Addis Ababa University College of Health sciences

Department of Public Health

Seminar of Health Care Ethics

Assisted Reproductive Technology

By: Beshadu Bedada (ID number-GSR/7532/17)

Department: PhD in public health nutrition
Submitted to: Adamu Addissie (MD, MPH, MA (Bioethics), PhD)

Addis Ababa, Ethiopia

January, 2025

Infertility and Assisted reproductive technology

Infertility
World Health Organization (WHO) define infertility as a disease of the male or female
reproductive system defined by the failure to achieve a pregnancy after 12 months or more of
regular unprotected sexual intercourse. It may occur due to male, female or unexplained factors.
Some causes of infertility are preventable. Treatment of infertility often involves in-vitro
fertilization (IVF) and other types of medically assisted reproduction. In male reproductive
system, infertility is commonly caused by problems in the ejection of semen, absence or low
levels of sperm, or abnormal shape and motility of the sperm. In the female reproductive system,
infertility is caused by a range of abnormalities of the ovaries, uterus, fallopian tubes, and the
endocrine system, among others. It affects millions of people. It is estimated that approximately
one in every six people of reproductive age worldwide experience infertility in their lifetime.

Infertility affects peoples in several ways including its impact on their families and
communities. It causes significant distress, stigma and financial hardship that affect people’s
mental and psychosocial wellbeing. A study done on the psychological impact of infertility
suggests that infertility is considered as a crisis situation in which the most common
consequences are visible at the level of mood disorders (e.g. anxiety, depression, marked
distress) and at the social level (stigma, divorce, social isolation, financial difficulties) (1).

Infertility need to be addressed because it negates several human rights particularly the
reproductive right. Human being has a right to the enjoyment of the highest attainable standard
of physical and mental health. Individuals and couples have the right to decide the number,
timing and spacing of their children. Addressing infertility can also mitigate gender inequality.
Although both women and men can experience infertility, women in a relationship with a man
are often perceived to suffer from infertility, regardless of whether they are infertile or not.
Infertility has significant negative social impacts on the lives of infertile couples and particularly
women, who frequently experience violence, divorce, social stigma, emotional stress, depression,
anxiety and low self-esteem. In some settings, fear of infertility can deter women and men from
using contraception if they feel socially pressured to prove their fertility at an early age because
of a high social value of childbearing.

However addressing and managing infertility is a great challenge particularly in low and middle
income country. Diagnosis and treatment of infertility is often not prioritized in national
population and development policies and reproductive health strategies and are rarely covered
through public health financing. Moreover, a lack of trained personnel and the necessary
equipment and infrastructure, and the currently high costs of treatment medicines, are major
barriers even for countries that are actively addressing the needs of people with infertility. While
assisted reproduction technologies (ART) have been available for more than three decades, with
millions of children born worldwide from ART interventions such as in vitro fertilization (IVF),
these technologies are still largely unavailable, inaccessible and unaffordable in many parts of
the world, particularly in low and middle-income countries (LMIC).

Government policies could mitigate the many inequities in access to safe and effective fertility
care. To effectively address infertility, health policies need to recognize that infertility is a
disease that can often be prevented, thereby mitigating the need for costly and poorly accessible
treatments. Incorporating fertility awareness in national comprehensive sexuality education
programmes, promoting healthy lifestyles to reduce behavioural risks, including prevention,
diagnosis and early treatment of STIs, preventing complications of unsafe abortion, postpartum
sepsis and abdominal/pelvic surgery, and addressing environmental toxins associated with
infertility, are policy and programmatic interventions that all governments can implement. In
addition, enabling laws and policies that regulate third party reproduction and ART are essential
to ensure universal access without discrimination and to protect and promote the human rights of
all parties involved. Once fertility policies are in place, it is essential to ensure that their
implementation is monitored, and the quality of services is continually improved.

Recognizing the importance and impact of infertility on people’s quality of life and well-being,
WHO is committed to addressing infertility and fertility care by:

 collaborating with partners to conduct global epidemiological and etiological research

into infertility;
 engaging and facilitating policy dialogue with countries worldwide to frame infertility
within an enabling legal and policy environment;
 supporting the generation of data on the burden of infertility to inform resource allocation
and provision of services;
  developing guidelines on the prevention, diagnosis and treatment of male and female
infertility, as part of the global norms and standards of quality care related to fertility
care;
 continually revising and updating other normative products, including the WHO
laboratory manual for the examination and processing of human semen;
 collaborating with relevant stakeholders including academic centres, ministries of health,
other UN organizations, non-state actors (NSAs) and other partners to strengthen political
commitment, availability and health system capacity to deliver fertility care globally; and
 providing country-level technical support to member states to develop or strengthen
implementation of national fertility policies and services (2).
Assisted reproductive technology
Assisted reproductive technology is using medical technology to treat infertility or to achieve
pregnancy in individuals who are having difficulty doing so spontaneously. Some of ART may
be used with regard to fertile couples for genetic purpose and also in surrogacy arrangement, but
not all surrogacy arrangement involve ART. The first In vitro fertilization (IVF) in humans was
performed in 1978 in England and later on the technology expands and starts to be used
worldwide. It involve procedures like intrauterine insemination, in vitro fertilization (IVF),
intracytoplasmic sperm injection (ICSI), cryopreservation of gametes or embryo and the use of
fertility medication.
Indication
ART primarily aimed to treat infertility. But it can also be used several situation like in patients
desiring preimplantation genetic testing before, fertility preservation, such as prior to
gonadotoxic therapy, or in patients desiring to delay childbearing.
Contraindication:
Any condition that may put the mother at risk of ART or pregnancy itself need to be assessed,
Example, cardiopulmonary conditions such as pulmonary hypertension and heart failure, are
relatively contraindicated.
ARTs involve intrauterine insemination (IUI), in vitro fertilization (IVF), intracytoplasmic sperm
injection (ICSI), cryopreservation of gametes or embryo and the use of fertility medication.
Intrauterine insemination (IUI): It is an artificial reproductive technology in which a washed
and concentrated sperm cell directly placed in the uterus using thin plastic catheter during
ovulation. It is used to treat infertility, for reproduction option for same sex female couple, for
women who need to have child without partner using donor sperm. It can be used in case of thick
cervical mucus, low sperm count/any sperm impairment, erection or ejaculation dysfunction or
semen allergy.
In vitro fertilization (IVF): It’s the commonest form of assisted reproductive technology in
which mature eggs are collected from ovaries and then fertilized by partner sperm in a liquid at
the laboratory. It involves ovarian hyper stimulation, the collection of oocytes from the ovary,
followed by fertilization in vitro, and transferring the resulting embryo into a uterus of the
women after culturing it for 2 to 6 days.
Mitochondrial replacement therapy (MRT): It is a special form of IVF in which the
mitochondria of the mother is replaced by other egg donor women if the mother carries
mitochondrial disease. Thus, the future baby’s entire mitochondrial DNA comes from the third
party. In this technique, the mother’s egg nucleus placed in the donor egg and this donor gets
fertilized. The child born will have a genetic characteristics of his/her traditional parents and will
also have 20 to 25 gene from the donor mitochondria.
In gamete intrafallobian transfer (GIFT): is a procedure in which a mixture of sperm and eggs
are placed directly in woman's fallopian tubes using laparoscopy following a transvaginal ovum
retrieval. In this procedure, fertilization will take place at natural cite.
Reproductive surgery: it is a procedure of treating fallopian tube and vas deferens obstruction
or surgical sperm retrieval(SSR) as the urologist obtain sperm from the vas deferens, epididymis
or directly from the testes in a short outpatient procedure(3).
Legislation for assisted reproductive technology
Introduction
Until the latter decades of the 20th century, the focus of medical interventions in human
reproduction was on fertility control, particularly by developments in contraception. The use of
promoting fertility or to overcome infertility by laboratory (in vitro) initiatives lay in the area of
animal husbandry. With assistance from veterinarians, the specialists in human reproductive
biology done the first assisted reproductive technologies (ARTs) in 1978 and the first
authenticated in vitro fertilization (IVF) baby, Louise Brown, was born in England.
Medical means to control fertility, protect fertility, and overcome infertility were brought
together in the 1990s under the concept of reproductive health. This unifying vision took shape
in the late 1980s within the World Health Organization, and received international impetus in
1994 when the concept was adopted, in an expanded form, in the Programme of Action
developed at the United Nations International Conference on Population and Development
(ICPD), held in Cairo. The concept was further endorsed the following year, when the UN
International Conference on Women, which met in Beijing, underscored that, whatever the
source of infertility, the physical burdens of overcoming it fall primarily on women.
WHO define reproductive health as state of complete physical, mental, and social well-being in
all aspects of the reproductive system. This allows people to have a safe and satisfying sex life,
the capability to reproduce, and the freedom to decide when and how to have a child.
Legislation and regulations
Developing laws to manage assisted reproductive technologies (ARTs) involves challenges due
to the growing nature of these technologies and their diverse applications. In many countries,
general laws, that do not consider ARTs, often lead to confusion with inadequate regulation. This
results in creating purpose-specific laws for ARTs to provide clear legal frameworks.
Economically developed countries enact specific ART legislation, though some rely on
professional guidelines or have not yet enacted such laws. There is a difference between
legislation and regulations. Legislation is created by legislative body and it has political debate
and majority votes in addressing broader principles. It can also be limited by constitutional
provisions or international treaty obligations. Regulation is a detailed rule than can be made by
the executive body to implement the legislation's purposes. It is flexible and can be amended
quickly.
Even though the first Assisted Reproductive Technology come up with relief of addressing
infertility, it was fueled with a fear of moral and social disorder, particularly alarming religious
institutions like the Roman Catholic Church. These fear in combination with feminist concerns
over potential medical exploitation of women, makes many government to establish committees
to recommend legal controls on ARTs. Thus, legislation and regulation that govern Assisted
Reproductive Technology (ARTs) developed in response to perceived crises or societal threats.
For example, the UK’s 1990 Human fertilization and Embryology Act and Canada’s 2004
Assisted Human Reproduction Act were developed in response to social crisis. Despite the
development of legislation and regulation, balancing moral principles with practical legislation
remains challenging, particularly when addressing contentious issues like abortion.
The aim of ART legislation is to relieve the frustration of reproductively impaired patients while
respecting embryonic life. But many legislation focuses on the ART regulation of technical
practices and it neglects their broader implications in family law. This causes legal challenges in
defining parenthood particular when genetic, social, and psychological parenthood deviate due to
sperm or egg donation, or surrogacy. Countries with strong religious influence like with Islamic
nations or those with strong Catholic roots, imposes restrictions on ARTs practices, by focusing
on genetic relation and protection of embryonic life. In some countries, like Poland, the struggle
to develop ART laws that respect religious values with accommodating modern reproductive
needs causes political and social tensions. Their proposal ranges from restricting ARTs to
married couple to freeze embryo o access people without sexual relationship. In Italy, the effort
to develop ARTs legislation by referendum face challenges from religious institutions
advocating for low voter turnout to prevent legal reforms.
Evidence-based legal policy
As observed in UK’s Human Fertilization and Embryology Authority (HFEA), similar to
evidence-based medicine, evidence-based social and legal policy was successfully implemented
in development of ART legislation. The HFEA provide licenses and monitors ART clinics to
ensure public transparency, and adapts policies based on new clinical practices and public input.
For example, For instance, when the HFEA, in the United Kingdom, refused consent for PGD to
create embryos to be born as savior siblings, able to provide genetically suitable bone marrow or
stem cells derived from umbilical cord blood for transplantation into existing sick children of
families, the parents traveled to the United States for the services, with an encouraging outcome.
This evidence persuaded the HFEA to relax its rules on acceptable PGD to allow for its
availability in the United Kingdom, subject to the agency’s approval. Legislation and
regulations rarely seem to address cross-border services, where the couple travels to other
country where there is a service or where ART is lawful. For instance, patients prohibited in
their own countries from attracting gamete donors by payment tend to travel to countries where
payment is allowed, and the same applies to surrogate gestation. While repressive laws tend to
make ARTs inaccessible within a given country, sometimes driving resident’s abroad, lax laws
and/or enforcement of laws may compromise quality of services. Applicants for treatment may
be inadequately assessed or counseled, for instance, and donors of gametes, embryos, and/or
surrogate gestation services may be inadequately screened on genetic, lifestyle, and other
relevant grounds.
The focus of legislation
The full costs of ARTs are not covered by government in many countries. This increases
financial burden of the couple. This condition coupled with high demand of the service increases
the marketing of ART by private clinics and exploitation of hopeful patients. Thus, to protect the
patients and to ensure the quality of the service some low restricts the use of some equipment
and ban some procedure. For example, Italy banned cryopreservation and enforces strict
regulations to limits on embryo creation per cycle to reduce multiple births' medical risks and
associated public health costs. Other countries like Turkey, limiting the number of embryos
transferred in IVF treatments based on the woman's age and treatment cycle.
Informed consent for treatment of fertility
Introduction
The court system reflects society’s values, among them the protection of human dignity, which
includes the right to experience parenthood. The doctrine of informed consent manifests the
judicial system’s acknowledgment of patient autonomy and the right to share in decisions
pertaining to a patient’s medical treatment. The right to autonomy, which is grounded in human
rights of dignity and privacy, gives rise to the autonomy of the family unit, the right of family
planning, and the freedom to choose the form in which parenthood will be achieved or access to
infertility treatment except there may be restriction in certain circumstances like aging.
Assisted Reproductive Technology which is invasive and performed solely on the woman
through donation of reproductive cells (sperm and egg), and even posthumously, mandate a
different approach to fertility-treatment consent than that required for other medical treatments.
This is so due to certain unique characteristics of fertility treatments: first, the aim of fertility
treatment and the measure of its success is the creation of a live newborn infant. Hence, the
wellbeing of the future child should be considered, as should the patients’ capability to undertake
parental responsibility. Second, fertility treatments are generally lengthy and difficult (physically
and emotionally) and are conducted in cyclic sessions. Thus, Consent in fertility treatments must
consider the rights of both spouses including the possibility of withdrawing consent and
treatment should be considered and the right to do so should be granted. Third, the existence of
cryopreserved (frozen) sperm cells and/or fertilized eggs in storage makes it possible to proceed
with the reproductive process even after the dissolution of the family unit and/or the death of the
donor of reproductive cells.
The right to experience parenthood and its standing
Informed consent for fertility treatment is a twofold issue: It concerns both the right of
autonomy and the right to experience parenthood. Being parenthood is human right and one
of humanity’s highest values. The right to parenthood embraces two important aspects of family
life: the right to have offspring (the biological act) and the right attached to it – which is also an
obligation to raise the children.
All men and all women have the right to fertility treatment and to realize their desire to become
parents, including by means of IVF. This do not impose obligation to government to assist
everybody. But, the state controls the procedure through both by allocating resources for
developing advanced medical technologies and by determining the medical services available to
health-fund members. Thus, imposing of restrictions on fertility treatments requires extra
caution.
The informed-consent doctrine
In order for the patient’s consent to be legally valid, it must be voluntarily provided, free of
coercion or extraneous influence, following proper disclosure by the physician of all the items of
information required for informed consent. In complying with duty of disclosure, the physician
must give the patient, as early as possible, every required detail including the risk, procedure,
treatment alternatives, and success rate to make the decision whether to accept or reject
treatment. Since consent for medical treatment is a contract between physician and patient and
entails legal consequences, the consent giver must be legally qualified to give consent.
Since fertility treatment is unique, both patient and physician need to understand the following.
first, the legal grounds for the consent requirement is not just patient autonomy but also the
patient’s right and desire to become a parent.
Second, the parties involved in the treatment should be alert to the distinction between the
consent of a single woman who cannot find a spouse and wishes to experience motherhood by
way of IVF and the consent of a couple wishing to become parents by the same means. In both
cases, the consent for treatment is the external manifestation of their willingness to do all that is
required, including taking risks, in order to achieve the desired pregnancy, and in both cases the
treatment is generally performed on the woman’s body.
Third, the patients should be aware that due to the continuation of the treatment and its cyclic
nature, the life span of the consent, the subject of their signatures, should be defined. Written
consent should be obtained.
Mutual consent of spouses
According to the standard practice in Israel, any act entailed in IVF of a married woman is to be
carried out subject to her husband’s consent, which must be given in the same document.
Procreation is a joint process, the fruit of a mutual decision of both spouses, even if medically
assisted. Parenthood is also mutual; the birth of a child entails legal consequences, and the
responsibility and concern for the well-being of the minor is imposed equally on both parents.
Since both spouses are involved in the act of procreation on various levels, mutual consent is
warranted.
The good of the child and consideration of parental capability
Implicit in the consent requirement of the spouse is the assumption, justified in itself, that the
good of the child also extends to the pre-procreation stage. Therefore, due regard should be given
to the question of whether the couple’s consent is sufficient to begin treatment, since, if it
culminates in the birth of a live newborn, the child will also and apparently primarily bear the
consequences of the treatment for better or worse. Every child has a right to expect that society
will do everything within its power to ensure that it is given a good chance to grow up in a
normal, warm, and harmonious family. Every child is entitled to be provided with the material
and psychological conditions required for its growth and education by parents capable of
fulfilling this role successfully. The medical institution and the treating physician before whom
the couple sign their consent for treatment are not the appropriate authorities for testing parental
capability and determining the good of the child. Therefore, in order to avoid future mishaps and
legal proceedings, consent for fertility treatments should be stipulated on a proper prior
undertaking by both spouses before a competent authority. The role of such authority should be
to test the ability of the patients to function as dedicated parents for the benefit of their child.
Validity of the consent
The test of a successful fertility treatment is the birth of a live child and, to the extent possible, a
biological offspring. However, until the desired pregnancy is achieved, many couples undergo
lengthy, painful, and recurring treatments. Due to the prolonged treatment, its cyclic nature,
physical and emotional strain, and the potential for disappointments, alternative options
(adopting a child), and dissolution of the family unit, the spouses may well despair, recoil, and
withdraw their consent for treatment. The same applies to a physician concerned about a
foreseeable or unforeseeable risk to the life of the female patient, which might develop in the
course of treatment.
Effect of the initial consent
The cyclic nature of assisted reproductive technology raise question whether the patient provide
written consent for each procedure or not. This depends on the interpretation given to the
intention of the concerned parties prior to signing the treatment consent. One interpretation
suggests that, once the patients were advised that the treatment would be lengthy and would
consist of several sessions, by signing the consent form, they manifested their intention to have a
child and agreed to each stage of the treatment. According to a different interpretation, the
patients’ initial consent remains in effect for each procedure required in the course of the
treatment, as long as neither one of them reports its withdrawal. Again, if additional
interventions are required, the couple will have to give their renewed consent prior to each act in
order to continue with the process. The first interpretation binds the couple to their initial consent
and breaches their autonomy. Therefore, practically speaking, the third interpretation, which
requires renewed consent for every invasive intervention, is preferable.
Withdrawal of patient consent
Withdrawal of consent should be permitted whenever it is requested by either one of the spouses.
Physician’s withdrawal of consent
Two systems of rules govern the treatment agreement between the physician and the patient. The
first, which regulates the rights of the patient, whether by bill of rights or by law, is reflected in
the doctrine of informed consent. However, stipulating the medical treatment on the patient’s
informed-consent agreement does not impose any obligation on the physician unless the
physician undertakes to treat the patient. In the absence of a legal duty obligating the physician
to treat the patient, the other governing system is the rules of medical ethics, which determine the
norm of conduct expected of the physician. The first duty of a physician is to benefit the patient,
and to do no harm. In the conflict between the patient’s autonomy and the physician’s
conscience, the physician should be entitled to be released from consent even if this is contrary
to the patient’s wishes. But there are those who maintain that respect for the patient’s dignity and
privacy shifts the balance toward honoring the patient’s autonomy; hence, the physician should
provide medical treatment, including fertility treatment, to any patient who requests it.
Legal control of surrogacy – international perspectives
Surrogacy is bearing a child on request for another family or person. A child, in this case, is born
not out of the maternal instinct of the surrogate but due to the commissioning couple’s or
individual’s intention to become parents. There are two types of surrogacy: traditional surrogacy
and gestational surrogacy. Traditional surrogacy occurs when the surrogate’s oocytes are used. In
case of gestational surrogacy there is no genetic link between the surrogate and the baby she
carries.
The right to procreate should not depend on gender, family, or sexuality. It is a natural,
inalienable right of any person to provide intergenerational continuity. One of the main
principles of modern bioethics is that the interests and welfare of the individual should have
priority over the sole interest of science or society (Universal Declaration on Bioethics and
Human Rights 2005). Refusing to allow childless people to become parents (when they can have
children through surrogacy) means refusing to treat them equally and is a classic example of
selective discrimination.
Prohibition of Surrogacy by legislation
In some countries (i.e., Austria, Germany, Italy, Switzerland), surrogacy is prohibited, and severe
sanctions are applied for doctors who arrange a surrogacy for their patients or for mediators who
help an infertile couple find a surrogate. In Germany the restrictive law for the protection of
embryos strictly prohibits artificial insemination of a woman who is willing to hand the child
over to commissioning parents upon birth in accordance with a surrogacy agreement. Criminal
sanctions are applied for noncompliance, ranging from heavy fines to imprisonment. Surrogacy
agreements, mediation in surrogacy, and related commercial and noncommercial advertisement
are prohibited by the law concerning adoptions. According to German legislators, surrogacy
should be prohibited because of the violation of bonus mores (morality). In Italy the Law on
Norms in the Area of Medically Assisted Reproduction completely bans heterologous (third
party) reproduction, including surrogacy.
Preimplantation genetic diagnosis in assisted reproduction: medical, ethical, and legal
aspects. Preimplantation genetic diagnosis (PGD) is becoming an established tool in assisted
reproduction for avoiding the transfer of the embryos with chromosomal abnormalities, which
contributes significantly to implantation failure and pregnancy loss.
PGD is an alternative to the traditional selection of embryos based on morphologic criteria in
IVF, because despite possible correlation between normal morphology and euploidy, many
morphologically normal embryos still may be found to be with chromosomally abnormalities.
Because of the potential for improving the implantation rate, decreasing the spontaneous-
abortion rate, and lowering the rate of multiple pregnancy loss, PGD has been applied in tens of
thousands of poor-prognosis IVF cycles. However, the utility of PGD for improving IVF
efficiency is still controversial, mainly due to the need for improving the accuracy of PGD
technology for chromosomal aneuploidy. On one hand, the current testing has been available for
only a limited number of chromosomes, and on the other, the widespread use of cleavage stage
biopsy appears to be insufficiently reliable for detection of chromosomal status of the embryo.
The benefit of avoiding aneuploid embryos from transfer, which contributes to the improvement
of the pregnancy outcome of poor prognosis IVF patients, and improving the overall standard of
medical practice, upgrading the current selection of embryos by morphological criteria to include
testing for aneuploidy is important ethical issue.
It may be expected that no IVF center without such an upgrade could be competitive, as the
informed patients will not opt for transfer of embryos with a 50% risk of chromosomal
abnormalities. The major impact of PGD will be on implantation rate, because only 1 in 10 of
recognized pregnancies are chromosomally abnormal, compared to 1 in 2 in oocytes and
preimplantation embryos. Incidental transfer of aneuploid embryos in the absence of
chromosomal testing should lead to implantation and pregnancy failures in IVF patients of
advanced reproductive age or may compromise the pregnancy outcome by leading to
spontaneous abortions.
PGD it is still a highly sophisticated procedure involving oocyte and/or embryo biopsy, which
may have detrimental effect on embryo development if not performed to rigorous standards. It
may be considered the legal responsibility of fertility specialists to provide information on the
availability of PGD to women of advanced reproductive age and those with poor prognosis so
that they have the opportunity to improve their chances to become pregnant and avoid
pregnancies destined to be lost due to aneuploidy.
Welfare of the child
The goal of ART is to allow an infertile couple to have a normal and healthy child. The birth of
such a child, however, exceeds its parents’ interests from the point of view of both the child and
the society. For ART, the concept of welfare of the child is essential, as ART has causally
contributed to the child’s birth, and the doctors are considered responsible in case the child is
born with a congenital defect.
The welfare of the child has at least two components: a physical one and a psychosocial one. The
former is more closely related to ART, since it includes potential complications of ART as well
as the risk of transmission of viral or genetic diseases. Although the psychosocial component is
more difficult to grasp, the identification of the child in the family or a group of peers is known
to have an essential impact on the development and integrity of the child’s personality.
Posthumous ART
Available cryopreservation has enabled women to achieve pregnancy after the biological
parent’s death. Nevertheless, posthumous assistive technologies (PAR) may provoke numerous
dilemmas concerning the informed consent of the deceased and the process of decision making
in those asking for treatment. Therefore, some centers have produced informed-consent forms
that enable the use of gametes and embryos after the other partner’s death.
Designer babies
Designer babies are babies whose genetic makeup has been intentionally modified or enhanced
through genetic engineering techniques. It is used to prevent genetic diseases, enhance the
desirable traits, Savior siblings, enhanced mental abilities, personalized medicine, the ability to
select physical traits, and potentially increasing life expectancy and improve overall human
health and well-being. The ideas of designer baby that intentionally alter the genetic make-up of
human being to select some desired trait raise several ethical concerns. These include the
following.
1. Consent and Autonomy: genetic modification would made on the child going to born
who cannot give consent on his/her genetic makeup and it becomes a decision made on
behalf of someone else. This challenges the principle of autonomy, as the child may be
subjected to genetic alterations they never consented to and may not agree with in the
future.
2. Commodification of Children: The creation of saviour siblings may be seen as treating
children as commodities or objects to fulfill the needs of others. Commodification opens
the door to potential exploitation of vulnerable populations. It raises concerns about the
instrumentalization of children, reducing them to means rather than recognizing their
inherent value and rights.
3. Unintended Consequences: even though genetic modification intended to enhance some
traits it may end up in unforeseen impact on the individual or future generation. This raise
questions about the ethical responsibility of altering the genetic makeup of individuals
without fully comprehending the potential risks and ramifications.
4. Stigmatization and Discrimination: The idea of designer babies raises serious ethical
issues related to discrimination and stigmatization. People who naturally exhibit
particular features may become stigmatized if those traits are viewed as undesirable or if
they are preferred over others. By dividing people between those who have undergone
genetic modification and those who have not, this could increase negative biases and
prejudices in society. Discrimination of this kind might harm people's self-esteem, mental
health, and social connections, eventually reducing the values of inclusion and equality
5. Medicalization of reproduction: Instead of procreation being a natural and intimate act,
it could be transformed into a clinical procedure aimed at manufacturing customized
individuals. This shift brings forth ethical questions about the commodification of human
life as well as the potential devaluation of natural reproductive processes and the intimate
relationships involved.
Social implication of designer baby
Designer babies, the concept of genetically modifying embryos to enhance desired traits,
pose significant social implications. The ability to select specific traits like intelligence,
physical appearance, or athletic ability could result in a society divided between those who
can afford such enhancements and those who cannot, deepening socioeconomic disparities. It
 may lead to a shift in societal norms, where certain traits become the standard, potentially
undermining the appreciation for natural variation and diminishing the concept of human
uniqueness. It also results in social inequality. The availability and affordability of these
genetic technologies could create disparities between those who can afford such interventions
and those who cannot. This may result in a two-tiered society divided along genetic lines,
where access to enhancement technologies becomes a privilege reserved for the wealthy. It
also causes reinforcement of stereotypes. If parents can selectively choose specific traits for
their children, it raises concerns that they may prioritize certain traits based on societal
stereotypes or prejudices.
Impact on Personal Identity and Self-Esteem: Designer babies could potentially affect a
person's sense of self and identity. If individuals are genetically engineered to possess certain
traits, it may raise questions about the authenticity of their achievements and abilities. It
could also lead to social stigmatization and feelings of inadequacy for those who are not
genetically modified.
Impact on diversity: Designer babies have the potential to impact genetic diversity within
the human population. Altering the genetic makeup of humans through selective breeding or
genetic modification could have unforeseen consequences for the human gene pool. It might
disrupt natural evolutionary processes, potentially reducing genetic diversity and making the
population more vulnerable to certain diseases or environmental changes(4) .
ART practice- religious view
Religious perspectives significantly influence reproductive health, particularly in areas like
procreation, abortion, and infertility therapy, reflecting the integral role of religion in many
cultures. Different religions approach bioethical issues with varying degrees of authority and
diversity of opinion, affecting public policy and individual decisions.
The Jewish law
The view of Judaism on ARTs varies with its different movements.
Orthodox Judaism: Orthodox Judaism who strictly adheres to Jewish traditional law and ethics
accept ARTs in on the context of husband donation (AIH). The use of semen from husband is
acceptable with the existence of certain qualification. There must have been a reasonable period
of waiting since marriage (2, 5, or 10 years or until medical proof of the absolute necessity for
artificial insemination by husband, or AIH), and, according to many authorities, the insemination
may not be performed during the wife’s period of ritual impurity. It is allowed by most rabbis to
obtain sperm from the husband both for analysis and for insemination, but a difference of
opinion exists as to the method to be used in its procurement. Masturbation should be avoided if
at all possible, and coitus interruptus or use of a condom seems to be preferred methods.
Reform Judaism: At early stage the Reform Judaism leadership agreed that all efforts should be
made to help infertile couples and approved of artificial insemination by husband (AIH). Later
The leaders allow artificial insemination by donor (AID) considering that it did not involve any
question of adultery. Reform thought identifies the semen and ovum donors as the legal parents
of the child. They also views that embryos below 40 days old were not in any way people and
could be used for experimentation, so there should be no problem with disposing of implanted
zygotes in IVF and the use of therapeutic cloning.
Conservative Judaism: in 1978 the committee of Conservative Judaism opposed artificial
insemination by donor. Later they in more recent years, most Conservative leaders have come to
accept the legitimacy of AID with the consent of the husband as a final alternative when nothing
else has helped. Finally, with similar reservations, in 1985, the committee approved the practice
of surrogate motherhood.
Christian Denominations
Roman Catholic Church
The Catholic dogma contains three leading principles related to the status of the family, the
child, and reproduction. The first principle commands the protection of the human being from
the moment of its conception, and thus, most assisted reproductive technologies (ARTs) are
forbidden. The second principle is related to the duty of procreation: A child is the fruit of
marriage, premarital sex is not allowed, and the Church condemns having a child outside the
institution of marriage. The newborn has to embody the love between a husband and his wife and
is considered the symbol of their eternal union. A third principle, related to integrity and dignity
norms, must be taken into consideration when it comes to ethics in assisted reproduction. The
catholic church have clear position against ART since Pope Pius XII defined artificial
fecundation as immoral and illegal because it affects human lives by separating procreation and
sexual normal function. But the Church permits assisted insemination when it aids the conjugal
act without replacing it. Techniques like gamete intrafallopian transfer (GIFT) are morally
acceptable as they assist natural conception.
Anglican Church
The Anglican Church allows assisted reproductive techniques, IVF, and ET and permits doctors
to use sperm obtained after masturbation; however, it forbids gametes donation. The church,
which believes moral status can be given only to an individual with a well-established
personality, does not offer it to the embryo. There are different views related to gamete donation.
Some argues that genetic origins of a child are fundamentally important and others argue that
what is more important is a loved child in a stable relationship. There is an argument that AID
involves third party into the intimacy of procreation and family life even though it do not
constitute adultery and infidelity and this threaten marriage.

Protestant Church
There are different approaches to assisted reproductive technology among different protestant
church. Moderate and liberal Protestant denominations tend to affirm the right of individuals to
discern for themselves how to make use of reproductive technologies. Conservative
Protestantism positions on reproductive matters tend to include an active opposition to abortion,
but assisted reproduction has not been much considered in formal church statements. In general,
they “tend to approve of methods intended to correct physical problems that cause couples to be
infertile, but they disapprove of methods that would violate the sanctity of the marriage bond by
using donated sperm and eggs, as well as any method that would tamper with or discard a
fertilized embryo.

Eastern Orthodox Church

The Eastern Orthodox Church’s stand on assisted reproductive practice is not as strict as the
Roman Catholic Church’s, allowing the medical or surgical treatment of infertility, but it is
against IVF and other ARTs, surrogate motherhood, donor sperm insemination. The Russian
Orthodox Church has condemned the practice of IVF methods viewing that “an embryo is a
future human being and not just an accumulation of cells or a part of a mother’s body,” and it
“defends the dignity of human life from the moment of its conception until the natural demise of
a human.” The Coptic Church accepts IVF only under the circumstances where the oocyte and
sperm are taken from the husband and wife and fertilization occurred in vitro, with no doubt
about gamete mixing. ET must be performed on the mother who is the source of the oocytes.
Surrogacy is an option when the sperm and oocyte are obtained from the married couple when
the wife has lost or does not have the ability to carry a pregnancy.

Hinduism
Hindu believer belief in reincarnation that soul is eternal and it passes from one living things to
other living things. Some Hindu traditions place the beginning of personhood between three and
five months of gestation, while a few believe that the soul’s rebirth can occur as late as the
seventh month. Their reproduction emphasis is on having male offspring. In Indian society, men
need children to have heirs and to prove their masculinity. There is a huge stigma attached to
being infertile in Indian society, especially for the woman. ARTs are acceptable in Hinduism
because there is no single authority to accept or reject it on behalf of the faith. The most
important condition is that the egg and sperm are from a legally married couple. In practice,
artificial inseminations of donor and oocyte and embryo donation are performed with an
anonymous donor. It is preferable that the sperm donor be a close relative of the husband.

Buddhism
Marriage within Buddhism does not have the high priority that it has in monotheistic religions.
Any technology that is used to achieve conception is morally acceptable, and treatment can be
given to unmarried as well as to married women. Buddhism allow gamete donation, but it should
be used as little as possible because the parents in general may feel difficulties in taking care of a
child who does not have their own genes. There is also a danger that donation of sperm or an
oocyte from a third party would involve commercialization and cause social problems, and
donation of gametes could lead to eugenics.

Islamic Laws
A central feature of Muslim identity and family structure is authenticity of lineage. In Islam,
treatment of infertility in married couples is encouraged, as it involves procreation and
preservation of humankind. The social status of Muslim women and their dignity and self-esteem
are closely related to their procreation potential, both for the family and for society as a whole.
Treatment of infertility, including ART when indicated, is encouraged to preserve the lineage in
otherwise incurable infertility. An ART guideline followed by Sunni Islam allow assisted
reproduction within the validity of marriage contract with no mixing of genes, but if the
 marriage contract has come to an end because of divorce or death of the husband, ART cannot be
performed on the female partner, even when using sperm cells from former husband. However,
the Shia guidelines, allowed a third-party gamete donation. It allows egg donation, sperm
donation, embryo donation, and surrogacy (5).
Ethical concerns of Assisted Reproductive Technology (ART)
I. from the perspective of moral status of the embryo
Englehardt, an American philosopher and bioethicist take a firm line on forbidding all third-party
reproductive technology except an artificial reproductive technology would be Permitted for
donor insemination by husband (DIH) and in this case the couple should ‘seek spiritual guidance
so that their struggle to have a child does not distract from their pursuit of the Kingdom of God,
does not cause them great spiritual harm.’ It is argued that because the foetus is a living being
with a rational human nature, we must conclude that a spiritual soul is created within the embryo
when each human being begins. Based on this argument, Samuel B Casey has opposed ART by
describing it as the destruction of so-called spare embryos, created for the in vitro fertilization
(IVF) process, in the following way: the ‘remaining ‘‘potential infants’’ – in a chilling reminder
of another Holocaust involving persons considered by their Nazi executioners to be ‘‘sub-
human’’ – were thawed out, destroyed with saline solution, and incinerated with other biological
waste.’ Maura Ryan, from the Roman Catholic tradition rejects third party forms of assisted
reproduction on the ground that ‘we are adopting forms of symbolic understandings of
reproduction that undermine our personal and social capacities to appreciate and embody these
core reproductive and marital values.’
In opposite to the above argument, there is another argument that fetus moral status evolves with
development of the fetus and allows for Assisted Reproductive Technology (ART). Tooley
argues that a fertilized avoum do not granted equal moral status as a person because the isolated
fertilized ovum is unable to actualize itself without environmental support for warmth and
nutrients(6).
2. Reproductive liberty and parental responsibilities.
Reproductive liberty involves the freedom from and the freedom to. Abortion and contraception
is about the freedom from: freedom from an unwanted pregnancy, freedom from the life-altering
responsibilities of raising a child. ART is about freedom to; which is freedom to be a parent, to
have and raise a child. When in vitro fertilization (IVF) was first introduced, it was seen as an
aid for couples who could not conceive a child through normal sexual intercourse.
There was disagreement between opponents and proponents of being parenthood through ARTs
on the what were seen as potential misuses of the new reproductive options, over erosions in
long-held social understandings and practices these new alternatives might cause and over the
creation, use and destruction of embryos. Reproductive liberty allows people to have or not to
have a child, but the welfare of the child to be created need to be also considered. In ARTs
people can create a child of any kind or a child with specific traits like intelligence, beauty, and
the like. This can raises questions about whether such practices respect the future child's
autonomy and well-being.
Again ART put moral obligations to not-yet-born children on people other than those directly
involved in the child’s procreation. For example a chemical industry that secretly release
chemical that damage growing embryo or affects gametogenesis in which the sperm pass through
this process can create viable embryo with some abnormality will be morally responsible for the
abnormality happened to the child. When we consider the ethics of ARTs we should employ a
robust standard, focused on our moral obligations to the not-yet-born children whose very
existence is the point of pursuing ARTs in the first place. Using such a standard would mean that
the welfare of the created children deserves full consideration, not merely the preferences of the
adults participating in that child’s creation. One of this considerations is that children created
through the ART should not treated as commodities or as product. This is because purchasing
reproductive services is not like purchasing a new car or a relaxing massage. The point of ARTs
is not to acquire or consume something, but to create a child with whom we hope to have a life-
long relationship.
Social implication of ARTs
Artificial Reproductive Technology reinforces social norms in several ways. If we consider the
impact of various approaches to assisted human reproduction on women and children, we need to
be concerned about the ways in which increased effort to ensure the birth of children with a
genetic connection to their social parents reinforces social norms about the importance of
biological reproduction in every woman’s life. This highlights the idea that a woman’s value is
tied to her ability to give birth to biologically related children. This makes women to repetitively
seek medical assistance to have a child. A study conducted in India to assess the ethical issues of
ARTs identified that women seek repetitive medical assistance to get pregnant because of social
pressure to have child despite they experience repetitive failure (7).
Feminists also question the implication of ART on women in which women undergo a painful
and risky procedure to produce genetically related child. Again they also raise question that ART
priorise an expensive procedure of producing child, while other children have un mate basic
need and in the problem of poverty (6). As argued by Chadwick, Medical professional views
reproduction as matter of injecting a sperm into an egg, ignoring the implication that
reproduction has a social dimension.
In assisted Reproductive Technology (ART) especially using donor egg or sperm, fertilization
can occur in the laboratory and can be transferred to a woman’s womb. The question is raised:
Who is the biological mother? The woman who bears the child or the woman from whom the
egg has come (8)?
Commercialization and exploitation
While assisted reproductive technology initially developed to assist infertile couples to have their
own biological children, its usage has been expanded for profit-making purposes over time.
This is seen through the transactions of reproductive body parts and the opportunity to choose
characteristics of the children based on the quality of the donated eggs and sperm. Therefore,
sperms and eggs have become potential commodities for the infertility business. If the woman is
aged and the man has a low sperm count they are advised to use donated sperms or eggs. (9)
But, Children are differ from mere objects. We describe our child quite differently from our
objects. We may describe as, “The child who lives with me, whom I love, for whom I have made
uncountable sacrifices, whose smile unfailingly cheers me, whose sadness penetrates my heart;
whose happiness and flourishing are central to my own life.” Related to exploitation, poor
women were vulnerable for exploitation. It is argued that trade in any kind of human tissue is
inherently undignified. But there are concerns, as there are in all kinds of trade in human tissue,
that the poor will be prime targets and that the relationship with the person paying for the eggs
will be an exploitative one (6). Currently, market for sperm and egg is flourishing, and this
remains a largely unregulated business. As stated by Debora Spar there were more than 100
sperm banks in the US in 1999. She identified that California’s Cryobank provides a lot of
information about the sperm donor; which includes age, height, weight, family background,
religion, education, hair/eye color, and employment details. If this was not enough, the clients
also send pictures of the person they would like their child to resemble. She also identified that
most of the sperm donor for California cryobank were students and they donate thrice a week for
several year to get cash for their education fee (10). In India students paid $50 per sperm
donation and it involves ethical issues for unlike donation of many other body parts, donated
sperm can create the irreplaceable, a child (11). Cryos International Sperm Bank in Denmark is
a leader in the sperm cell market and it exports sperm to more than 50 counties (10). The fertility
clinic in India not only sell biological materials and reproductive technology, but also include the
characteristics of the child such as beauty, intelligence, athletic ability, and economic success are
genetic in origin. Thus, sperm and egg banks are influenced by these characteristics (12). In
fertility business, eggs became potential commodities.
In United States several fertility clinic provide lists of healthy young women who would provide
eggs for about $2,000 per removal. With the aid of these new genetic diagnostic tools perhaps
“defective” embryos can be identified and destroyed and desirable ones can be implanted (13).
Access and Equity
Currently, ART services are heavily privatized and are limited in access due to their high cost. A
wide variety of people, including heterosexual couples, same-sex partners, older persons,
individuals who are not in sexual relationships and those with certain medical conditions, such as
some HIV sero-discordant couples and cancer survivors, may require infertility management and
fertility care services. Inequities and disparities in access to fertility care services adversely affect
the poor, unmarried, uneducated, unemployed and other marginalized populations.
Assisted reproductive technology In Ethiopia
On Thursday, September 30, 2017 EC, a bill was introduced to the House of People's
Representatives with a provision allowing sperm donation in Ethiopia to treat infertility. The bill
presented to HPR highlights that the previous decree related to artificial reproductive technology
does not explicitly mention that it is legally permissible. The bill submitted to the House, on the
other hand, outlined the possibility of sperm donation and what the process should be.
According to the draft, semen can only be harvested by a separate institution of the Ministry of
Health for this purpose. It is settled on the draft that anyone can donate their semen to an
institution identified by the ministry. Despite this provision of the decree, the draft stipulates that
sperm should be taken from donors "only when it is medically proven that they do not cause
significant harm." It is forbidden to "donate, collect or sell semen" other than the provisions of
the draft decree. The bill states that semen can be used to collect sperm from an authorized
facility to provide technology-assisted reproductive services to beneficiaries. The draft adds that
through this medical service, "spouses who have acquired a child will be the legal parents of the
child to be born."
According to the draft decree, the beneficiaries of the service are legally married and must
provide proof from the relevant authorities for this.
The other requirement is that "it is proven by an expert in the field that they cannot have children
in a natural way." It should be confirmed by a medical professional that the treatment given can
have a positive effect and does not cause harm to the consumer's health (14).
However after weeks of debate, Ethiopia's parliament rejected gamete donation for married
couples, highlighting the cultural, religious, and ethical challenges the faces in addressing
infertility. The HPR approved that couple in valid marriage can get assisted reproductive
technology service by using their own gamete (15).
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