Fertility symbols

The UK’s National Institute for Clinical Excellence (NICE) has recommended that infertile couples should receive three ‘attempts’ of IVF treatment free on the national health service (NHS) (1).

Some have welcomed this move as an end to the unfairness of the current ‘postcode lottery’ for fertility treatment in England and Wales, which means that only some couples receive some attempts at IVF on the NHS, and others have to pay large sums of money to have the treatment privately. Others have raised concerns about the misuse of scant NHS resources, about whether this will subsidise couples having children ‘on demand’, and about whether the wrong kind of people will be encouraged to use IVF for the wrong reasons.

What’s the story here? In what seems like a peculiarly specific discussion about exactly what form of fertility treatment the NHS should provide to whom, two more general issues are being raised. One is the ongoing question about rationing on the NHS: how the health service prioritises its resources, at a time when it is presumed to lack the money and other resources to treat everybody for everything.

It says something about our anti-political times that this issue tends to emerge around specific, controversial and apparently arbitrary issues, such as IVF, or treatment for smokers and obese people, rather than being dealt with head-on as a political question. It is also telling that such decisions tend to be made by committees such as NICE, rather than by a government apparently committed to staking its future on the health service.

The other issue at stake in the IVF-on-the-NHS discussion has very little to do with health and services, and is more about morality. Twenty-five years on from the birth of the world’s first test-tube baby, Louise Brown, fertility treatment has become increasingly effective and taken up by couples. But the techniques remain controversial: not so much because of what they are, but because of why people are seen to use them.

NICE’s recommendation is that women over 23 and under 40 should be entitled to three free attempts at IVF. The aim, clearly, is to provide treatment for couples who are infertile because of biological reasons or previous medical treatment. They are old enough to have tried getting pregnant ‘on their own’, and young enough for IVF to have a reasonable chance of success. There are few real objections raised against young(ish) couples prevented by nature or tragedy from having children: most people are sympathetic to them, and therefore sympathetic to their treatment.

A more widely voiced concern today is the relationship between IVF treatment and social factors: specifically, the trend towards delayed childbirth, and the reasons behind this. As the average age of first motherhood creeps up towards 30, the abortion rate continues to rise among women in their twenties, and as people ‘settle down’ later to family life or start second families with new partners, those opposed to the widespread use of IVF raise worries that fertility treatment is increasingly used for ‘frivolous’ reasons. Or, to put it another way, that people are somehow choosing infertility, by leaving childbearing too late, and using IVF as a way of over-planning pregnancies that really should happen naturally.

As it goes, there is something worrying about society’s attitude towards sex, pregnancy and parenthood today, which is reflected in the discussion about IVF and delayed childbearing. But this has little to do with the science of IVF, the morals of embryo freezing, or the actual reasons why people opt for fertility treatment. It is a discussion about how we view ourselves, and our relationships with each other.

For anybody committed to the advantages of family planning, it is difficult to have sympathy with the argument that IVF is a problem because it leads to babies on demand. Yes, women are having children later; yes, this reduces their fertility and almost certainly makes it more difficult for them to become pregnant naturally. But many of the reasons behind this trend are positive. Women’s ability to be able to avoid unwanted pregnancy, through access to effective contraception and abortion, has contributed greatly to their ability since the 1970s to play an equal role in society to men.

The move away from motherhood being viewed as something natural, inevitable and something that happened in somebody’s mid-twenties has allowed women to make choices about their careers, relationships and families that never existed before. If family planning now means not just that women can plan to avoid pregnancy, but that they can plan to have a pregnancy, this surely represents one more positive step forward.

But. While some women undoubtedly do have very positive reasons for waiting until they have children, the trend towards delayed childbirth is more ambivalent and complicated than that. And while the effectiveness of IVF has improved enormously, it does not amount to a guaranteed, planned pregnancy. It remains a fairly unpleasant procedure that might not work, raising and dashing hopes for the couples concerned. The notion that pregnancy can be delayed because, in the final analysis, there is always IVF, is nothing like so straightforward in practise.

As I have argued previously, while the reasons underlying delayed childbirth are many and varied, one powerful motivator in today’s society is fear (see Scared of being mother). When it comes to the question of whether and when to have children, society’s general fear of commitment, change and responsibility are played out at the most personal level. We have come a long way from the days when people were expected to marry, have children, and simply cope with the consequences. Today, far from being seen as the natural course of things, pregnancy is pathologised and parenthood is professionalised.

Women approaching pregnancy are counselled to think very carefully about whether they are ready to make such a big step, and counselled through what to eat, how to behave, and how to think about their unborn child. After the birth, they are presumed to be vulnerable to post-natal depression, rows with their partner, and general feelings of stress and trauma.

Parents are bombarded with advice about every aspect of their behaviour and the impact this might have on their children, while everything from the school they choose to the words they use around the home is presumed to have a major, life-altering impact upon their precious offspring. In this context, no wonder couples appear to approach parenthood with a certain trepidation, and delay their decision to take the plunge.

And no wonder some of them panic if, having made the decision to get pregnant, it doesn’t happen quite so easily as they thought. In a climate when personal decisions are supposed to be rigorously planned for, and when the decision not to get pregnant can be rigorously planned for, it is hardly surprising if IVF becomes a point of call for couples who, really, might do better relaxing a bit and having more sex.

So what? you might ask. Contraception means that sex does not lead naturally to pregnancy, and that’s a good thing. By a similar token, there is nothing inherently better about having wanted children through intercourse than via a test-tube. Anything that gives women the option of more control over their fertility is a good thing. The problem, however, is that the uptight character of current discussions about late motherhood and IVF take-up do not indicate greater control over fertility so much as a heightened sense of insecurity about procreation, parenthood and even about sex.

Two recent studies reported in the British Medical Journal suggested that one in three men, and half of all women, have some kind of sexual problem (2). These problems included a lack of interest in sex and anxiety about their performance in the bedroom (men) and a loss of sexual desire and an inability to reach orgasm (women). One study, of patients attending GP clinics in London, found that one in three had talked to their doctor about the problem; the other, a nationwide survey of sexual attitudes and lifestyles, found that one in 10 men and one in five women sought help.

Denise Knowles, a sex therapist and member of the relationships charity Relate, told the BBC that the rise in sex problems is a consequence of the stresses and strains of modern life: long working hours, job insecurity, which leads to exhaustion. She encouraged people to seek help because ‘a loving sexual relationship has real benefits, physiologically and psychologically’.

It is intriguing that, at a time when people apparently have more choices about their lives, partners and sexual behaviour than ever before, they are encouraged to seek out more and more problems and demand more medical advice and intervention. Is loss of interest in sex, or inability to reach orgasm, really a medical problem requiring a chat from the doctor?

If sex itself is presumed to be so problematic, the pressures surrounding sex that could result in the birth of a child – Are we ready yet? Is this the right time? What if it doesn’t happen now? Have we left it too late? – is presumably the source of such anxiety that you almost wonder why people don’t abandon each other entirely, and head straight for the clinic. At least that cool, clinical environment appears to provide some certainties, and some clear answers.

The trouble is, it doesn’t. For couples that are infertile, IVF is a wonderful thing. For couples that are not, IVF at best is as hit-and-miss as intercourse. Most people know this, which is why couples’ decisions to use IVF are anything but frivolous. IVF has become accepted as just another fraught decision in the already fraught process of deciding whether and when to have children, and how best to take that leap. Now we have the ability to plan these things better than ever before, one sometimes wonders if we might be better off planning them rather less.

Read on:

spiked-issue: Love and sex

(1) NHS ‘should offer free IVF’, BBC News, 26 August 2003

(2) Britons have problems with sex, BBC News, 21 August 2003