By Abby Lippman

It was almost 40 years ago that I first began to question and explore what were then the "new" reproductive technologies. Reflecting back on those decades reveals how much-and how little-has changed. Many of the technologies themselves are now the realities only imagined then. However, the questions and concerns about them are basically still the same, and still just as hotly debated. Are we (again) on the verge of "designer babies?" Will women's bodies be commercialized to provide children for those contracting surrogacy services? Will women's eggs be high-priced commodities for profit-making international brokers? Why do we still know so little about the environmental and occupational determinants of infertility? Perhaps the most notable change in the discussion has been a subtle shift in emphasis from concerns about their eugenic implications to the economic ramifications of the use of the technologies, as what Debora Spar has called the "baby business" proliferates and as "choice" has been reduced to a consumer option.

Assisted human reproduction comprises a range of technologies that were initially developed to make it possible for some women considered infertile because of biological problems to have children. Over time, many of these technologies have become primarily ways to circumvent social factors that prevent a woman or a man from being the biological parent of a child without outside assistance. And yet, despite being viewed as merely a "choice" for women, there continues to be grossly inadequate regulation and surveillance-or full public discussion-of their use, so that information necessary for informed decision making is woefully inadequate. 

Canadian feminists began calling for the regulation of the range of reproductive (and genetic) technologies in the 1980s. This led to the formation of a Royal Commission to examine the "New Reproductive Technologies" and to the long-delayed release of its final (two-volume) report, "Proceed with Care," and its almost 300 recommendations in November 1993. Another decade passed before the federal government approved (in 2004) the Assisted Human Reproduction (AHR) Act and the creation of an agency to oversee activities in this area.

The jurisdiction of the federal government to act in what was labeled a matter of "health" (a provincial matter in Canada) was rapidly contested by Québec and no real progress - not even with regard to the practices the AHR Act proscribed as criminal offenses-  was made to regulate the expansion and increasing use of the NRTs while the matter was (for too many years) before the courts. Thus, when the Supreme Court of Canada supported most of Québec's claims and thereby rejected the AHR Act in December 2010, it became a matter for the provinces to draft legislation to protect the health and interests of women and society.

In Quebec, this has turned out to be fairly shallow protection at best. Yes, this province now covers in vitro fertilization (IVF) with public funds as part of the universal medical care coverage offered to almost all residents. However, none of the regulatory and surveillance measures long demanded are in place. And while this financial coverage gives the appearance of promoting equity, since IVF technologies may now be available to any woman accepted as a candidate and not only to those with the financial resources to pay for the procedures involved, this "equity" may actually be more apparent than real.

The political decision to fund IVF and not midwifery programs, proper school-based sex education, or to expand publicly-funded daycare demonstrates the allures of-and lobbying for-technological fixes over societal and structural change that can truly reduce inequities. In this regard, funds allocated for these high tech procedures could have been better used to remove some of the major determinants of "infertility" and to develop policies that will address those situations that now lead to women delaying their childbearing.

Thus, what has happened in Québec reflects what too often has happened with reprogenetic technologies everywhere: willful ignorance of the processes, policies, and other "upstream" societal, environmental, and structural determinants that lead to demands for interventions to circumvent infertility. And, while we lack the proper downstream regulation of assisted repro technologies necessary to ensure the health and safety of users and the children to be born, this is not all that's needed. Essential as they are, having laws-and even registers that track users and their offspring-must not deflect attention from what women need for social justice and for their complete sexual and reproductive health, measures that will also prevent infertility: safe places to grow up, live, work, and play; a system in which social and economic rights are secured; and conditions in which bodies and body parts are not commercialized.

It remains a priority, unaddressed even after 40 years of arguing for it, that we frame assisted reproduction within an overall reproductive health policy-one that would, for example, attend to ways to reduce infertility and not just ways to manage it once it was diagnosed. High tech interventions should be last resorts at the margins, not the center of things. And to refocus, we need to reduce the space given to the scientific, commercial, and medical interests that tend to dominate the discussions and consider what the technologies and the technological approach means for individual women and women collectively.

Reproductive technologies are not a treatment of infertility but merely a way of circumventing some of the problems that keep women from having the children they may want. Unfortunately, there is still overemphasis on expanding access to these technologies rather than on seeking the causes of the underlying problems and ways to prevent them. It's not just my impatience at how slowly things change that makes me hope we will have the discussions we sorely need to set in place the social systems that will truly promote and protect the reproductive and sexual health of ALL women, those who do and those who do not want children. We don't have another four decades to act.

Abby Lippman, PhD, is a Professor in the Department of Epidemiology, Biostatistics, and Occupational Health at McGill University and a Board Member of Fédération du Québec pour le Planning des Naissances (FQPN).

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