We all know that story of the one couple that has three girls or three boys and is continuing to try for a little boy or girl. Maybe you are that family. When it comes to fertility treatment, science has come a long way. It is now possible to choose the sex of an embryo prior to implantation.

If you are considering gender selection for family balance, you may have some questions. You may be wondering if family balancing is ethical. You may be wondering if there are many options for selecting the gender of your next child. It is also possible that you are wondering how you can choose the right fertility clinic for your family. All these concerns will be addressed.

The Ethics of Family Balancing

Gender selection is illegal in a number of countries around the world. Some of these countries discriminate against gender. It is legal in only a few countries like USA as there doesn't seem to be a pattern of discrimination in regards to gender. Most parents that want to choose a specific gender do so because of balance. One family may have two/three boys and want a girl or may have two/three girls and want a boy.

Gender selection is considered a controversial topic. Some clinics don't feel comfortable engaging in gender selection. They may only favour one gender over the other if the child has the risk of developing a genetic disorder that is gender-specific. Some clinics think of gender selection as a slippery slope to couples demanding a child that has a specific eye color or height.

Some doctors consider gender selection for the purpose of family balancing as ethical because the parents want to experience both genders. It seems parents who want to practice family balancing are wishing to celebrate both genders.

The American Society for Reproductive Medicine (ASRM) hasn't taken a stance on whether they consider family balancing to be ethical. Instead, they request that individual clinics decide for themselves what situations they feel a gender selection would be appropriate.

The ASRM has stated, "Practitioners offering assisted reproductive services are under no ethical obligation to provide or refuse to provide nonmedically indicated methods of gender selection."

As for the American College of Obstetricians and Gynecologists (ACOG), they oppose gender selection. While they acknowledge that family balancing falls in line with gender equality, they believe it can cause some ethical concerns.

Providers at fertility clinics are unable to know the true motives of parents and why they are requesting a specific sex. The ACOG also believes that preferring a child of a certain sex may point to the parents having sexist views which can create an environment for sexism to flourish.

ASRM has some concerns in regards to selecting the embryo sex for nonmedical reasons. The truth is no one knows the long-term effects of pre-implantation genetic screening (PGS), the procedure that is done to find out the sex of the embryo.

There is also the risk of a slippery slope. It is very easy to cross the line of choosing other physical traits of the embryo. Doctors are finding that more people are requesting gender selection. Although most families use PGS for the screening of diseases and conditions, quite a few people are interested in gender selection alone.

For those that wish to do PGS to choose the sex of their embryo, they have to pay out of pocket. There is a concern that once PGS is covered by insurance companies, it will be more popular. In 2013, it was noted that 6% of IVF cycles in the USA used PGS.

Options for Gender Selection

MicroSort

One option for gender selection is sperm sorting, also known as MicroSort. MicroSort is when sperm is sorted by their weight. This should improve the chances of having a baby of a specific gender during artificial insemination. However, the process doesn't seem to be that effective. Once its clinical trial was completed, MicroSort wasn't approved by the Food and Drug Administration (FDA). Therefore, MicroSort is only available outside of the United States.

The Ericcson Method

The Ericcson Method uses sperm spinning to choose the gender. The principle behind this is that Y chromosome sperm, which are responsible for producing male embryos, tend to be smaller and lighter than X chromosome sperm responsible for producing female embryos. Due to the fact that Y chromosome sperm are lighter, centrifugation is used to separate the two sperm types.

The process of the Ericcson method involves putting the sperm in a tube with different protein gradients. The protein is albumin. Albumin that is more concentrated and denser makes it more difficult for the sperm to get through. Therefore, if the Y chromosome sperm is lighter, it moves faster which means it has a better chance of reaching the tube's bottom and getting through the different albumin gradients. So, the Y chromosome sperm will be at the bottom of the tube while the X chromosome sperm will be at the top.

The embryologist then takes sperm from either the bottom or top of the tube to select the gender. Usually, intrauterine insemination (IUI) is the conception method for sperm that is collected through the Ericcson method.

Although the initial results of the Ericsson method had a 75% to 85% rate of success in selecting a male and a 70% to 75% rate of success in choosing a female, other studies have not been able to replicate these results. As a result, this method of gender selection is not considered reliable. There are some fertility clinics that offer this option, though.

Timing

There is another option for selecting gender, but it involves timing. Sperm that results in a female child tend to move slower as they are heavier and survive longer than sperm that results in a male child. So, if you are trying for a girl, you can try to conceive before ovulation. For a boy, you would try just after ovulation. This technique involves predicting ovulation precisely. The chances of this working, though, are 50%.

Pre-Implantation Genetic Diagnosis

Some embryos that have been created through IVF treatment are screened in order to choose the most viable ones. This process is known as Pre-implantation Genetic Diagnosis (PGD). During the PGD process, each embryo completes a chromosomal analysis.

The PGD screening is most appropriate for women over the age of 35, families who have experienced multiple miscarriages, or people who have previously experienced failed IVF cycles. A typical cycle has a 40% to 50% chance of the implanted embryos resulting in a healthy pregnancy. A screened embryo has a 60% to 70% chance of resulting in a healthy pregnancy.

After the PGD screening, patients can choose the gender they wish to implant, provided the embryos of that gender are healthy.

PGD is the most successful way to select the sex of the embryo for implantation. Although gender selection is available in the United States, it is not all that popular. This may be because of the hefty price tag. For every cycle, fertility treatment with PGD costs $15,000 to $25,000 in the United States. In Europe you can find IVF clinics that can offer IVF treatment with PGD from EUR 6000 (without medication).

Patients who seek IVF with PGD simply for gender selection are not common. The number of people who do this is unknown and unreported as clinics don't have to report why their patients are seeking fertility treatment.

The Pre-Implantation Genetic Diagnosis Process

When it comes to the accuracy of gender selection, it is pretty close to perfect. Rare mosaicism seems to be the only reason why gender selection would fail. However, ovarian hypersensitivity can be a risk for patients.

Pre-implantation genetic diagnosis is an important process, not only for gender selection but also because the embryologist is screening for single-gene disorders like Tay Sachs. Disorders like hemophilia A and B are sex-linked. If your family has a history of these disorders, they are screening for them as well.

If one or both of the biological parents have a genetic abnormality, testing is done on the embryo to see if it also has this genetic abnormality. Embryos can also be screened for aneuploidy even if both genetic parents are presumed to lack chromosomal issues.

This testing has proven to be a great alternative to other tests, like amniocentesis and chorionic villus sampling. Amniocentesis and chorionic villus sampling are genetic tests that are done after the embryo has been implanted into the uterus. Pre-implanting genetic testing is the only option for avoiding the conception of a child with genetic diseases before implantation.

Embryos are made as a result of eggs being retrieved and fertilized. Once the embryo has divided itself into eight cells, the embryologist will remove one cell by piercing the embryo. This cell will undergo chromosomal analysis. Afterward, one or two embryos are selected for implantation.

This process needs to be done very quickly and efficiently as embryos don't thrive outside. Therefore, it is important to select a clinic that is well-practiced in this process. Seeking a clinic that has a high success rate is your best option for resulting in a healthy pregnancy.

How Sex-Linked Diseases are Inherited

Sex chromosomes determine a person's sex. A female has two X chromosomes, and a male has an X and a Y chromosome. Sometimes, mutations can occur in the X or Y chromosome. These mutations can cause sex-linked diseases to occur. When it comes to genetic disorders, sex-linked diseases are among the most common.

An example of a sex-linked disease is Duchenne muscular dystrophy (DMD). DMD is usually linked to the X chromosome and can cause issues like severe muscle weakening and even death. DMD is also recessive (X*).

There are a few scenarios for a woman whose family has a history of DMD. If she has XX, she doesn't have the disease. If she has X*X*, she has DMD. If her sex chromosomes are XX*, she won't have the disease because the X chromosome that doesn't have the genetic disorder is compensating for the one that does (X*).

A female receives X chromosomes from both their parents. So, if only one parent has the recessive gene for developing this disease, her probability of getting it is much lower than a male. Her only risk is possibly being a carrier for the disease.

For a man whose mother has the XX* chromosomes, it can be more precarious. If she gives him the X chromosome, he will not develop the disease. However, there is a 50% probability that she could give him the other chromosome (X*). This will result in him developing DMD because his sex chromosomes will be X*Y.

This is why PGD is such an important part of the fertility process for parents that have a history of genetic disorders. Embryos with genetic disorders can be discarded for healthier ones. In situations like this, it also goes to show why an embryologist may select one sex over the other.

Choosing the Right Fertility Clinic

The average of fresh, non-donor eggs resulting in live births is in the USA 41.7% for women that are 34 years old and younger. For women that are 35 to 37 years old, the number is 31.9%. As for women that are 38 years old to 40 years old, 22.1% of them have live births. Women that are 41 to 42 years old have a percentage of 12.5%. If you can find a clinic that has similar or better results, you have a good chance of success with fertility treatment.

IVF research is still important as new information is coming up regularly. For example, fertility clinics have found that a large number of their patients are not able to produce the right amount of eggs necessary to start the IVF process. It was believed that this was an issue with infertile women. However, research has shown that even fertile women experience aneuploidy.

The Human Fertilisation and Embryology Authority has a few tips on how you can choose the right fertility clinic. You want to find out what treatments are provided by the clinic. If you are considering family balancing, know that some clinics don't offer gender selection.

You also want to think about how much the IVF procedure will cost. This is especially important if you are paying out of pocket. The location of the clinic is also very important as you will have to make multiple trips to the clinic.

Look at what past patients and inspectors have to say about the clinic. When looking at fertility clinics, you also want to look at the rate of multiple births vs single births. Multiple births are risky for both the mother and babies. Compared to single babies, premature birth is six times more likely in twins. Premature birth can cause breathing issues, cerebral palsy, and a number of other problems.

You can avoid the risk of a multiple birth by implanting one embryo. Although some clinics prefer putting two embryos in the womb, an elective single embryo transfer(eSET) can have a similar success rate as transferring two embryos.

You may also want to find out if you are eligible for treatment. Some clinics have age restrictions in regards to who they will offer treatment to. Providers at the clinics may also weigh any health risks you have with the chances of IVF treatment resulting in a healthy live birth.

Some governments also require clinics to complete an assessment on the welfare of the future child before they can even begin treatment. If they feel the future child or any children you already have could be harmed in any way, they may refuse to offer you treatment.

What About the Unused Embryos

Once a family has their desired children, they may not know what to do with the other embryos. Embryos that are unused many times are just sitting in liquid nitrogen in a lab somewhere.

According to the Health and Human Services Department, about 620,000 embryos are cryopreserved in the United States. Some of them will be used to make beautiful babies. Others will remain cryopreserved until the people who made them have decided what they will do with them.

There are three options for these embryos. They can continue to be preserved. They can also be discarded or donated. For families that aren't sure what to do, it may be best to hold onto these embryos. You may have a friend that would appreciate you donating the embryos to them. There are some families who have lost a child and have gone back to the fertility clinic for an embryo. These cryopreserved embryos can last decades. There was a story back in 2017 of a little girl that was born after being cryopreserved for 24 years.

You can also thaw and discard the embryos. Some people find closure doing this. Others find it wasteful due to the price of IVF treatment and the fact that other people also want a baby. There are quite a few organizations that can facilitate embryo donation.

Helping families who are experiencing fertility problems that you probably have experienced can feel good. However, some people hesitate to give up the embryos to other families because they feel like they are giving up their children for someone else to raise. ReproTech, one of the largest facilities for fertility cryopreservation, reported that just 1% of their clients have donated their embryos in a given year.

You may be thinking that donating to science may be another option. However, there are only a few programs that accept embryos for research. The embryos that are accepted are usually because of genetic disease. Stem-cell facilities also don't need new embryos.

Some patients have decided to just stop paying for the storage of their embryos. Storing an embryo can cost around $200 a month in the United States. Not only is a financial burden removed, but these families that do this also feel like they don't have to choose what to do with the embryo. Fertility clinics have found it difficult to get in contact with the people that make this choice.

In the United States, embryo abandonment is estimated to be between 1% and 24%. The reason for the large disparity of percentages is because there seems to be a difference in opinion within the fertility treatment community of what abandonment actually means.

There are some clinics that consider 90 days of nonpayment to mean abandonment. For the American Society for Reproductive Medicine, former patients who are no contact for 5 years are considered abandoning their embryos. Embryo-abandonment has become a real problem because of the costs that come with running a fertility clinic. The electricity needs to continuously work. The liquid nitrogen also needs to be good.

Most clinics encourage couples that are seeking IVF treatment to consider their options before starting the fertility process. They request that these couples sign a consent form as to what will be done with the embryos should they die, get divorced, or stop paying for the storage of embryos. Even with the consent form, many clinics hesitate to destroy the embryos. They are worried they will be sued.

Unused embryos have become an issue in family court. A couple may be going through a divorce, and the wife wants to keep the embryos in the event that she wants to have children later on. The husband may object to this because he doesn't want to pay child support.

There are some governments that have put laws in place to mitigate some of these problems. In Britain, there is a 10-year cap for cryostorage. Some doctors have suggested reducing the number of eggs needed during a cycle thereby reducing the number of embryos that are made. Genetic testing may also help. If a family knows that one of their embryos has a low chance of making it to becoming a live birth, they won't feel so bad about discarding the embryo.

Although clinics can help patients figure out what their options are, it is important for patients to take responsibility for their actions and make choices. Some families hesitate about what to do with the embryos as they feel that if they do lose a child, an unused embryo can help them cope with the loss. Others feel like they don't need to make a decision right now.

The Wrap Up

Even with money being a barrier, gender selection is becoming a little more popular every day. There doesn't really seem to be any consensus as to whether or not it is ethical. However, it is legal in a few countries, like the United States. Pre-Implantation Genetic Diagnosis is the best way to find out if an embryo has any genetic or chromosomal conditions. It also is the best way to find out the sex of an embryo.

Choosing the right fertility clinic involves considering the live birth success rate of the clinic, the cost to do the fertility treatment, the proximity of the clinic to your home, and your eligibility for undergoing fertility treatment. Another thing to consider is once you have balanced your family, what to do with the unused embryos. All these points have to be considered when deciding to conceive with gender selection in mind.