Reconfiguring Reproduction: Feminist Health Perspectives on Assisted Reproductive Technologies

Acknowledgements

Preface

THIS ANTHOLOGY WAS conceptualised after an International Consultation on Commercial, Economic and Ethical aspects of Assisted Reproductive Technologies, organised by Sama Resource Group for Women and Health. It contains papers presented at the Consultation and those by Sama that explore the issues and contexts in which assisted reproductive technologies are embedded.

Sama has been active in the campaigns against coercive population control measures and technologies that target women’s bodies, whether to control birth or facilitate investigation into the sex of the foetus. While working on these issues, we came across another set of technologies, called assisted reproductive technologies (ARTs), that assist in conception—and that were gaining ground day by day.

In searching for material and analyses to build our own perspective, we found that the issue had not been adequately addressed, especially in the Indian context. A research project was undertaken to understand the social realities and family dynamics through which women experience control over their fertility in varied ways, and to put together a picture of the ART industry in India. In June 2006, Sama held a Consultation on these new reproductive technologies to discuss the spectrum of issues raised— the public health context and social impact of infertility; the growth of the ART industry; the use and misuse of technology; the quality of regulation; the concerns of feminists, disability rights activists, and the sexual rights movement; emerging genetic technologies; and new eugenics.

With the understanding that conceptive and contraceptive technologies lie on the same continuum, and looking at the rise in unregulated and unethical practices in the field of ARTs and surrogacy, it was felt that these issues needed to be debated on a wider and larger platform to incorporate different perspectives. The subsequent Consultation, held in 2008, highlighted the need to promote greater public discussion on the social and ethical implications of ARTs and to influence the development of regulation and monitoring in this field. The ART Regulation Bill & Rules 2008 was made public by the Indian Council of Medical Research (ICMR) and the Ministry of Health and Family Welfare (MoHFW) at this Consultation, following which, critiques of the Bill were formulated by Sama and other participants independently and conveyed to ICMR and the Ministry.

Drawing linkages with the concerns with this Draft of 2008, Sama also developed a critique of The Draft Assisted Reproductive Technology Bill and Rules 2010. The Draft Bill still falls short of addressing many concerns vis-à-vis women’s health and rights, especially in the context of what has turned into a complex global phenomenon, yielding many complexities in the operationalisation of these technologies.

Attempting to keep pace with the growth of the industry as it was crossing regional and international boundaries, an effort was made to understand the global discourse on ARTs and cull out strategies towards building a movement around new reproductive and genetic technologies. Although the advancement of these technologies and the related discourses are at different stages in different countries, we felt it was important to compare and learn from each other’s experiences. The International Consultation on Commercial, Economic and Ethical aspects of Assisted Reproductive Technologies, 2010 brought together activists, scholars, and researchers from different movements, networks, and organisations across the world working on similar concerns. At the Consultation, several issues and differences emerged on technologies, the quantum of choice, and on rights.

This volume is a step towards continuing these debates and discussions. Given the proliferation of these technologies and the current political economy, there is a need for continued alertness, preparedness, information sharing, and strategising. We hope that the issues highlighted and questions raised here will enable a better understanding of this phenomenon, and help all concerned to move towards drawing linkages with different movements and networks working on issues of public health, women’s rights, sexual rights, disability rights, child rights, law, and bioethics, among others.

Sarojini N

Vrinda Marwah

Introduction

TECHNOLOGICALLY ASSISTED REPRODUCTION is not a new phenomenon. Yet, the development and consolidation of Assisted Reproductive Technologies (ARTs) as a distinct group of procedures designed to circumvent infertility by assisting in conception, or the carrying of a pregnancy to term, is relatively recent.¹ Along with assisting reproduction, these technologies are also redefining how babies, parents, and family and kinship ties are made. The basic steps of intrauterine insemination (IUI) and in vitro fertilization (IVF) have led to many variations through their use with other evolving techniques and procedures. For instance, sperm can be extracted directly from the testes if sperm ducts are blocked, and individual sperm can be injected into ova in the lab, a procedure known as intra-cytoplasmic sperm injection (ICSI).

With sperm and ova donation and surrogacy, ARTs can involve commerce in body parts and bodily processes. Like other technologies used for the management of labour, contraception, abortion, and prenatal and genetic diagnosis, ARTs can be situated within the larger umbrella of ‘new’ reproductive and medical technologies.

The use of these technologies is not unmediated by social axes of power, such as class, race, religion, sexuality, caste, gender, and so on. As such, these technologies are easily harnessed to the service of institutions like patriarchy, the medical market, an overarching (and neo-Malthusian) state etc. These technologies overwhelmingly target women’s bodies, which have historically been sites over which others, rather than women themselves, exert control— this is true of women’s labour, sexuality, reproduction, etc. Today, ARTs are marketed by providers as pro-women; as meeting the need and desire of ‘desperate’ women to be mothers and therefore, to be ‘complete’ women. While the right to have a biologically related child may be seen as a reproductive right, socially the value accorded to biological parenthood within heterosexual marriage is far superior to the value accorded to voluntary childlessness, adoption, or alternative family structures. It is for this reason that ARTs have been criticised for being patriarchal and capitalist, and for accommodating rather than questioning power relations that equate motherhood with womanhood.

Further, a pathologisation of infertility has legitimised the proliferation of ARTs as standard procedure, when ARTs are in fact closer to a ‘hit and trial’ technology, given their low success rate of roughly 25 per cent globally. The World Health Organization (WHO) defines infertility as ‘the failure to conceive after at least one year of unprotected coitus’. This definition is a revised version of what existed earlier— till 1975, up to five years of unprotected sex without conception were grounds for infertility. WHO brought this figure down to two years in 1975, and in 2005, down further to one year (Sama 2006: 10). As the number of years decreases, the number of people incorporated into the definition of infertility increases, thus medicalising their situation of childlessness into a condition in need of treatment.

Yet, ARTs do not ‘treat’ infertility but instead sidestep it. As such, they remain an expensive and experimental technology which is invasive and can carry considerable health risks for women as well as the children born as a result. In fact, not enough is known about the health risks of ARTs, because credible and long-term studies regarding health implications for mother and child, both procedural and drug-related, do not exist. Known risks include ovarian hyper stimulation syndrome (OHSS) and ovarian twisting, ectopic pregnancies, multiple pregnancies, foetal reduction and spontaneous abortion, increased risks of cancer, increased likelihood of c-sections and heightened stress levels. Drugs commonly used in ART procedures such as Pergonal, Lupron, and Clomiphine have their own set of side effects, just as there is a separate set of side effects for children born of ARTs, such as pre-term births and genetic abnormalities.

ARTs have also opened up newer arenas for the play of neo-eugenics. Users may seek surrogates or donor gametes from a particular religious background, just as they may want male or able-bodied embryos to be selected for implantation. As such, newer ethical issues that lie at the intersection of technology and society remain yet to be addressed; for instance, stem cell research may use ‘spare’ IVF embryos. For this, informed consent needs to be obtained in a non-coercive manner from users, just as the question of who has the right to the genetic material which is a by-product of ART procedures needs to be resolved, and malpractices like the over-stimulation of the ovaries to obtain more embryos for research need to be guarded against. With the commercialisation of ARTs, surrogacy has become a significant area of contest and debate. A more comprehensive understanding of the implications of ARTs, including commercial surrogacy, the lives of women, as well as an examination of the social, political and economic influences that surround the development and use of these technologies is required.

THE INDIAN CONTEXT

The history of the development of ARTs in India cannot be studied in isolation, and must be understood as a point on the larger continuum of in/fertility control. It may seem odd that the development and promotion of contraceptive technologies go hand in hand with technologies related to conception; however, in both cases, technology is used to exert control over women’s reproduction, by either preventing them from giving birth, or by meeting the pressure/desire to have a child.

India’s first ‘scientifically documented’ IVF baby was born on 6 August 1986 as a result of a government initiative by the National Institute for Research in Reproduction (NIRR). The NIRR initiative to foster research on ARTs stemmed from its larger concern with population control. This rationale was quite categorically stated in the bulletin of the Indian Council of Medical Research (ICMR):

If a couple is convinced that pregnancy could be achieved with certainty by the IVF-Embryo Transfer technique, in the event of their losing the existing children, they might readily accept tubal sterilization as a method of family planning. Thus, in vitro fertilization could be of great relevance to our national family welfare programme. (ICMR 1984)

Although undertaken in India as a government initiative, the research into and promotion of ARTs soon moved to the private health sector, and has since flourished as a private enterprise. The public sector eventually discontinued the ART programme (although a handful of public hospitals are now re-introducing this), but the ART industry in India has continued to expand steadily. Clinics providing infertility ‘treatment’ and commercial surrogacy have mushroomed all over the country, including in smaller towns. Besides the increasing numbers of Indian couples seeking these procedures, ‘clients’ are coming in from foreign countries as well. The rise of India, in recent years, as an international destination for ARTs and commercial surrogacy brings to the fore new ethical, economic, and political questions regarding reproduction, an arena commonly regarded as personal. In response to these concerns, considered and effective regulation is required. However, the status of regulation in the country at present is far from encouraging. The National Guidelines for Accreditation, Supervision, and Regulation of ART clinics in India were developed in 2005 by ICMR and the National Academy of Medical Sciences (NAMS) India. However, these guidelines are not legally binding. More recently, legislation for the regulation of the ART industry was drafted in 2008, and updated in 2010. While regulation is welcome, the contents of the draft bill 2010 leave much to be desired; additionally, participation from civil society stakeholders such as groups advancing women’s rights, child rights, public health rights, research ethics, and sexual rights has been conspicuous by its absence.

ARTs raise concerns both old and new, particularly from a public health perspective. As Imrana Qadeer points out, infertility is ‘rooted in the social situation that breeds infections, under-nutrition, values that undermine women and inequity of access to services’ (Srinivasan S. 2010).² Since ARTs bypass rather than ‘cure’ infertility, they should not be promoted as the quick technological fix for the problem of infertility, which has a broad spectrum of causes and corresponding solutions. Infertility can be the result of untreated sexually transmitted infections, pelvic infections, tubal factors in females, unsafe abortions and poor maternal health care, malnutrition, anaemia, and other dietary deficiencies, as well as contributing factors like lifestyle, environmental pollution, and occupational hazards. Yet, the state’s response to infertility has been far from holistic. India’s public health system does not offer adequate preventive, curative, and counselling services for infertility. With the move towards liberalisation, privatisation, and globalisation, the priorities of the Indian state have shifted away from strengthening India’s public health system and towards promoting medical tourism. ARTs are the latest addition to a long list of services that India is selling to the world, with the comparative advantage of lower costs, English-speaking staff, advanced medical care and technology, and an unregulated environment, even as the commercialisation of health care in general continues to restrict access to health care for India’s poor.

ABOUT THIS VOLUME

In the three-and-a-half decades since the birth of the world’s first documented test tube baby, Louise Brown, in Lancashire, UK, in 1978, ARTs have made their way into different regions in different ways, raising concerns both similar and dissimilar. Power imbalances have impacted how reproduction is being re/produced, and how technologically assisted reproduction is being generated, executed, and challenged across the world. At a time when gametes, technologies, and even the people who seek these technologies are crossing borders, the issues contained in these technologies have also gone beyond national, even regional, boundaries.

This volume contains papers that emerged from an International Consultation organised by Sama in January 2010, titled Unravelling the Fertility Industry: Challenges and Strategies for Movement Building. The Consultation aimed to discuss the commercial, economic, and ethical aspects of ARTs, and saw participation from eminent activists and scholars from around the world—particularly from regions that are experiencing the implications of these technologies. This volume also has papers drawn from Sama’s primary research Constructing Conceptions: The Mapping of Assisted Reproductive Technologies in India, on ARTs in India, conducted from 2008–2010.³ These will examine themes of gender in infertility and ART use, ART industry, commercial surrogacy, and the re-workings of the family.

In the first essay, Betsy Hartmann addresses the critical question of how to organise a movement around ARTs. Towards this, she schematises into clusters the issues that must be confronted, and reminds us that the speed with which technologies and markets are proliferating today poses a political challenge. She begins with geneticisation, within which ARTs may be considered one dimension. In observing what geneticisation excludes, rather than includes, Hartmann reveals its double-edged nature— biological determinism and the disaggregation of the human body, particularly the female body, into genetic capital. It follows that to understand and respond to how geneticisation operates, we must locate it within larger processes and networks. Hartmann asserts that there is an urgent need for feminist politics to engage with markets, particularly with the issue of what kind of regulation is acceptable. Regulation has traditionally been a difficult issue to resolve, and to know whether and what kind of regulation we want, we need to learn from the experiences of different countries. Equally necessary is an assessment of science and the role of research within a progressive, feminist health politics. For instance, to be politically effective, feminist health activists need to know about the connection between the fertility industry and scientific research; how spare human gametes and tissues are travelling, as well as the creation, operation, and transition of markets like medical tourism. With the corporatisation of research, the boundaries between public finance and private gain are becoming more and more blurred. As such, this is the time to be ‘bold and scientifically literate’. Lastly, Hartmann draws our attention to the many interactions between ARTs and gender, sexuality, race, class, disability, and nationality, of which some are obvious, and others less so. She illustrates this with debates that have been contentious—the problematic choice to abort a disabled foetus, the exploitation and the opportunity that appear together in surrogacy in India, the right of lesbian and gay couples to have biological families modelled on the middle class nuclear family, etc. Hartmann concludes with some political dilemmas around alliance-building and position-taking that require collective reflection.

Sarah Sexton’s essay examines the market behind reprogenetics, and in doing so turns the common refrain ‘there is no alternative’ (to neoliberalisation) on its head, to say instead that ‘there is no alternative but to pursue alternative paths’. Sexton begins with an overview of the ‘futures’ or ‘derivatives’ market, which allows profits to be made from speculation (repackaged as ‘securitisation’) and makes risk more contagious. This is comparable to ARTs and biogenetics, where the hoped-for future is a take-home baby, or where the human embryonic stem cell is defined speculatively in terms of what it might do. However, the coming together of biology and capital has proved more problematic than expected. Sexton examines the contexts and processes that resulted in the global financial crisis of 2009 in particular, and that lead to indebtedness in general. She compares the push to households to take loans even beyond their means, to the push to opt for ARTs without considering their implications or effectiveness, and makes the point that speculative capital gambles with human desires, even if it not only leaves them unfulfilled, but also actually the worse off for it. Sexton asserts that the financial crisis happened not because there was no regulation but because of selective deregulation, lobbied for by the banks. In fact, both deregulation and reregulation are hallmarks of neoliberalism, and are designed to benefit corporate interests. Sexton points out that no regulations existed when ARTs were introduced, and different countries debate and oversee ARTs in very different ways. Conflict of interest is deeply entrenched in the highest offices of government today, with banks gaining influence within bodies that are supposed to regulate them. In embryonic stem cell research, the rules of the game are in the process of being set, and advice is being sought from the very people being regulated. Like financiers who evade regulations that are inconvenient for them, ART providers avoid domestic restrictions by encouraging ‘reproductive tourism’ or ‘cross-border reproductive care’. Sexton is critical of these terms—they mask structural inequities and conjure up romantic images—just as she is critical of the General Agreement on Trade in Services (GATS), which was pushed for by financial service companies and has provisions that facilitate the movement of capital while disallowing government regulation. She cites the protection of patents and other forms of intellectual property as an example of regulation that has benefited both finance and biotech, by altering the notion of property itself. Irrespective of whether the cell line will produce any therapeutic value, or who owns it, collecting patents on the speculative value of cell lines attracts investors to corporate research. Thus, not only is commodification of biological life effected, but also its ‘transmutation into speculative surplus value’. Sexton draws attention to the rising public opposition to gene patents in recent years, including legal challenges and the belief of many scientific researchers themselves that patents are stifling rather than stimulating innovation. She reminds us that to reclaim finance, fertility, and regulation is to reclaim ‘the public’ and ‘public good’ through grassroots mobilisation for change.

Renate Klein begins with tracking Australia’s early successes in IVF, as well as the feminist resistance that followed closely on its heels. She finds that questions from twenty years ago are being asked again today—be it ICSI then, or SCNT now, eggs for embryo research are extracted from women’s bodies at considerable risk to their health. Klein points out that while international feminist resistance, from the likes of FINRRAGE for example, was able to at least slow down the spread of these technologies in the 1980s and early 1990s, little such effort is alive in Australia today. Instead, IVF has become accepted medical practice, despite occasional reports of side effects for women and children. Klein concludes, ‘IVF technology in Australia has departed from the newspaper headlines and gone mainstream’. Despite high costs, low success rates, and inadequate research into drugs, using ARTs is presented as a matter of choice. Klein terms this the ‘choice trap’. In discussing surrogacy, she highlights that public opinion regarding surrogacy appears to have significantly shifted. In the 1980s, surrogacy was widely regarded as controversial and several laws restricting the practice were passed. In recent years, surrogate mothers have referred to themselves as ‘just an oven’ or ‘just a suitcase’, language that was historically condemned by feminists. Australia’s ART Bill, enacted in 2010, renders invisible the birth mother by allowing the transfer of legal parentage to commissioning parents, including putting their names on the new birth certificate. Klein comes down strongly on this so-called ‘child-centered approach’, calling it reproductive slavery in which women are reduced to wombs, while also being denied the ‘produce’ of their wombs. Here she also brings in the field of stem cell research; although Australia is not the ‘world leader’ it would have liked to be in stem cell research, the use of both leftover IVF embryos as well as SCNT embryos is currently permitted. Klein tracks the developments, or rather the lack thereof, in this ‘elusive and expensive’ enterprise. The essay ends with a look at the role of the women’s health movement, both internationally and in Australia, in opposing reprogenetic technologies. Klein throws light on the many challenges that groups like FINRRAGE have had to face in recent years. While some women continue their critical work, ‘concerns about women’s health have been so mainstreamed that they have become invisible’. Klein stresses that discussion and mobilisation is required, at the grassroots and between activists internationally, in order to investigate the systemic coercion in so-called free choice that is being pushed for at the policy level. She concludes with for a moratorium on reprogenetic technologies.

The escalation of ARTs in India into a veritable fertility industry has happened for many reasons. Sarojini N’s paper places the biogenetic industry within the larger political economy framework of globalisation and privatisation, thus employing a lens that is often omitted from mainstream discussions on ARTs, but has direct and significant bearings on the ART industry in India. Her essay presents the features of the ART industry through an examination of its on-the-ground operation. It begins by locating the research within the larger context of India’s expanding health care and medical tourism market, which has seen an unprecedented boom in recent years, aided and abetted by the Indian state. Within this, the author explores the increasing spread of ARTs, including fertility tourism, and the ‘rationale’ behind this spread and the features of the industry; as elaborated on by providers in research states. The actors and agencies that constitute the ART industry are examined, including newer players and international collaborations.

The essay also examines in detail the features of this industry as emerging from the research—attracting clientele through aggressive marketing and reducing operational costs through schemes, concessions, and treatment in camps and batches. In the absence of regulation, there is a lack of standardisation in terms of costs, procedures, information, counselling, and consent, as well as the potential for unethical practices like sex selection and multiple-embryo implantation that threaten women’s health and rights. The ART industry also deploys and re/produces the patriarchal imperative to mother, while being able to posit and market itself as pro-women, ‘delivering desperate women’ from the ‘trauma’ of ‘childlessness’. Sarojini points out that not only has the ART industry transformed the character of fertility technology in India, it has also streamlined the commodification of body parts, reducing women to ‘vendors’ of ova and ‘renters’ of uteri, and providers of tissue for stem cell research. She concludes that a combination of biological factors, social pressures, eugenics and commerce all drive the ‘baby business’, raising several ethical concerns. Sarojini’s paper is a necessary reminder that the need for regulation of India’s burgeoning ART industry cannot be overemphasised.

Hedva Eyal’s paper takes us through Isha L’Isha– Haifa Feminist Centre’s involvement in legislation on egg donation in Israel. The law, passed in June 2010, allows and regulates egg donation for assisted reproduction as well as research. Israel’s pro-natalist policy is perhaps one of the strongest in the world, with IVF treatments funded by the state for up to two births from the woman’s current partner. Israel also has the highest number of IVF clinics in relation to population. Eyal contends that religious, national, and social reasons lie behind the birth-encouragement in Israel. Yet, Israel does not unequivocally champion all motherhood; benefits for single mothers have been drastically cut. Clearly, there is more to Israel’s rise as the superpower in fertility technologies. Eyal reminds us that ARTs are also a thriving economy in Israel, drawing women from different parts of the world. When the government proposed to regulate the great demand for eggs (including for stem cell research, which does not necessarily serve women), Isha L’Isha sought to build a coalition to protect the rights of egg donors/sellers. Eyal reflects on this process, particularly the dynamics with other women’s groups, religious groups, and medical professionals, and also on questions such as ban versus regulation, and conflict of interest. We learn about the way in which the rhetoric of women’s ‘need’ was deployed to secure research interests—the 2007 bill stipulated that up to 49 per cent of donated eggs could be used for research. Egg donation for research purposes was even painted with an altruistic veneer, thus making it ‘ethical’, while simultaneously trying to evade pressing ethical issues in health research, such as obtaining consent with full information on risks and other research-related details. In revisiting key debates during the legislative process, Eyal also highlights the issue of donor anonymity; the divergence in perspective between Isha L’Isha and other parties involved in drafting the legislation is clear, as is the nature of dialogue in general: necessary, but not always successful. While Eyal sheds light on a whole array of issues that the legislative discourse around egg donation included, she mentions also issues that it excluded: how acceptable is it to expose a woman to health risks to fulfil the desire of another woman? In a material environment of inequity and exploitation, how free is ‘free choice’? Is it even correct to say egg ‘donation’ when what is really going on is egg sale? What are the different relationships and family-types that are possible with ARTs? And finally, what implications do we need to be prepared for in international egg trade? Eyal concludes with a quick overview of the law that was eventually passed, as well as Isha L’Isha’s continued engagement with the issue.

Marcy Darnovsky and Judy Norsigian begin their paper on US feminists and the fertility industry with the important disclaimer that there has been no one perspective on the issue. Amongst the questions they raise at the outset are whether multiple embryo transfers are acceptable, and what kind of insurance for infertility is appropriate. The essay presents an overview of the largely unregulated commerce of fertility technologies, a multi-billion dollar industry in the US that is aided in no small measure by the absence of insurance in most states. Fertility clinics are highly competitive, offering special deals and targeting ‘new market niches’, including gay couples and people who are not infertile, but might be willing to pay for procedures like sex selection, and egg freezing. While different states have different laws, there is no binding federal policy on a range of fertility technologies including ARTs. This is one of the factors that have contributed to USA’s status as a reproductive tourism destination, albeit for the better off. The authors remind us that because abortion rights in the US are so tenuous, many progressives justifiably want to keep the state out of fertility technologies. Yet, the authors argue that malpractices in the absence of regulation are far too grave to remain unaddressed. They reflect on the controversies, from the late 1990s onwards, around reproductive cloning and stem cell research; the authors and their respective organisations were pro-choice opponents of cloning research, though they supported stem cell research. This position was criticised, not unproblematically, by other feminists who were wary of strengthening the anti-choice lobby, and advocated for choice to be completely individual. Emphasising the need for feminist engagement with new genetic technologies, the authors reflect on a 2004 meeting, ‘Gender and Justice in the Gene Age’, where several points of agreement as well as strategies emerged. The changing landscape of feminist engagement with genetics in the US is mapped, with reference to central issues and organisations involved. The article then moves on to discuss ARTs specifically. The authors point out that despite the increasing demand for eggs (for reproduction, as well as research), little is known about the risks of egg retrieval. They also trace efforts of feminists and disability rights activists to confront sex- and trait-selection using reproductive technologies. The essay concludes by advocating for effective public policy to protect all involved in infertility treatments, and notes that it is important to focus on primary prevention of infertility.

In their paper discussing the Canadian experience with ART regulation, Shree Mulay and Madeline Boscoe begin with highlighting the relentless media focus on enhancing access to ARTs in Canada, particularly in the present context of Canada’s declining birth rates, rising age of parents at first birth, and rising infertility. They trace the trajectory of today’s scenario back to a long and complex engagement with regulation. Against the backdrop of proliferating ART use and new ethical dilemmas, the Canadian government appointed a Royal Commission (RC) on New Reproductive Technologies in 1989. Though this was intended to deliver considered advice, it became a lengthy process of consensus-building between differing voices. The final report of the RC banned some procedures altogether, while seeking to regulate others. In 2004, ten years after the release of the final report, the Assisted Human Reproduction Act (AHRA) was passed. Since then, there have been legal challenges to the Act and to the agency set up to implement it, the Assisted Human Reproduction Agency of Canada. Further, in the years that it took for the regulation to be enforced, the landscape of ART provision in Canada has changed dramatically; procedures like ICSI, once considered unprecedented, are now routine. Mulay and Boscoe argue that geneticization has fundamentally altered the discourse around these technologies in Canada—the focus is now on the concerns of the users of these technologies, rather than on larger social questions that lie at the intersection of science and market. The much fought-for regulation appears to be becoming redundant in many ways; older bans, such as on creating human animal chimeras, are being revisited, while newer aspects of reproductive tourism and citizenship remain unaddressed by the law. The authors argue that an appropriate response to the challenges in ART provision will have to go beyond strong national regulation and will have to harmonise their international provisioning, such as for prevention of trafficking, reduction of secondary infertility, access to information and the establishment of consumer protection laws. Further research is also needed in areas like health outcomes of ARTs. Mulay and Boscoe remind us