The first successful human pregnancy using in vitro fertilization, or IVF, was nearly 50 years ago.
Today, there are more than 100,000 babies born annually through IVF in the United States, according to the Society for Assisted Reproductive Technology.
And 20 years from now, Harvard University professor Ivan Glenn Cohen believes it will be possible to create human life from stem cells − starting with skin cells, with no need for invasive egg retrievals. Stem cell fertility treatments could come to clinics even sooner, within a decade, according to Henry Greely, a Stanford professor who specializes in the ethical, legal and social implications of new biomedical technologies and whose provocatively-titled book "The End of Sex" published in 2016.
It's called in vitro gametogenesis, or IVG, and it's one of several developing fertility technologies being tested around the world. Cohen, a leading expert on the intersection of bioethics and law, told USA TODAY this technology could eventually make it possible for same-sex couples to reproduce without a donor, for more than two people to have a genetic connection to one child or for a single person to procreate on their own. Proponents say these advances will change medicine and are the long-awaited next frontier in fertility. Critics argue some implications may be unethical.
"It is one of the things that people have dreamt about for many years," says Dr. Thomas Molinaro, a board-certified reproductive endocrinologist, obstetrician and gynecologist, and chief medical officer of Everleap Fertility. He adds that several groups are working on this research now, "but I think we're still a long way off from this being routine and something that is offered as a treatment."
Other inventions that might sound like science fiction to some are being developed across the globe to help with human conception and gestation, including genome editing and artificial wombs. The future of fertility is full of possibilities, including a world in which humans could have the option to create an embryo in a petri dish from skin cells, edit the embryo's genetic composition and grow that child to term in a machine without compromising the physical health of the baby's parents. This hypothetical opens up a lot of fear, for some, about eugenics and the possibility of creating workforces or defense forces with traits tailored to efficiency. It sounds far-fetched, but science moves relatively quickly, Greely says. A lot could happen in the next 50 years.
But just because science has this potential, should humans pursue a world in which babies can be made in machines? What would that world look like? Would it solve declining birth rates and fertility struggles, or create new problems? While scientists move forward and commercial investors buy in, legal and ethical scholars are trying to keep pace.
"I don't think there's such a thing as thinking about something too early when it comes to the future of reproduction, because this kind of stuff will fundamentally change the way that we (make babies)," says Elizabeth Chloe Romanis, a biolaw professor at Durham Law School. "Everybody has a really strong stake in it."
'The business of creating families'
Romanis' research is focused on ectogenesis, or the possibility of machines that could "just grow babies from scratch for us." Full ectogenesis is probably 50 years from humans, she says, but scientists at the Children's Hospital of Philadelphia have successfully taken a premature fetal lamb from its mother's womb, placed it in a womb-like machine and carried the fetus to term there. The goal, researchers say, is to provide better outcomes for premature human babies. But full ectogenesis could be good for women with diabetes or other pregnancy-related illnesses, or someone diagnosed with cancer during pregnancy. It could eventually become an alternative to surrogacy.
"Some people argue ectogestation is a solution to women's inequality," Romanis says, but she's not so sure. Society treats pregnant people poorly, she says, labeling them as economically unproductive and potentially risky toward their fetus. That could get worse with ectogenesis, she says, if ectogestation is seen as safer than women's bodies.
"There is a deep and I think passionate split in the feminist movement about ectogenesis, where one wing says, 'This is patriarchy's final attempt to get rid of us altogether. If they don't need our wombs, then they don't need us,'" Greely says. "And the other wing says, 'This is so liberating, we can have children without having to be pregnant.'"
If we've learned anything from IVF, it's that it's a business, says Nava Dimer, director of reproductive bioethics for Rader Law Group and IVF Law Group − "the business of creating families."
Yet the pace of advancement in fertility technology doesn't always leave room for stakeholders to stop and think about the broader impact it might have on people, says Sonia Suter, professor of law and founding director of the Health Law and Policy Program at The George Washington University.
"What worries me the most," she says, "is a lot of the biggest efforts are happening in the commercial sector." She adds, "The capacity and the wisdom of developing these technologies are two very different things."
The target audience for any fertility technology is someone who wants to be a parent. That desire, Dimer says, can put people in a vulnerable position.
"If standing on your head resulted in more successful pregnancies, many of my patients would stand on their head for eight hours a day," Molinaro says.
Scientists still have work to do on IVG
IVG has been successful in animal birth trials, Cohen and Greely say, and human embryos have been created this way. "Nobody has done it (for) human reproduction all the way," Cohen says, adding that the United States prohibits IVG births in humans and any research on embryos older than 14 days. Biomedical companies in the United States are campaigning to loosen embryonic research restrictions, and in the meantime other countries in Europe and Asia are forging on in hopes to bring IVG to patients as soon as possible.
While it's exciting that scientists have successfully taken IVG to live births in mice, Greely says, "mice aren't people. And even if you can do it, the safety issues are huge."
Dr. Paula Amato, director of the Oregon Health & Science University's Division of Reproductive Endocrinology & Infertility, is one of the researchers working on IVG. The human embryos her team has made, she says, lacked certain chromosomes after fertilization.
Still, she thinks the technology could be ready for human clinical trials in about 10 to 15 years, giving same-sex couples, menopausal women, cancer survivors and others who currently can't reproduce a chance.
While giving same-sex couples the opportunity to have genetically-related children could be an argument for equality, Cohen and others worry about society's obsession with genetic connectedness. The LGBTQ+ community has spent a lot of time emphasizing that genetic connection doesn't matter so much, Suter says. Would IVG undermine the value of chosen family?
"The ethical questions here, I think, are wrapped up in some cultural wars that we're experiencing in this country," Suter says. The resistance some people have to same-sex parents "let alone genetic parents," she says, could lead to potential backlash.
IVG could also give people the option to reproduce with multiple partners by "collapsing generations," Suter says. Cells from two people could create one embryo, and cells from another two people could create another embryo, and then scientists could create egg and sperm from those embryos to create another embryo, in several iterations. In theory, Greely says, 16 people could have a child together with IVG. "They'd be like great-great grandchildren," Suter says.
And then there's the wildest possibility, Greely says, of a single genetic parent to what he calls a "unibaby." It's different from cloning, Suter says, because the person's offspring through IVG "wouldn't be the exact identical mix of genes." Who would want to do this? Solo parents, Suter says, who want to avoid the personal or legal challenges that can arise from using donor gametes.
"But it does raise some ethical concerns about safety," Suter says, "because it's a bit like having incest on steroids."
Anna Louie Sussman, a journalist and cultural critic who wrote "Inconceivable" on her own fertility journey, says IVG "sounds nice," but she's not sure what it will look like in practice. Enduring a small skin biopsy that doesn't even need stitches is "obviously preferable to shooting yourself up with hormones," she says. But what will the monetary price be, and what about success rates?
"I would imagine most people prefer the old-fashioned way," Sussman says. "It's free."
Genome editing, 'designer babies' and the slippery slope to eugenics
One of the arguments in favor of expanding IVF and eventually IVG, Greely says, is the ability to screen for genetic diseases in embryos through a technology called preimplantation genetic testing, or PGT.
Several companies are working to make the IVF process better and more efficient with the help of robotics, automation and artificial intelligence. The hope is that it's cheaper and more accessible, giving more potential parents the option to prevent diseases like spina bifida, sickle cell disease and other disorders in their babies.
But it's a slippery slope, and some of this technology is "bordering on eugenics," Dimer says.
The tension between embryonic genetic testing and the disability community is palpable.
"I think part of it is just kind of deciding, as a country, what do we think are appropriate uses of reproductive technologies?" Suter says, adding that many countries have restricted testing for serious health conditions. "The U.S. is pretty laissez-faire about this."
Dr. David Sable, who has been at the forefront of IVF and founded companies including Assisted Reproductive Medical Technologies and Reprogenetics, says screening for some diseases like cystic fibrosis is easy, but the math is much harder for other diseases. It's even more difficult to screen for consumer traits like hair color, eye color, athletic ability, perfect pitch and intelligence. "It's not like ordering a salad from a takeout place," Sable says, disputing the possibility of "designer babies" outright.
Molinaro, too, says this technology is "largely considered experimental." That doesn't mean some companies aren't trying to capitalize on the possibility of genetically selecting, or someday even editing, embryos to have those traits.
"It's being offered to patients and marketed to patients," Sable says. "Depending on who you talk to, validation is a work in progress."
Little to no regulation means these companies "don't have to prove to anybody that they're accurate," Greely says. "And they're selling it for a nice profit."
And if not just embryo selection, but heritable human genome editing, is possible, Cohen says, what then? There are reports that a scientist in China already was successful in gene editing, which "many people view as problematic and unethical," Cohen says. That scientist, He Jiankui, was sentenced to three years in jail after after the twin girls at the center of these allegations were born, American Association for the Advancement of Science reported in 2019.
Embryo selection can have elements of eugenics and possibly sends "negative signals to disability communities," Cohen says. But with gene editing, "it's kind of on steroids because there's no limit to how much of this you can do."
There's an argument, Cohen says, that genetic selection of embryos isn't so different from the donor selection process. "We have these catalogs full of people, and they compare them," he says. "They're like, what were their LSAT scores? How beautiful? How tall is she? Where did she go to school?"
But really, Cohen says, most people's interests in growing their family don't hinge on heritable traits.
"Most people have actually very similar interests: I want a child that's healthy, I want a child that's going to live long, I want a child that's going to be happy," he says. "So it's not, like, so bespoke."
Madeline Mitchell's role covering women and the caregiving economy at USA TODAY is supported by a partnership with Pivotal and Journalism Funding Partners. Funders do not provide editorial input.
Reach Madeline at memitchell@usatoday.com and @maddiemitch_ on X.
This article originally appeared on USA TODAY: Babies made from stem cells. Same sex couples with no donors. This is the future of fertility
