The baby business

How money, science, and politics drive the commerce of conception
Debora L. Spar and The baby business How money, science, and politics drive the commerce of conception 2006 Harvard Business School Press. Boston, Massachusetts, USA. 1-59139-620-4 (hardcover).

March of Dimes, White Plains, New York, USA.E-mail: ngreen@modimes.org

Throughout much of Western history, the uterus was considered an independent organism, a voracious animal within the female body that required "feeding". That conceptualization rendered women mere bearers of children, despite very high risks of maternal and infant mortality. While complication rates have plummeted, having children is no longer viewed as satisfaction for the ravenous animal within. Yet as Debora Spar aptly describes in The baby business: how money, science and politics drive the commerce of conception, this hunger for children drives the booming business of reproductive technology. Approximately 15% of all couples in the United States admit to some degree of infertility. Thankfully, infertility is no longer considered a taboo-ridden measure of female or male inadequacy.

Assisted reproductive technology (ART) provides the joy of childbearing via technologically controlled conception, regardless of etiology. At least 1% of births in the United States and western Europe are conceived by ART, with most of the procedures consisting of in vitro fertilization (IVF). As one of several states mandating insurance coverage for ART, Massachusetts has an astounding ART rate of 4% of births. ART is a $3 billion market in the United States each year. The cost for IVF is $60,000 and up, excluding the usual child-rearing expenses of diapers, orthodonture, and college tuition. With all that hope, money, injected hormone cycles, and painful microdissection of reproductive biology and sex, why shouldn’t the consumer seek specialists promising outcomes of "perfection"?

The author’s key message about assisted conception is correct: while a true service for those desiring children, ART is a form of commerce, so buyer beware. As a professor of business administration at Harvard Business School, she is highly qualified to assess this darker aspect of the trade. An engaging writer, she presents an accurate formulation that is well documented and logically presented. Boutique ART clinics advertise technically skilled service and the perceived monopoly on the "best" practitioners, which appeals to unswervingly determined, highly vulnerable would-be parents with potential deep sources of cash and dwindling biological windows: a "perfect storm" for commerce.

The business of ART has largely escaped public oversight or regulation, although the relevant professional societies have begun some genuine self-regulation of practice. Individual ART clinic outcomes are reported to a national database managed by the Centers for Disease Control and Prevention (CDC). However, success is defined by the rates of pregnancy achieved rather than rates of healthy deliveries. With success rates of 30–40%, there are also generally underplayed risky outcomes of multiple births (35% of all ART births by recent CDC tally; ref. 1), the 1.5- to 2-fold elevated risk of birth defects (2), and delivery of the rare but devastated child with a neurobehavioral imprinting defect like Angelman’s syndrome.

Spar analyzes ART through an economic lens, looking at national figures, per capita costs of sperm and egg banking, surrogates, IVF cycles, and the like. Reproductive endocrinologists help support many academic OB-GYN departments. At the extreme end of the spectrum of specialists, a prison term was recently reported for the so-called "dyno-gyno" — a New York City ART specialist to the stars, who was found guilty of defrauding insurance companies of several million dollars by deceitfully billing for gynecologic services that were actually ART procedures not covered by insurance. While this practice may be considered modern Robin Hood–ism by spreading access to ART to the middle class through creative reimbursement, the legal system did not concur with that defense.

The baby business falls surprisingly short on issues pertaining to human cloning. Reproductive cloning, which is thankfully still distinct from reality as far as anyone has honestly reported, is mistakenly conflated with therapeutic cloning. A noncritical reader of that chapter may infer that reproductive cloning may make the same meteoric commercial ascent as ART, when in fact there are significant international legislative, scientific, and bioethical boundaries set to prevent its entry into the market. Moreover, the description of cloning lacks the novel economic perspective that drives the rest of the book and comes across as stale. There is an absorbing chapter on the sociologic history of adoption in the United States, even though it seems to represent an adjunct to Spar’s main thesis.

Despite these reservations, this book will appeal to medical and nonmedical audiences, with refreshing economic arguments on an increasingly popular form of modern technocommerce. Spar makes a number of practicable suggestions for protecting the consumer, such as national oversight of the unregulated market of "reproductive services," a clearer legal framework, and better data reporting. In fact, those considering ART are advised to reflect on this realistic view of the financial toils and spoils of the business. While the information within may or may not provide rescue or options, at least the informed consumer could use it to decide if — and when — to embark on this journey and at which point to cease.

References

Wright V.C., et al. 2005. Assisted reproductive technology surveillance--United States, 2002. MMWR Surveill. Summ. 54:1–24320 pp.

Green N.S. 2004. Risks of birth defects and other adverse outcomes associated with assisted reproductive technology. Pediatrics. 114:256–259.