Anyone who’s ever considered fertility treatment, adoption or alternative ways to have children has had to deal with the business side of a very personal decision.

In terms of fertility, many in my generation of peers seem to have prioritized their careers while in their twenties. For those reasons and because we all believe that medical technology is pushing out the biological envelope (despite our mothers, aunts, and anyone who could speak telling us that was not true), most of my girlfriends are having/will have/had their children while in the thirties.

There are, of course, the lucky ones, who think about getting pregnant and the next second, they are miraculously expecting. I think this is fabulous and am truly happy for them (you know who you are! 🙂 )

But the norm seems different. Most of the women I know (both in India and here in the US), have had some experience with the fertility process. Usually the Ob/Gyn gets you going but as soon as you go to a fertility specialist, it is a factory of sorts. Get tested to make sure both partners are fine, start with IUI, if it doesn’t work go to IVF. I mean factory in a good way since there are clear processes and everyone knows what to do and what’s next. But you very quickly realize that it is a business. In case you don’t realize it when you walk in, you will as soon as your insurance stops covering you (most insurance doesn’t cover IVF) and you realize that each cycle involves a significant monetary cost.

In addition, there is an “alternative” channel and I think it is great that it exists. Not just for gay and lesbian couples but also for couples who want to have the children be biologically related to at least one parent. Very close friends have happy, healthy kids this way, and here again, there is a process, albeit a slightly different one — find an egg donor and/or sperm donor, pay for fertilization and storage, find a carrier/surrogate and impregnate said carrier. Couples are paying for every step in the process, the most expensive being the carrier since the time involvement is the longest.

And then there is adoption, which has it’s own complications. Instead of paying for pieces of biological “content”, you are paying for a child. It is easier to say that a parent and child are “matched”, but the costs of travel, paying all the agencies and the fees all add up. Whether it is blatant or not, there is payment involved.

Into this fascinating world comes Debora Spar. From an article in Harvard Business School’s Working Knowledge:

“We have a business that doesn’t feel like a business,” said Spar. “Nobody wants to acknowledge the extent of commercialization.” Yet Americans alone spent $2.7 billion on fertility treatments in 2002. Procedures such as egg and sperm donation, in vitro fertilization (IVF), surrogacy, and adoption demand payments of $10,000 and up.

Despite the classic components of supply, demand, advertising, and differentiation, this market does not function normally, said Spar:

• Prices are excessive. “We have a product that 90 percent of the population gets for free. The other ten or fifteen percent have to pay anywhere from $25,000 to $60,000 and up. You don’t see that kind of inequity often.”
• Inconsistent standards of payment. Only ten U.S. states have some sort of mandate regarding insurance coverage for fertility treatments. In some cases, desperate couples are relocating for the sole purpose of obtaining coverage.
• Ambiguous legislation regarding ownership of children. “Court decisions have been all over the map,” said Spar.
• Absence of property rights. “Do you own a child—even your child? Do you own your body?” asked Spar. “The law says yes and no.” Until there is more clarity, the market cannot thrive.

I think Spar raises some really important points about the disfunctional “market” that need to be addressed. There is too little structure right now – who you work for and where you live has a huge impact on how much conceiving/procuring your child is going to cost. Most insurance in NY, for example, is not required to cover IVF. What is a middle-class couple (let alone a poor couple) who is infertile supposed to do? We certainly don’t punish poorer people with diseases this way – why is infertility a special case?

In cases where the sperm or eggs are “bought”, there are several legal issues that Spar highlights. In some countries in Europe for example, paying for an egg is illegal – what rights does that mean to parents of such children? Lawyers in such cases get reams of documentation and signatures in the hopes of protecting their clients, but it is an evolving space.

And finally, Spar raises an extremely interesting point – does the cost parents bear entitle them to choices like gender and other genetic characteristics?

Spar suggests four lenses within which to frame this debate:

First is simply information. We should think about the kind of information that is most important to us (health data, for example, or cost data or comparative studies of clinical success rates or adoption placements) and then provide these data through public sources. Right now, it’s simply too hard for would-be parents to get accurate and reliable information.

The second is cost. Because no one likes to think of children as existing in a market, we have been very wary of discussing cost. But it costs money to acquire a child through non-traditional means. So we need to be very upfront in discussing what these costs are, and which pieces of them should be borne by society, rather than by the parents themselves.

A third framework would relate to equity. As a society, we need to think about what fairness means in this realm. Is the ability to reproduce a basic human right? Is it part of medical care? And does it extend to all people, regardless of their age, sexual preference, and health condition? Once we get even a rough consensus around this issue (even if that consensus is forged at a state, rather than a national level) we can begin to craft policies that make sense.

Finally, tough as it may be, I think that we also need to think about appropriate limits to parental choice. Where should we draw the line on what kinds of children people can create, and what kinds of technology they can employ? We’ve already said no to reproductive cloning. There may well be other prohibitions that we also want to consider.

I think that’s a great start. Ever single issue she raises is worthy of hours of discussion and we need to have discussions like this in the policy realm. It will clarify and hopefully ease this process for thousands of couples dealing with a very emotional issue.

And I have added Spar’s book to my reading list – can’t wait for it to get here.