An Explainer

What Is IVF Sex Selection? Your Questions About The Controversial Practice, Answered

Reproductive endocrinologist Dr. Anate Brauer weighs in.

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IVF sex selection, although currently legal in the U.S., remains a controversial practice.
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For people who've struggled to get pregnant, having access to fertility treatments like IUI and IVF has been life-changing. After years of not being able to conceive, many parents have proceeded to have healthy babies through these methods. Now, thanks to scientific advancements, parents cannot only conceive their baby through IVF, but IVF sex selection also allows them to determine the genetic sex of their future children with nearly foolproof accuracy.

But what are the risks — physically, emotionally, and financially — of choosing your baby's sex through IVF? What does the process entail? This guide will walk you through everything you should know when considering IVF sex selection as part of your conception journey.

What is IVF sex selection?

Just as it sounds, this refers to the process by which a prospective parent or parents choose the biological sex of their child (male or female), which is only possible using IVF embryos.

You may also hear IVF sex selection referred to as IVF gender selection, but it's important to note the fundamental differences in the definitions of those terms. According to the World Health Organization, sex refers to "the different biological and physiological characteristics of males and females, such as reproductive organs, chromosomes, hormones, etc." Gender, on the other hand, refers to "the socially constructed characteristics of women and men — such as norms, roles, and relationships of and between groups of women and men."

In other words, you cannot select gender as it's how a person (in this case, your future child) self-identifies.

Celebrity couple Chrissy Teigen and John Legend used IVF to ensure their first child was a baby girl, a decision she shared via Instagram. “Not only am I having a girl, but I picked the girl from her little embryo,” said Teigen in her post.

How can sex be selected in IVF?

Sex selection is not a standalone procedure. According to Dr. Anate Brauer, M.D., FACOG, a board-certified reproductive endocrinologist, undergoing IVF for gender selection is done through Preimplantation Genetic Testing for Aneuploidy (PGT-A). Typically, this type of genetic test is employed in an older infertility population and for cases of recurrent pregnancy loss. It is used to create embryos and test them for their number of chromosomes.

"Our genetic information is housed in structures called chromosomes. We all have 23 pairs of them, along with sex chromosomes, which are labeled as X and Y," says Brauer. "As women age, their eggs age and develop more and more DNA mutations, leading to eggs — and eventually embryos — with the wrong number of chromosomes. Therefore, employing the technology of IVF with genetic testing of embryos can reduce time to pregnancy by finding the best embryo sooner, as well as decrease miscarriage rate by identifying the embryos with the correct number of chromosomes, including identification of X and Y chromosomes which determine sex." (Baby girls are made from XX chromosomes, while baby boys are made from XY chromosomes.)

As a result, says Brauer, such a technique may be requested and employed in situations where families carry a genetic disorder that may impact one sex more than the other. However, she says, "In recent years, couples have taken advantage of this technology for the purposes of 'elective sex selection' or family balancing, where one sex is favored over the other."

So, how does sex selection work? Once the sperm and eggs have been combined, the embryo(s) is sent to a genetics lab for chromosomal analysis before undergoing genetic analysis. Then, once they receive the results, the parents can choose which embryo (XX or XY) they wish to implant.

Why would someone want IVF sex selection?

There are many different and personal reasons why a person or couple might consider IVF sex selection. These include but aren't limited to:

  • As Brauer mentioned, many couples choose IVF sex selection for "family balancing" — meaning they have three boys and now want a girl, or vice versa.
  • Parents might select IVF sex selection if they are at risk of passing on a genetic disease or condition, including being carriers of sex-linked genetic disorders.
  • Some parents might have lost a child of one sex and wish to have another baby of the same.
  • In other cases, parents might feel more "equipped" to raise one sex over another.

How much does IVF to pick sex cost?

It varies since it's composed of several different procedures with different fees. The average cost of gender selection in the U.S. is around $4,000 to $5,000, but it can be as low as $2,000. Then you must factor in the cost of IVF, which can run between $11,000 to $12,000 on average, along with any other lab and testing fees.

What happens to unused embryos?

If the embryo is not the gender the parents prefer at the time; there are several steps that can happen next. They can donate it to a couple or a person who wants a child or donate it to medical research to further fertility and development studies. The parents can also choose to freeze the embryo and use it later in life.

What are the risks involved?

"IVF comes with risks. It is an invasive and expensive technology, often without insurance coverage for elective indications," says Brauer. "Risks of IVF include bleeding, infection, damage to surrounding organs from the retrieval itself as well as ovarian hyperstimulation syndrome and anesthesia complications."

Additionally, she says, "PGT-A testing is a screening test and does not have 100% accuracy. This is a very important and often looked over point — you may spend thousands of dollars and put yourself at risk and end up with the opposite sex of what you were hoping for, which can have a major impact on parents and children psychologically."

While Brauer says IVF and genetic testing technology have come a long way and helped millions of couples realize their dreams of becoming parents, "The technology comes with a very slippery ethical slope, which starts with elective sex selection."

This brings us to the final question...

Is IVF sex selection ethical?

While PGT-A screening for medical reasons is a generally accepted practice, using it for the sole purpose of sex selection remains ethically ambiguous in the medical community and at large.

"Nonmedical use of in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A) expressly for sex selection is an ethically controversial practice," states the Ethics Committee of the American Society for Reproductive Medicine. But ASRM acknowledges that arguments in support of and against both exist, making this a complex and weighted matter.

Arguments Supporting Its Permissibility

The preeminent ethical considerations supporting nonmedical IVF sex selection are patient autonomy and reproductive liberty. In other words, if technology enables a person or persons to choose the sex of their child before conception, that may serve as a material aspect of their reproductive decision-making. And policing parents' underlying reasons for having a preference could be perceived as overstepping the scope of fertility care and infringing on a patient's autonomy and privacy.

Another argument supporting the procedure centers on intention: A person's preference for having a particular sex doesn't necessarily reflect gender bias (and, in fact, ASRM has found that there is less likelihood of this type of discrimination with patients who cite family balancing as a reason for sex selection).

Arguments Against Its Permissibility

As you may have guessed, the primary argument against PGT-A for nonmedical sex selection is the possibility of discrimination.

According to ASRM, nonmedical IVF sex selection "raises concerns that parents engaging in sex selection may impose inappropriate gender norms on their children and reinforce ideas of gender essentialism, such as that there are certain characteristics inherent to being female and others inherent to being male."

Sex selection for nonmedical reasons could also result in gender imbalances in society, particularly in countries with a documented history of gender discrimination. Other social justice concerns include diverting medical resources otherwise earmarked for the treatment of infertility and fears that the practice may only be available to those with the resources to pay for it.

While nonmedical IVF sex selection is currently legal in the U.S., it merits noting that the practice remains prohibited in Canada and some European countries over the aforementioned ethical concerns.

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