for stem-cell research is approved, then the government apparatus will be established to more closely monitor all technologies involving the creation of human embryos.
Q: Where is regulation most needed, in your opinion?
A: In cutting down on multiple births. There should be laws, I believe, dictating the number of human embryos that IVF doctors are permitted to transfer into a human uterus. I think it’s arguable that it should never be more than two. I’m not sure this will ever happen, though. It would be good, in general, if insurance companies would begin to cover IVF, and exercise greater oversight. In some states, where insurance coverage is mandated for IVF, the insurance companies—wanting to avoid the tremendous costs that can accompany multiple births—have limited the number of embryos that can be transferred. I think that’s a good thing. And if IVF were more affordable, this would cut down on the number of poor and working-class patients who turn to fertility drugs alone, which are in general much less controlled and more likely to result in high-order multiple births.
Q: What role do religious institutions play in this debate now? How do you see that role changing, if at all, in the future?
A: The Catholic Church is opposed to IVF; other religious institutions generally do not take a hard and fast line on the technology as a whole. I think where religious institutions come into play—aside from the public debate over stem-cell research and the moral standing of the embryo—is when patients seek private counsel from their priest, pastor and rabbi. This is happening more and more; the New York Times did a story on training for rabbis having to do specifically with IVF technology and the questions it raises.
Q: As a mother and a woman, was it difficult to separate your personal views from your reporterly duties (so to speak) as you wrote EVERYTHING CONCEIVABLE?
A: Well, as a parent myself, I sympathize, of course, with anybody who wants children and has difficulty having them. I think the public in general can be harsh toward infertility patients, and I don’t share this attitude. These are people working very hard to have children, and social research shows that children of IVF technology are very loved and very wanted.
I’d like to say, however, that I don’t think a basic empathy toward many of these patients interfered, at all, with my reporterly duties. To the contrary. I feel very strongly that there is a lot of judging and attitude displayed toward ART patients and the industry as a whole. There is a lot of blogging, opinionizing, etc. Attitudes are a dime a dozen. I felt very strongly, starting out—and still feel—that this is realm that cries out for vigorous, unbiased and extremely thorough and informed reporting, reporting that looks at the politics, the personal decision making, the science, the medicine, and the overall industry. I am trained as a newspaper reporter, and that training teaches us to be objective toward our subjects. In the end, I felt quite objective. I wanted to present readers with a rich lode of reported information, and let readers make their own judgments, but from a more informed standpoint. In this, I think my reporterly duties tracked perfectly with my instincts as a parent and a person.
Q: How have women’s groups and pro-choice organizations responded to the debates stemming from ART?
A: Well, it’s been very hard for them. Many pro-choice organizations are still having to expend a lot of time protecting abortion rights, and have been slow to pay attention to assisted reproduction issues. There have been a few low moments in which women’s groups, such as NOW, have objected to public campaigns to educate women about the age at which fertility declines, as if such a campaign is oppressive and retrograde. And it’s hard for many mainstream women’s organizations to decide whether pro-choice philosophy should embrace all choices that are now available—such as sex selection of embryos. One thing that women’s groups are struggling with are the ethics of egg donation by young women, either for reproductive purposes, or for stem-cell research. Many of them don't quite know what to think. These are all such novel issues and entirely newfound choices. If a young women can choose to get an aboriton, should she also be able to choose to donate eggs? Is she being exploited, or exercising her own free reproductive choice? What about donating eggs for stem cell research? Is she advancing science, or making a lot of money for some biotech firm? This is very, very difficult for them, and like many of us, they are undecided, but at least the debate is beginning to happen.
On the other hand, there are now some smaller reproductive groups on the horizons that are very attuned to ART, family-making, fertility decline, and want to raise awareness and inspire public debate. It’s really fascinating to see these groups gaining power and voice; the voice of women in their 20s and 30s who look at the future, wonder how to combine children and career, and hope that technologies such as egg-freezing may help them do it.
Pro-life organizations are of course having a hard time too; there is a hard-line pro-life philosophy that says that human life begins at the instant of conception. Many legislators who adhere to this philosophy have been very, very challenged by the stem cell debate, and by widespread public support for federal funding for stem-cell research on IVF embryos. It’s fascinating to watch some politicians trying to thread this particular needle: to embrace both a hard-line pro-choice view, and justify an often newfound support for stem cell research.
Q: Money plays a huge role in ART—in developing the technologies, undergoing the treatments, securing the genetic materials (egg or sperm) or the womb itself (as with surrogacy). What effect has this had on the industry?
A: Yes, money does play a huge role. Patients pay a lot of money for these treatments, and I do think that as a result, a bit of a consumer mentality prevails. Sometimes patients will ask that three embryos be transferred, rather than two, because they don’t want to “waste” a perfectly good embryo. This is not a good way to look at a crucial medical process. The ironic thing is, insurance often does not cover IVF; but if three embryos are transferred, and triplets are conceived, and they are born prematurely and the birth is very costly, then insurance WILL have to pay for that.
Also, of course, fertility doctors make a lot of money from IVF, and as a rule, would like to continue doing so. There is a lot of competition, and some clinics are inclined to respond to this by transferring more embryos than they should, as a way of keeping pregnancies rates high, and staying competitive. You don’t hear a lot of fertility doctors agitating for more and better insurance coverage, because if the insurance companies come in, they’ll drive down doctor compensation.
What was very moving, for me, was interviewing patients who had worked very hard to afford these treatments; I interviewed one man who had sold his truck to afford a single round of IVF.
Q: There are many moving stories of individuals and families struggling with various aspects of ART that demonstrate the human toll of all of this new technology. Do these stories and people stay with you? Any one in particular?
A: I think about them all, actually. I spent a lot of time talking to people, and meeting their children, and talking about the risks and rewards of what these people had gone through to have families. I think about the woman who had a hysterectomy as a result of delivering twins—as a surrogate for a gay couple—and who said, “I would do it again in a heartbeat.” I think of how hard most of the people I spoke with had worked to achieve this basic, fundamental human pleasure. Some of the stories that I think about most are the tragedies; the woman who conceived triplets, which were born very prematurely, and who had to deliver three dead and dying babies. That is a heartbreaking story that is impossible to forget. But she went on to conceive twins, beautiful girls. And now she and her husband are wrestling what to do with their excess frozen embryos. These are such dramatic personal stories, involving entirely new moral decisions that were, pardon the pun, inconceivable twenty years ago.