When two men wish to raise a child together, they must either adopt (where neither of them will have a biological contribution) or use an egg donor and surrogate (where only one of them will make a biological contribution). In the future, that might not be the case. A new paper published in Cell describes the role of genetic regulators which influence whether an immature germ cell differentiates into a male or female cell, and how that process can be manipulated. In the future, it could even be possible for stem cells from a male to be used to produce an egg, allowing an infant to have two biological fathers.
Primordial germ cells (PGCs) are the stem cells that are able to give rise to either sperm or egg cells. The body typically uses hormonal signals and certain transcription factors in order to determine whether to make the male or female germ cells naturally. While SRY is the gene most widely known for its sex-determining function, the paper describes the importance of another SOX family gene, SOX17. As it turns out, SOX17 is another regulator of human PGC-like cells, and altering the gene can alter the fate of those cells. Rather than just building on our understanding of sex-determining processes, this could potentially have staggering implications for a number of families.
In the coming years, researchers may be able to manipulate this process and make it possible for two men to father a child without the need of an egg donor. This could occur by taking PGCs from one father, manipulating SOX17 and inducing those cells to become oocytes. Because the male has all of the relevant maternal information on his one copy of the X chromosome, the resulting egg cell would theoretically be fully functional. The second father would then need to provide a sperm sample with which to inseminate the egg, though a surrogate would be required to carry the baby throughout gestation.
Of course, there is a laundry-list of logistical and ethical concerns before this can become a reality. Primarily, human genetic modification to this degree is a huge gray area, with many against the idea of “designer babies” that would lead to a Gattaca-like society. This technique wouldn’t be employed to avoid potentially devastating diseases, such as the three-parent IVF which was recently approved in the United Kingdom. Thus, it could be harder to justify such drastic means solely for procreation.
While it is unfortunate, there is another barrier: Those with prejudices against homosexual couples could block the development and implementation of this technology. Though the number of children being raised by same sex couples has nearly doubled since 2000, they are still far and away a minority and face many prejudices.
There is still a great deal of research that needs to be done before the time comes to decide how or if the technique will be implemented.
When Sarah Fain, a TV writer-producer for The Shield and The Vampire Diaries, decided at 37 to be a single mom, she started online sperm-donor browsing. “It’s like online dating, only you don’t have to have a relationship with the person,” she says. “It’s not: ‘What if this is the love of my life?’ It’s: ‘This person doesn’t have Alzheimer’s in their genetic history.’ ” Fain lined up a fertility entourage that included a therapist, acupuncturist, nutritionist and private chef for when she was too busy developing shows for Warner Bros. to cook. “I did acupuncture, herbs, teas; I juiced wheatgrass daily for months because my reproductive endocrinologist [RE] said anecdotally people who did got pregnant,” she says. Despite her efforts, Fain required two years and nine rounds of intrauterine insemination (or IUI, which involves “washing” the ejaculate to up the sperm quality before injecting it into the uterus, at about $1,500 a pop to conceive). At age 40, Fain had a girl named Violet.
When Violet was a toddler, Fain took her to a music class, where “two women walked in with two boys about Violet’s age,” she says. One of the boys looked familiar. Fain went home and checked her Facebook group comprising 15 families who had conceived with her same open donor. (Open donation, in which the donor’s info can be released on the child’s 18th birthday, is a growing trend.) She recalls: “There they were,” just a mile and a half away.
Now they all have dinner every Sunday. “They’re my family,” says Fain. In September, the Facebook group rented a vacation house. “Talk about crazy — there were 12 2-year-olds,” says Fain, who adds: “It’s one of those things that feels incredibly bizarre for half an hour. Then it feels totally normal.”
At a time when Apple and Facebook are picking up $20,000 tabs for employees to freeze their eggs as well as offering other generous high-tech fertility benefits, it’s clear that professional women have more and more options with assisted reproduction technology. Many of them will need it: At least one in eight couples overall suffer from infertility, and much of that is due to delayed childbearing. Even as the U.S. birth rate is at an all-time low, multiple births have skyrocketed from fertility drugs and in vitro fertilization treatments involving multiple embryos. In 1980, there were 70,000 twins born in the U.S.; in 2012, there were 131,269, along with 4,598 triplets and 276 quadruplets.
Credit goes to the 450 high-tech fertility clinics in the U.S., 75 of them in California. The Centers for Disease Control keeps statistics on IVF success rates by age; many clinics in Los Angeles beat the national averages. “California is widely regarded to be the most friendly state in terms of assisted reproduction,” says attorney Richard Vaughn, whose twin sons with actor husband Tommy Woelfel (Mr. & Mrs. Smith) were born with the help of an egg donor and surrogate mother: “Our courts are very friendly to the intended parents and their rights.” In California, case law makes clear that “regardless of genetics, intended parents are the natural parents,” adds Vaughn. “If not for their intent, the child would never have come into existence.” His firm, the International Fertility Law Group — along with some of the world’s most famous fertility clinics, sperm banks, egg donation agencies and surrogacy brokers — has made L.A. a capital of high-tech fertility.
Even so, media coverage of glowing older celebu-moms — from Halle Berry, who just had her second child at age 47, to Laura Linney, who gave birth to her first child in 2014 at 49 — can mislead. “My concern is when celebrities in their mid- to late-40s announce they’re pregnant,” says Guy Ringler of California Fertility Partners, one of Southern California’s most in-demand clinics. “It gives many people false hope that you can get pregnant at any age. It’s not realistic.”
L.A. women in particular have misguided expectations, adds Ringler: “Many of our patients eat well, exercise, are very health-conscious.” Then they realize physical health and appearance largely are irrelevant to the viability of their eggs. Desperate Housewives actress Brenda Strong, who in her late 30s and early 40s struggled to get pregnant with a second child (known as secondary infertility), adds that Hollywood hyper-vigilance about weight can create its own issues. “Dr. Ringler said, ‘Your hormones are off-kilter because you’ve lost too much body fat,’ ” recalls Strong. After her successful first pregnancy, which she attributes to yoga and fertility acupuncturist Daoshing Ni, the actress and American Fertility Association board member suffered a miscarriage at 40 and decided not to pursue more treatments: “They’ve done studies that found going through infertility is equivalent in stress to cancer or HIV.”
Though TV writer Fain achieved success using IUI — the first choice for single moms and lesbians — a growing number of doctors feel it’s “becoming a dinosaur,” says Jeffrey Steinberg, a veteran of the team that produced the first “test-tube baby,” Louise Brown, in 1978, and head of the Fertility Institutes, a clinic in L.A. and New York that specializes in cutting-edge genetic procedures. In states where insurance is required to cover infertility, some plans require that a patient fail several IUI rounds before moving on to in vitro fertilization. IVF is a more complicated process in which sperm and harvested eggs are joined in a petri dish to become 100-cell blastocysts. The best one or two embryos are implanted; the rest are frozen for later use. A round of IVF costs from $15,000 to $18,000; most women in their late 30s or 40s require more than one round.
Alicia Wyld, senior vp field publicity at Paramount, had five failed IUIs and IVFs (including one in which her RE transferred seven embryos at once) before finding a new RE, Sam Najmabadi, who said her body was overstimulated from too many fertility drugs. A few months after reducing her meds, and a year and a half into her fertility struggle, Najmabadi extracted 18 eggs, implanting two embryos. “Just two, that’s normal,” says a relieved Wyld, who gave birth to twins at 40. “Going through all the IUIs and IVFs felt so isolating. I felt my body was failing me and my husband.”
Genetically testing the embryos, known as preimplantation genetic diagnosis, or PGD, is one way to stack the odds in favor of a pregnancy. Nearly every embryo that Steinberg transfers has been tested to confirm that it has the correct number of chromosomes; other tests confirm the lack of certain inheritable-disease genes such as BRCA, the breast cancer gene that Angelina Jolie carries. Steinberg says PGD reduces miscarriages: “What that’s done is eliminate Down syndrome. We can’t guarantee a perfect baby, but we can guarantee that anything you’re concerned about isn’t there.” (Including the wrong eye color: In 2009, after admonishment from the Vatican and the medical community, Steinberg stopped allowing parents to choose their babies’ blues — the most popular color — but quietly started up again with 15 infants last year: “There’s a huge interest. Even when we retracted, the emails just kept coming in.”
Despite genetic testing, IVF still has significant limitations. “A woman in her 40s has a less than 5 percent pregnancy rate per treatment cycle,” say Ringler, while a woman in her early 30s has up to a 70 percent rate. One proven way to conquer fertility decline from aging eggs is using a donor egg. (A woman’s eggs start to decline in fertility in the late 20s. “At 40, most women drop off the cliff,” says Steinberg.) “For a woman in her mid-40s who uses a donor egg, her pregnancy rate jumps up to 75 percent per treatment cycle,” says Ringler, who thinks donor eggs are the best option for “all women 44 and older, an age when 95 percent of eggs are chromosomally abnormal.” Adds Steinberg, “Nature won’t let abnormal embryos make babies.”
Egg donation, however, is a largely unregulated industry. Says the owner of an entertainment PR firm that reps top actors and musicians who experienced secondary infertility at age 41, “Nothing’s done to say the donor’s fertile, sane or healthy.” After spending $2,500 on tests for a donor who proved to have low fertility, the publicist and her husband chose a second donor who produced eight eggs: “She looked like me, had a great GPA and was athletic.” Two embryos were transferred, and she had twin girls at 44.
Most donor eggs come from women in their 20s, paid $5,000 to $10,000 to undergo egg retrieval. “Bloating was the biggest downside,” says an egg donor named Sara, who first donated eggs in 2007 when she was a 22-year-old acting student. (Sperm donors are paid $75 to $150 a go for a vial of sperm that might sell for $700 or more.) Regardless of the number of eggs produced, they all belong to the intended parents. Sara knew nothing about her client except that he wanted an Italian baby and she’s Italian. “You don’t sign up to be part of someone’s family,” she says. “You do it because it is selfless and you are strong enough to deal with the idea afterward.”
Disclosure is one of the stickiest issues with egg-donor use, which one L.A. mom, who suffered three miscarriages on the way to a biological son at 42, calls the “last bastion of shame” in fertility medicine. It’s common for couples to seek out a donor who resembles them to “pass” — letting family, friends and the kids themselves believe they are the genetic parents. Several Westside fertility doctors say that about half their patients plan to keep their offspring’s origins under wraps; Steinberg estimates 70 percent of his patients do. The PR firm CEO is one of them: “I carried them. My blood ran through them,” she says. “I don’t want them to think they’re not mine.”
Clinics that see more gay couples and single women are likely to report more openness; those parents have to explain their children’s origins somehow. Says psychologist Elaine Gordon, author of Mommy, Did I Grow in Your Tummy?: “What we’ve learned is that for children who know and know early, it’s not that big a deal. There’s no ghost living in the house with them.”
Oddly perhaps, hiring a stranger to carry a child for you has become less taboo than buying an egg. Nicole Kidman used a surrogate for her youngest child, born when she was 43. Sarah Jessica Parker used a surrogate to carry her twin daughters, who went home to a 44-year-old mom. Both actresses were effusive in their thanks to their carriers but avoid discussing the genesis of the eggs.
The evolving norm is that the gestational carrier (the preferred term over surrogate) and egg donor — assuming there is one — should be two separate people. Agencies with the strictest standards recruit only carriers who have completed their own families. Paid between $20,000 and $30,000, a carrier might go through as many as five pregnancies, sometimes returning to work with the same family when they want a sibling.
“Personality-wise, both egg donors and surrogates are motivated by a mix of altruism and healthy narcissism,” says psychologist Kim Bergman, co-owner and co-founder of Growing Generations, a top surrogacy and egg donor agency with a comprehensive approach. This highly selective agency, with just 1 percent of women who apply qualifying for the job, brokered Parker’s twins. Contracts are firm, and while parents pay medical bills and other expenses — including a premium of $5,000 to the carrier in the event of multiples — fees are kept modest. “It’s not a million dollars for a reason,” says Bergman. “We want the surrogate to be compensated for her pain and suffering” but not to be in it for the money.
Steinberg’s clinic, which has in-house surrogates, is unusual in that it will accommodate clients who prefer carriers to remain anonymous — to them. “We do a lot of celebrities who use a surrogate mother,” he says. Steinberg recruits repeat surrogates for anonymous jobs “all the time,” but it’s challenging because “what surrogates get out of it is that emotional bond. If they don’t know whom they’re helping, it’s tough on them.”
Once a healthy child is born, parents are faced with what to do with unused embryo “siblings,” which cost hundreds of dollars annually to keep in deep freeze. Increasingly, people are allowing excess embryos to be “adopted” (it is considered unethical for embryos to be bought or sold). Those embryo adoptions often are anonymous, creating full biological siblings who may never know of one another’s existence.
Some of these conundrums may be avoided by freezing eggs before fertility declines. Sperm and embryos are easier to freeze than eggs, which contain lots of water. In the past few years, clinics have adopted vitrification, which flash-freezes the egg without forming ice. It has quadrupled the egg-survival rate, contributing to the American Society for Reproductive Medicine’s 2012 decision to upgrade egg freezing from “experimental” to “standard.” Says Steinberg, “Now we say a frozen egg is pretty much as good as a fresh egg.”
Sheryl Ross, a Santa Monica OB-GYN with a long roster of A-list patients, says she talks to them in their early 30s about egg freezing (which is becoming a go-to college and grad-school graduation gift among well-off families). “To freeze your genetics and take the pressure off is so empowering,” says Ross. Most clinics charge $5,000 to $10,000 a cycle, which produces anywhere from a couple of eggs to a couple dozen; most doctors recommend banking 15 to 20 eggs. Egg-freezing costs are “frankly what some people spend on purses,” says Beverly Hills RE Mark Surrey, who treated Kim Kardashian as she prepared to freeze her eggs in 2012 (she ended up conceiving naturally).
Steinberg notes that egg freezing is “one of the most common things bringing in celebrities right now, if you’re doing a movie and you’ve got three more lined up.” Steinberg has had actresses in their early 20s freeze their eggs: “Fame may last a long time, but fertility is fleeting.” The Real Housewives of Miami alumna Joanna Krupa, 35, got married in June but says she’s still two years away from motherhood; she froze her eggs with Steinberg in December. “I’m going to have kids when I’m ready so I can give them 100 percent,” says the reality star.
One Missouri clinic is flash-freezing entire ovaries, surgically removing the healthy organ and reimplanting it years later when a woman is ready to be a mother. Though most patients so far have been cancer victims facing radiation or chemo treatments, Dr. Sherman Silber of the Infertility Center of St. Louis believes the procedure is cheaper and more effective than egg freezing. To date, more than 35 infants have been born from the ovaries-on-ice approach worldwide, four of them from Silber’s clinic.
But among fertility doctors, “the worst is the woman who at 43 wants to talk about egg freezing,” says Ross, who agrees with Ringler that ceaseless coverage of aging celebrity moms is to blame. “We in the medical world know that 99 percent of those women used donor eggs. That’s what’s not discussed in the story.”