Last summer, when I was in England, birthplace of Louise Brown and the ever-expanding field of in vitro fertilization, the British tabloids were full of the latest lurid tale involving a convoluted surrogacy situation. This one, as I recall, had to do with a mother who carried her own daughter's baby but gave birth in India, where she lived, as opposed to England, where the daughter/genetic mother lived, raising the question of what the heck country the child was automatically a citizen of. That same week, a longstanding IVF controversy made front-page news in mainstream papers: Should the agency that regulates British fertility clinics permit the creation of "savior siblings," babies conceived as tissue-match donors for existing children suffering from genetic diseases?
This robust public discussion of IVF ethics seemed remarkable to me, even though at that point I had spent a year researching American fertility medicine. In the United States, we do not have much in the way of public discussions of reproductive technology, in part because we do not seriously regulate it. For better and worse, in England and much of Europe there are laws and/or bureaucrats determining which procedures can be offered and to whom. The decisions that get handed down invariably lead to public disputes, which lead to ongoing, anguished attempts to hammer out a collective moral consensus. Here—where the U.S. Centers for Disease Control and Prevention does little more than track patient loads and outcome rates for clinics that choose to be monitored—moral "consensus" often means doctors sitting around a table, or e-mailing bioethicists, or deciding on their own. Rarely do these discussions bubble over into the public. For that, we can now turn to the new NBC drama Inconceivable, which tries to bring the issues of modern-day conception into the American living room.
NBC's decision to set an overdetermined, soap-operatic, pretty seamy, never-quite-funny drama in a fertility clinic is itself a barometer of the national mood on the subject. Just as the network gay shows signaled the arrival of the cultural moment when everybody either knew a gay person, knew someone who was related to a gay person, or was gay, so now we seem to have arrived at a point where every adult has either undergone fertility treatment or has a friend who has. According to the CDC, between 1996 and 2002, the number of rounds, or "cycles," of IVF performed at U.S. clinics rose by 78 percent, from 65,000 rounds to more than 115,000. Fertility-related medical visits now number in the millions each year. Truly, fertility medicine is the perfect vehicle for Hollywood drama: ordinary enough now to feel universal, but still emotionally charged and, often, genuinely dramatic. I found myself watching the pilot episodes (the series airs Fridays at 10 p.m.) with revulsion and fascination. The scenarios were often far-fetched, and there was lots of fudging with science and with normal lab procedure. Still, what rang true was the sight of clinic staffers deciding, on their own, whether to accede to the desires of, for example, a soldier who wants to conceive a child using eggs frozen by his soldier-wife before she shipped out to, and died in, Iraq. What rang true were decisions quietly made based on bottom-line profit-making; fear of lawsuits; the desire for publicity; scientific principles; committed medical professionalism; fundamental decency; what's known in science as the "yuck" factor; and real delight in giving somebody a baby.
Inconceivable is set in a fictional Beverly Hills fertility clinic, Family Options. It was a good geographical choice, given that if the show were set anywhere else, the staff might have to—for purposes of verisimilitude—occasionally decide not to go ahead with something. There is a real difference between the culture of East Coast fertility medicine, which is more hidebound in clinging, at least nominally, to the notion of "medical necessity," and the West Coast, especially Los Angeles, where a more consumer-minded approach to patient care prevails. In the Washington, D.C., area, where I live, many clinics still will not work with gay males, justifying this on the grounds that technically IVF is a medical treatment for infertile people. Many of these same clinics, however, will provide sperm donation services for lesbians, partnered or single, and other unmarried women whose infertility amounts to "no male partner." In Los Angeles—by way of contrast—there are doctors who specialize in gay couples. In L.A., land of 48-year-old actresses-turned-first-time-mothers, the trade in donor eggs is so active and so normalized that the college-age daughter of a friend of mine, sitting at a cafe in Santa Monica, was approached by an unknown couple who asked if she would be their donor. Surrogacy laws are friendly in California. Fertility treatment is cheaper in California. In Los Angeles—I think this is fair to say—doctors may debate ethics, but chances are the end of the debate will be: Yes. Which means that in the case of Family Options, almost every patient can be an unfolding storyline.
Certainly that's what happens in the first two episodes. Some of the minidramas are dispensed with rapidly, and some you can see are going to last way longer than you want them to. Among its many faults, the drama is dizzyingly front-loaded. Family Options seems to attract a relentless stream of unusually tortured situations. Many are simply implausible: an extreme makeover type who wants to secretly use an egg donor so her husband won't know she carries ugly genes and was once herself an ugly woman; a staffer who, after being dumped by the unctuous main doctor, Malcolm Bowers, steals his sperm and switches it with the semen sample of a patient. Others are plain confusing: Why are they offering cytoplasm transfer, a fringe treatment once offered to women with old eggs, to a couple whose problem seems to be male infertility?
And there is way, way more surrogacy in this practice than there is in the real world, where surrogacy accounts for about 1 percent of IVF cases. There are more counselors and coordinators, too: a whole troupe of women whose job is to find donors and surrogates but also to help couples sort through ethical issues. The truth is, many clinics have only one, or at most a few, overburdened nurse/egg-donor coordinators, as well as a counselor to whom some patients are outsourced.
And yet, I kept asking myself, are these scenarios really so far-fetched? The series was created by two gay men who themselves have families with the help of surrogates, which makes it odd that among the most unappealing characters is a gay man who spies on his surrogate to make sure she doesn't eat pork rinds or drink alcohol. But it's true: People who hire surrogates can overstress about fast-food habits. I once watched a roomful of real and potential gay fathers debate how fat is too fat in a surrogate. And many real-life scenarios are every bit as melodramatic as those the creators have come up with here. I once spent the day with a clinic psychologist who had received a request from a bereaved mother who wanted to use her dead son's frozen sperm, and a surrogate, to create an IVF grandchild. The psychologist had herself lost a parent young, and had a horror of "creating orphans," as she put it. So her clinic said no to cryo-grandma, even though a competing clinic had already agreed to take her on. One counselor mentioned that a patient on her egg-donor waiting list had been waiting a while because she specifically wanted a donor who was blonde and good-looking, better-looking, in fact, than she was. Other doctors regularly struggle with whether to help patients who are really sick: women with autoimmune diseases, for example, or who are dangerously diabetic, whose bodies may be endangered by pregnancy. Another doctor I interviewed was approached by an infertile man who, wanting a baby as close to "his," genetically, as possible, asked to use his own father as sperm donor. Since there is no rule book here, the doctor called her father, a minister, to ask him what God would think of this. Her father told her he thought that God would think it was OK. Technically, it was something close to incest. The family, according to the doctor, is incredibly happy. Many scenarios doctors face really are unprecedented, and in truth, it's hard to see how government regulation could determine the outcome of them all.
The central drama of the opening episodes has to do with baby-switching, which remains one of the fundamental horrors of the field. The series opens with the birth of a black baby to a surrogate who contracted with a white couple (of course it's a black baby; does no one ever consider having a white baby born to horrified black people?), and then of course there is the sperm-switching. In this country, patients are still haunted by two high-profile cases of genetic deception: that of Ricardo Asch, who in the '90s was indicted for stealing embryos and eggs from patients in his highly respected clinic at UC-Irvine and secretly giving them to other women or using them for research; and Cecil Jacobson, the Virginia fertility doctor who was secretly the sperm donor for scores of his patients. (Jacobson, in part, was the impetus for the regulation we currently have.) Doubtless, even now mistakes or deceptions happen. But the clinics I've spent time with are obsessively concerned with the proper care and handling of sperm, egg, and embryo. Before the series started, I happened to be meeting with Robert Stillman, a doctor at Shady Grove Fertility, one of the largest practices in the country, who in response to Inconceivable had drawn up a detailed description of the clinic's lab practices, anticipating that patients would be unduly worried. "It's every patient's worst fear," he said to me, the text, or subtext, of so many initial consultations: If I go through with this, will I really be raising my own child? Or somebody else's?
Which is ironic when you think about it. Shady Grove, like most clinics in this country, does a brisk and growing business in egg donation. Studies have shown that even now, more than half of patients who conceive via egg donation do not tell their child the truth about how they were conceived. So while some IVF patients may fret about the remote possibility of unknowingly raising a child who is not genetically related to them, the far more prosaic reality of fertility medicine is the other way around: The parent is fully aware of the fact of genetic unrelatedness, and it's the child who doesn't know. It's a complicated world, full of compromise and contradiction. At least somebody is paying attention.