Assisted Reproduction Issues

[Broomstick]

The New York Times is running a series on "21st Century Babies" that may be interesting to folks here as a jumping off point for issues around assisted reproduction. So far, two articles have run. They are quite lengthy so I will not quote them in their entirety here, but I will provide links.

The Gift of Life, and Its Price discusses IVF, in vitro fertilization, and some of the consequences both good (babies!) and bad (sick babies!).

Some background not covered - I remember the birth of the first IVF baby, Louise Brown. Not the singular "baby". These days, more and more IVF births are twins. As 60% of twins are born premature the mere fact of being a twin carries some risk. Now, clearly, not all twins have a problem. "Premature" might mean a week early, and many twins suffer no problems from sharing a womb. On the other hand "premature" can mean months early and yes, there can be serious consequences.

Some quotes from the article:

But an exploration of the fertility industry reveals that the success comes with a price. While IVF creates thousands of new families a year, an increasing number of the newborns are twins, and they carry special risks often overlooked in the desire to produce babies.

While most twins go home without serious complications, government statistics show that 60 percent of them are born prematurely. That increases their chances of death in the first few days of life, as well as other problems including mental retardation, eye and ear impairments and learning disabilities. And women carrying twins are at greater risk of pregnancy complications.

In fact, leaders of the fertility industry and government health officials say that twins are a risk that should be avoided in fertility treatments. But they also acknowledge that they have had difficulty curtailing the trend.

Many fertility doctors routinely ignore their industry’s own guidelines, which encourage the use of single embryos during the in-vitro fertilization procedure, according to interviews and industry data. Some doctors say that powerful financial incentives hold sway in a competitive marketplace. Placing extra embryos in a woman’s womb increases the chances that one will take. The resulting babies and word of mouth can be the best way of luring new business.

Doctors are also often under pressure from patients eager for children, who have incentives to gamble as well. Frequently, they have come to IVF as a last resort after years of other treatments, are paying out of pocket, and are anxious to be successful on the first try. And many do not fully understand the risks.

The industry creates preterm infants with in-vitro and other fertility treatments even as government and nonprofit groups work to fight the nation’s 12.7 percent rate of prematurity, regarded as a major national health care problem.

While IVF multiples are typically the children of affluent women, much of the effort at reducing premature birth has been focused on prevention and prenatal care for low-income women. A study released last week by the March of Dimes cited fertility treatments as one of the main reasons for a 36 percent increase in prematurity in the last 25 years.

The government estimates that caring for premature infants costs $26 billion a year, including $1 billion for IVF babies, expenses that eventually get passed through the system and on to businesses and consumers.

The two medical organizations and the federal Centers for Disease Control and Prevention have been promoting the use of single embryos in many cases to reduce the number of twins. But that has not translated into major action at the 483 fertility clinics across the country. The latest figures from the industry show that women under 35, the group most likely to get pregnant from the treatments, choose to use single embryos in only 4.5 percent of in-vitro rounds.

“You can’t convince a couple that having twins is a bad thing,” said Dr. Maurizio Macaluso, who runs the C.D.C.’s women’s health and fertility branch. “That’s a major communication problem.”

Ms. Mastera’s insurance would cover about $8,000 for the procedure and drugs. Frequently, insurance does not cover anything. Almost $18,000 in clinic fees and other costs remained for the couple, who proceeded to cash out their 401(k) and money market accounts and put the remaining balance on a low-interest credit card.

Like many families, the Masteras could not afford a second cycle. So when the couple was given a choice by their doctor of implanting one or two embryos, they decided to increase their chances with two.

“This was our Hail Mary pass,” said Ms. Mastera, now 33. “We thought, let’s just do it. At the time, it was like, twins, they can be fun. They are fun, but holy cow.”

Some public health experts are frustrated by the disconnect between the medical risk of twins and society’s perception.

Dr. Alan R. Fleischman of the March of Dimes, which has begun distributing literature discussing single embryo transfer, said a result of playing down the risks of multiple births is that many women undergoing in-vitro prefer to have twins.

“It’s not just a matter of hoping that if you put two embryos in, you’ll get one baby,” Dr. Fleischman said. “There are many women who actually want to have two children and would like to have their full family with one pregnancy.”

In March, the United States Chamber of Commerce and the March of Dimes held a luncheon in Washington to discuss preterm babies. “The human costs are staggering,” Dr. Steven K. Galson, then the acting surgeon general, told the group. “The medical costs are staggering. That’s why we’re here.”

“Today you’re going to hear that preterm birth is not just a significant public health issue,” Dr. Galson said, “but that it also impacts businesses and employer health plans.”

The hospitalization and doctor’s care for Ms. Hare and her son exceeded $1 million. Most of that, about $750,000 to $800,000, was for Carter. The bill was picked up by the self-funded health plan of the Trammell Crow Company, the Dallas real estate investment company where Ms. Hare worked.

“The following quarter during the earnings release, somebody asked why there was a sharp increase in medical costs,” Ms. Hare said. No one identified her, but Ms. Hare knew that her family had contributed heavily.

In Atlanta, the Centers for Disease Control and Prevention hired an economist to predict what would happen if single embryo transfer were used in a large number of IVF cases.

Dr. Macaluso, the C.D.C. reproductive health official, estimates the patients, businesses and insurance providers would save more than $500 million annually, even taking into consideration the cost of extra in-vitro rounds, by lowering neonatal intensive care, special education and other costs of premature babies.

To reduce the number of twins, some clinics are experimenting with programs that provide IVF with single embryo transfer with free freezing of extra embryos and free transfer of frozen embryos if the first try does not work. Others are working to develop ways to identify the specific characteristics of a single embryo that will turn into a healthy baby.

Now, of course, twins will happen no matter what. Even if a single embryo is transferred there is the possibility of it splitting to wind up with two babies (even three - identical triplets have occurred). And I am all in favor of doing what we can to have healthy outcomes for twins and premature babies. There are many people who were born premature and went on to have healthy, productive lives - including my eldest surviving sister, who was born two months premature but not only produce two lovely children of her own and is a highly intelligent human being, but is now a doctor who unquestionably provide benefit to society. Her prematurity apparently has had no lasting ill effects. However, it is one thing to manage the outcomes of nature and chance, quite another to be manufacturing twin births.

Of course, the is a multi-factorial problem. It is entirely human to want babies. Evolution has selected for the desire to reproduce. Society only emphasizes that drive by social rewards given to parents, which is often increased for the "super fertile" (whether they are that way naturally or artificially). Doctors at fertility clinics do want to stay in business and make money, of course, but that is not incompatible with a sincere desire to help couples have babies.

So... what is the solution? Greater regulation? Greater education as to the risks involved? What?

[Broomstick]

Grievous Choice on Risky Path to Parenthood discusses the problem of "super multiples", pregnancies with 3, 4, 5, even 6 fetuses. IVF allows very precise control over the number of babies (barring spontaneous identical twins), but intrauterine insemination, abbreviated IUI, does not have such fine control. This can lead to a choice between a very high risk pregnancy, prematurity, and losing some or all of the babies at birth or shortly after, or opting for "selective reduction", where you basically sacrifice some babies to increase the odds for those remaining.

But something had gone wrong. In April, an ultrasound revealed that Mrs. Stansel was carrying not one but six babies, and Dr. Grunert was recommending a procedure known as selective reduction, in which some of the fetuses would be eliminated.

The Stansels rejected Dr. Grunert’s advice and, since then, their vision of a family has collapsed into excruciating loss: the deaths of three children after their premature births on Aug. 4. More than two months later, the three other infants remain in neonatal intensive care, their futures uncertain. One of them, Ashlyn, is near death.

But the procedure the Stansels used is actually the major cause of quadruplets, quintuplets and sextuplets — the most dangerous pregnancies for both mother and children. While less effective than IVF, intrauterine insemination is used at least twice as frequently because it is less invasive, cheaper and more likely to be covered by insurance, interviews and data show

An example of how ability to pay, or to get others to pay, is an enormous factor in these issues. Also, how short term thinking - save money now - can result in long term loss: dead babies, injuries to mothers who carry multiples, babies needing lifetime care, and so forth.

“I think, and so many of my colleagues think, it’s a primitive approach,” said Dr. Sherman Silber, a fertility doctor in St. Louis. “The pregnancy rate is lower than IVF, and you don’t have control over multiples.”

Some insurance plans require women undergoing fertility treatments to have several rounds of intrauterine insemination before they will pay for in vitro fertilization. Because of the cost, other plans cover intrauterine insemination but not in vitro.

But a recent study led by Dartmouth Medical School suggested that because IUI often requires repeated tries, it would ultimately lower both costs and the risk of large multiple births if many patients avoided the procedure and moved straight to IVF.

Jon and Kate Gosselin, who already had twins, had wanted just one more baby, but IUI resulted in the sextuplets made famous on the TLC program “Jon & Kate Plus 8.” The same thing happened to Jenny and Bryan Masche, stars of “Raising Sextuplets,” the TV program on WE, the Women’s Entertainment network.

Mrs. Masche became seriously ill from acute heart failure brought on by her pregnancy, but she has recovered. The Gosselins have separated under the stress of raising multiples. But the Masche and the Gosselin sextuplets are the success stories. They are healthy.

Women who have gone through large multiple pregnancies with poorer results say the shows give viewers a misleading picture by failing to present the wreckage left behind in many cases — babies who are stillborn, spend months in the hospital undergoing painful procedures that require morphine or suffer from long-term disabilities.

Multiple babies who arrive very early require the highest level of acute care for a longer time than any other patients. Despite the lower cost of IUI on the front end, many doctors point out that insurance plans bear higher costs when IUI goes awry and large broods are born.

“We have families that have babies here for three or four or five months, and they’re having discussions with their insurance companies because they have reached the lifetime limit of their medical coverage,” said Dr. Scott Jarriel, a neonatologist who works at the Woman’s Hospital of Texas and treats the Stansel babies.

The Stansels’ decision to use intrauterine insemination was based largely on finances. The treatment can cost as little as $2,000 to $3,000, compared with $12,000 to $25,000 for in vitro fertilization.

Mrs. Stansel’s insurance would not cover IVF but would pay for six rounds of IUI. She consulted Dr. Grunert in April 2008, just over a year after the Stansels were married.

Three years ago, Keira Sorrells, an interior decorator in Monroe, Ga., had found herself in a predicament similar to the Stansels’. After intrauterine insemination, Mrs. Sorrells learned that she was carrying quintuplets.

She said she was in shock at hearing the news and ill prepared for the next step. Before he had even closed the door to his office, her fertility doctor suggested selective reduction to Mrs. Sorrells and her husband, Richard. “We had never heard of it,” Mrs. Sorrells said.

“I think there’s a huge problem in the reproductive technology industry,” Mrs. Sorrells said. “I was told the chances that I would have triplets were less than 1 percent. There was no talk of being faced with a decision like that until the day that we had the ultrasound. Then you have two weeks to decide. And you don’t get counseling from anybody.”

In the next two weeks, Mrs. Sorrells and her husband struggled to make a decision on whether to eliminate fetuses and, if so, how many. The specialist gave her 50-50 odds that her babies would survive and said twins or a single baby would be safer.

Hoping to save as many babies as possible, Mrs. Sorrells decided instead to eliminate two of the fetuses, reducing her pregnancy to triplets. Even then, her pregnancy was troubled. She developed pre-eclampsia, a complication of pregnancy that includes rapidly increasing blood pressure.

On Dec. 20, 2006, at 25 weeks and 5 days gestation, Mrs. Sorrells had to have an emergency Caesarean section.

The most severely ill of her three premature daughters, Zoe Rose, was born with multiple problems. Zoe died last year of a drug-resistant staphylococcus infection at age 14 months — nine of them spent in a neonatal intensive care unit. The Sorrellses’ two surviving daughters, Lily and Avery, are doing well despite their extreme prematurity and four-month stays in neonatal intensive care.

Dr. Brian Kirshon, a doctor in Houston who specializes in high-risk pregnancies, says some couples do not understand the implications of multiple births, even when the risks are explained.

“I think a lot of them don’t really understand the risks of prematurity, the risks of losing their babies, the risk of long-term complications, blindness, deafness, cerebral palsy, development delay when they have extremely premature babies, or the ultimate risk of losing their marriage,” Dr. Kirshon said.

Many opponents criticize selective reduction as a form of abortion. And for many parents who elect to carry all of the fetuses, the decision often hinges on religious convictions. There is also a chance, up to 5 percent, that selective reduction will be followed by a miscarriage of all the fetuses, according to the American Society for Reproductive Medicine.

For the Stansels, the decision was influenced by their membership in the Church of Jesus Christ of Latter-day Saints. The church generally opposes abortion. After learning that Mrs. Stansel was carrying sextuplets, the Stansels decided to meet with church elders and consult with a reduction specialist.

“It just never felt right,” Mr. Stansel said. “We prayed many nights. A lot of sleepless nights. Originally we thought we might do the reduction. We chose to carry all six and, we believe, let God do what he’s going to do.”

Right, the two of you are infertile. That used to be called "God's will". Then you go through all sorts of interventions and technology to conceive despite that. NOW, facing sextuplets, NOW you decide to hand the mess back over to God?

It seems to me that if you have the audacity to usurp "God's will", that is, the "natural" order of things (which is, after all, what we do with our technology) then you have the responsibility to take care of the consequences. You can't just give up halfway through and give it all back to God. What an immature attitude. You go through all that but you haven't the backbone to make a hard decision when it really, really counts.

Um... is my bias showing....?

“There wasn’t anything we could do,” Dr. Kirshon said. Instead, Mrs. Stansel delivered the sextuplets on Aug. 4, about 14 weeks premature. The babies were born so early that no medical care would have been rendered unless the parents requested it.

Dr. Jarriel, the neonatologist, said the survival rate of babies at the stage they were born was about 60 percent to 65 percent. If they survived, the Stansels were told, there was a 100 percent chance that they would have problems.

But the couple asked the hospital for the most extraordinary measures to save them.

“We wanted to do all we could for them, to save them,” Mr. Stansel said.

“Give them that chance,” Mrs. Stansel added. “That’s the doctors giving their statistics. God doesn’t work in statistics.”

There it is again. They let their God work his will, and it seems God pulled the handle to flush and start over. Not good enough - gotta save the babies!

Really, it's like the joke about the man who drowned after refusing rescue and who asked God why God didn't save him, only to be told "I sent you two boats and a helicopter! Wasn't that enough?"

By the way, according to their blog their daughter Ashlynn died yesterday at 8:30 pm, leaving them with only two children, both still in the hospital in neonatal intensive care. Now, I do feel bad for them, losing a child is a horrific thing no matter the circumstances, but I can't help but think that they share an enormous part of the responsibility for these circumstances.

“I knew the babies would come early,” Mr. Stansel said in a recent interview at the couple’s suburban Houston home, near Humble. “I knew they’d be in the NICU. I knew there would be challenges.”

Mrs. Stansel added: “I don’t think I realized how tough it would be.”

I don't think she realized that the outcome wouldn't be six happy, bouncing babies but rather seeing four of her children die before they were even a year old. Before they were even half a year old.

[Broomstick]

Oh, wait - maybe I should state my position on all of this.

I am not without sympathy for infertile couples. After all, my own marriage is without children due to my mate's infertility. We, however, opted to simply not have children. I do wish there was more support in society for this option. I have numerous times been confronted with a pro-reproduction bias that seems to expect me to be a sobbing wreck because I have not birthed a baby. Yes, I know that for some women that is an enormous tragedy, but really, most people can cope with the notion. I once worked with a woman who, after numerous miscarriages (something like eight in 10 years) finally just resigned herself to being childless. It was certainly a sad thing for her, but she did adjust her life plans and move on. As it happens, later on she did manage to have a child, quite unexpectedly, which was almost as tumultuous a crisis as her prior coming to grips with infertility. The point being, she hadn't spent hundreds of thousands of dollars grasping after a child but had moved on with life. Thousands of couples manage to come to grips with not having children, or even choose simply to not have children even when they are fertile. Adoption is also an option, although it is not for everyone and I have had issues with people who, upon learning that I am part of an infertile couple, start pushing adoption. Or pushing artificial insemination. Or whatever.

Look, we need a little more permission in this society for people to simply not have children. It's OK. It's not a sobbing daily tragedy. You can have a happy life without kids in it. I wouldn't want to force that on anyone, but really, there are some compensations. No, I'm not in denial. Really. Honestly, I've known about adoption and fertility assistance for decades, if it was really that important to me I could have obtained a child but I chose not to.

That said, I also have no qualms with people going to some effort to have children. That is, after all, why adoption was invented, right? Well, one of the reasons. Some forms of assisted reproduction are quite cheap - artificial insemination being simple enough to do in one's own home, provide there is a cooperative sperm donor available and the stereotypical "turkey baster". It's also no more likely to result in multiple births than natural conception. Some of the ovulation-stimulating drugs are relatively cheap, too, although the risk of multiple birth does go up... and the ethical issues increase.

But for the high ticket items - things like IUI and IVF - I question if they should be covered by insurance at all. If you want such procedures, if having a baby is that important to you, then I think there should be an argument made that you should pay for it yourself. However, the cost of these procedures is, realistically, out of reach for most people. As are some of the potential consequences. Financial issues lead to women asking for multiple embryos, as indicated in the article, or opting for cheaper procedures that nonetheless increase the risks for all involved.

And, of course, because these children can be sooooo expensive to keep alive, society winds up bearing the cost. It is one thing when multiples or prematurity happens by chance... quite another when people are engaged in activities that increase the risk of such things, in some instances guarantee enormous costs. Yet society would find it utterly unacceptable to force a woman to selectively cull a half dozen embryos in her uterus.

There are, of course, the psychological issues involved. A woman who has been infertile and agonizing over it who is suddenly given a chance to have babies is not in a position to think rationally about this. That some of them do is remarkable (and selective reductions ARE performed every year, even cases of natural multiples, because some parents are capable of making hard choices). I don't think some of these women really understand that they may wind up holding one of their babies as he or she dies, or even holding several children as they die, that these oh-so-desired children may wind up disabled for life. Yes, there may be mental pain from abortion for the rest of a woman's life, but for goddamned sure the pain of watching your child die is horrific and it WILL, without question, follow a parent to his or her grave.

Now, I am completely behind giving disabled people as good a life as possible, I even married someone disabled, but until you live with that sort of issue you don't really understand it. It brings additional pain and expense and problems and that doesn't go away. Ever. It IS an additional burden, and can be just as painful as infertility ever was.

I don't have a clear answer here. I think perhaps women opting for IUI should perhaps be given a few tours of neonatal intensive care to see the possible consequences up close. I also think that, for some women caught in the haze of "BABIES! I CAN HAVE BABIES!" that won't penetrate.

Even normal parenthood with normal children is difficult, exhausting, expensive, and stressful along with all the rewards of parenthood, which I will leave for actual parents to enumerate. This is a complicated issue, but it's not going away. It's not an issue that past generations had to deal with - oh, sure, infertility and prematurity and disability are nothing new, but it's no longer solely in "God's hands". WE have taken a more active control than we used to, to my mind, that means we also incur greater responsibility as well. I don't think everyone involved is actually fulfilling their end of the bargain.

It is a difficult moral question. It's much like the "lifeboat" problem in ethics - when is killing a person, or letting a person die, justified in order to save others, or is it never justified? The fact that is a difficult question and not hypothetical is all the more reason it must be faced.

[Simon_Jester]

Look, we need a little more permission in this society for people to simply not have children. It's OK. It's not a sobbing daily tragedy. You can have a happy life without kids in it. I wouldn't want to force that on anyone, but really, there are some compensations.

The catch, to my way of thinking, is that for the "Yes! I want to have sextuplets!" types, they're not just having children because of social pressure. Or if they are, then it's a level of social pressure so ubiquitous and so far under the radar of official society that no amount of support for the no-children outcome is going to change their mind.

Remember, as you note later on, that there is no correlation between infertility and really wanting to have children, so much so that it causes the would-be parent to stop doing the ethical arithmetic. And those are the ones who are taking the Path of Octomom.

[Broomstick]

There is a difference between the Stansels, which did not explicitly set out to achieve a multiple birth, and Octomom, who did. Octomom used IVF and deliberately induced a high-multiple pregnancy. The Stansels would have been entirely happy with just one child (arguably even happier than they are now, given the outcome) and, while they did things that increased the risk of multiples, weren't hoping for that outcome from day one.

One of the questions I'd be interested in discussing is if insurance coverage for fertility treatments should be barred, leaving people entirely on their own devices for it, or if the long term best interests of society are best served by paying up front for initially higher cost assistance, such as IVF, that is less likely to result in major multiples and high medical costs down the line.

For example, society might say, OK, you get 6 rounds of IVF in order to conceive. Just one, or at most two, embryos will be transferred per attempt. After two children, that's it. (Obviously, if you end up with an accidental triplet we won't kill off kid #3, but most often the most you'll get is twins). So if your first try you get twins, that's it. If you want more kids then adopt. If takes until your sixth attempt to get one kid, that's the breaks. If you get one kid on try two and another on try five, that's also it, congratulations, you're a parent. That would seem to satisfy the need to reproduce without adding to the population problem (most of the countries wealthy enough for assisted reproduction have stable or negative population growth, and a high percentage of couples simply won't conceive no matter how many times they try).

I still have reservations about that idea, but it would limit some of the negative consequences of this technology. Of course, somebody is always going to find something to bitch about, but it allows some compromise, and, as I said, limits the damage, especially to the children who have zero say in being involved in these things, or being put at risk of life-long problems or an early death.

Octomom does show one of the problem of our current buy what you want approach - she already had several children, what justification is there for her to have more via technology? We don't let people purchase open heart surgery or kidney transplants on a whim, should we permit anyone who shows up with money to purchase conception of however many children they want on demand?

[Simon_Jester]

There is a difference between the Stansels, which did not explicitly set out to achieve a multiple birth, and Octomom, who did. Octomom used IVF and deliberately induced a high-multiple pregnancy. The Stansels would have been entirely happy with just one child (arguably even happier than they are now, given the outcome) and, while they did things that increased the risk of multiples, weren't hoping for that outcome from day one.

I don't claim Octomom was a representative sample of the population, but as the most extreme example of a trend (high order multiple births through IVF), she got the category named after her for my purposes. It is, shall we say, a road that points to Octomomdom, even if very few of the women who set out on that road would ever consider following it to the end.

One of the questions I'd be interested in discussing is if insurance coverage for fertility treatments should be barred, leaving people entirely on their own devices for it, or if the long term best interests of society are best served by paying up front for initially higher cost assistance, such as IVF, that is less likely to result in major multiples and high medical costs down the line.

I suspect so; driving people to get the medical care they can afford rather than the care most effective to their situation is rarely cost-effective in other areas.

[Alferd Packer]

Is it possible to terminate all but one of the implanted embryos? It seems that'd be an ideal solution: you implant two or three embryos, and if they all take, you terminate the excess embryos and bring a single one to term. Is this too risky to do, or is it more of a social stigma that prevents this from being a widespread practice?

[Broomstick]

There is at least a 5% risk in any selective reduction procedure of inducing a miscarriage that leads to the loss of every fetus. For some women that risk is probably higher.

Yes, it is possible to reduce to all but one, but although there are some higher risks associated with twins, twins are usually considered manageable and are far less likely to have the dire, high-cost, lifetime complications. So it's considered acceptable to reduce to twins, particularly for a woman who truly may have only one opportunity to achieve pregnancy.

[Alyrium Denryle]

I will be honest:

We need to be doing everything we can to reduce our population growth to replacement or lower. No ifs, ands or buts. With this in mind, people who are infertile should stay that way, unless there is some sort of cap and trade system on babies that gets implemented. The problem with that is of course that only catholics, mormons, and other religious crazies will reproduce.

[Broomstick]

The population problem is not uniform across the planet. As I pointed out, the countries where these issues come up at all are already at replacement or lower. That is also why I suggest a 1 or 2 child cap on assisted reproduction - infertile couples utilizing such technology would only be replacing themselves.

Keep in mind, too, that only some infertile couples opt for assisted reproduction - quite significant numbers look to either adoption or, like myself and my spouse, come to terms with not reproducing. In addition, there are significant numbers of fertile couple who choose not to reproduce, an informal form of that "cap and trade" you mentioned.

Saying "you're infertile, you're stuck with it, we won't allow you access to the technology that exists" is NOT going to go down well even with atheist infertile couples. The drive to reproduce is independent of religion (though clearly religion can impact decisions in that area). On the other hand, if you permit 1 or 2 child caps you may get the buy in you need from the couples wanting to use this technology in a less confrontational way that maximizes cooperation and minimizes people trying to get around the system and rules. Cooperation is usually more beneficial than confrontation. You don't want this technology going underground where it may become entirely uncontrolled and unregulated, that would be worse than the present situation.

[McC]

Saying "you're infertile, you're stuck with it, we won't allow you access to the technology that exists" is NOT going to go down well even with atheist infertile couples. The drive to reproduce is independent of religion (though clearly religion can impact decisions in that area).

Speaking as half of an atheist couple, I can confirm that we would feel as Broomstick indicates if faced with infertility. My fiancee and I plan to have 2-3 children.

Tangential rambling follows.

From a eugenic perspective, I would like atheists to have more children than religious nutjobs. The world doesn't need more of the latter; it needs more of the former. Unfortunately, atheists also tend to be educated enough to realize how bad having enormous numbers of children is (both from financial support and global resource strain perspectives), and thus aren't as prolific reproducers as the staunchly religious. The idea doesn't work anyway; the world as a whole needs to be having fewer children, so spurring one group to have more than other groups is counter-productive in a global sense.

Commence flaming as desired. These are my opinions and I stand by them.

[Alyrium Denryle]

The population problem is not uniform across the planet. As I pointed out, the countries where these issues come up at all are already at replacement or lower. That is also why I suggest a 1 or 2 child cap on assisted reproduction - infertile couples utilizing such technology would only be replacing themselves.

A lot of it is envionmentally mediated for one.

Second of all, every child in western nation uses a hell of a lot more energy (as a proxy for other resources) to raise to adulthood than a kid in the third world. Thus it makes sense to control our reproductive rate even more than we are.

Saying "you're infertile, you're stuck with it, we won't allow you access to the technology that exists" is NOT going to go down well even with atheist infertile couples.

Hence Cap and Trade. If they want children, they do have vouchers for a set number. Any more than that and they need to obtain a voucher (for an exorbitant amount of money) from someone who does not want offspring.

The religion angle comes in when religious groups pool their resources to stock up on offspring vouchers.

[Bedlam]

Moving slightly away from the original question but if you limit people to say 2 children a couple how do you deal with couples that split and rejoin.

Say Man A and Woman B have 2 children, then they splt up and Man A meets Woman C who has no other children, can the pair of them have another child? 2 children?

If it works out that each person can have 1 child 'assigned' to them then presumably the second couple can then have a child and assign it to Woman C but then Man A has three children, Woman B has 2 and Woman C has 1 fine as far as keeping the population down goes but Woman C might feel she has lost out on having multiple children. Additionally one of a couple might feel that the other partner forced them into 'assigning' a child to them so they could then go off and have children with another partner i.e. She made me use up my child rights so that she could then leave with the child and have more children with her new man.

How would you deal with this so that everyone has a fair right to have children? How did to work in China or was it just assumed that all couples would stay together?