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'The Handmaid's Tale' And Modern Fertility Struggles

I first read The Handmaid's Tale soon after it was published in 1985. In 1985, I did not know that I would one day become a reproductive endocrinologist and fertility doctor who would specialize in in vitro fertilization (IVF). Indeed, I likely did not know what IVF was.
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One of the earliest recognized handmaids was Hagar. Sarah asked her husband Abraham to "lie with" Hagar so that she might have children by her. Before assisted reproductive technology (ART), people who could not conceive naturally might have children through traditional adoption or traditional surrogacy. Hagar was, by today's definitions, a traditional surrogate. A traditional surrogate is a woman who provides both her egg and her uterus for a potential pregnancy.

I first read The Handmaid's Tale soon after it was published in 1985. The story centres around a Republic of Gilead that demotes women and experiences frustrated reproduction secondary to pollution and sexually transmitted diseases. As a solution to the latter, handmaids became a primary assistant to the lady of the house. The handmaid's purpose was to perform household duties as well as to "lie with" the man of the house in a "ceremony" to produce children for the couple whose female partner is presumed to be infertile.

In 1985, I did not know that I would one day become a reproductive endocrinologist and fertility doctor who would specialize in in vitro fertilization (IVF). Indeed, I likely did not know what IVF was:

1. The first IVF (test-tube) baby was born in 1978: Louise Brown. She has children of her own.

2. The first successful donor egg pregnancy followed in 1983.

3. The first gestational surrogate (GS) pregnancy occurred in 1986.

Each event made the subsequent success possible.

Today, traditional surrogacy is not often performed because the surrogate may refuse to give the child to the intended parents. Since the egg and the uterus belong the traditional surrogate, in many jurisdictions she may be able to keep the child. A GS differs because the egg and sperm are from two other people and the GS hosts the pregnancy for the intended parents. The GS does not have a genetic link to the child, making it more difficult for her to make a claim.

Laws around gestational surrogacy vary among countries, provinces and states. In British Columbia, for example, the Family Law Act (2013) allows for three parental names on the birth certificate and the intended parents are not required to "adopt" their child from the birth mother. In other jurisdictions, intended/ genetic parents are required to adopt the child from the birth mother (surrogate).

Who needs a gestational surrogate?

1. Women who do not have a uterus:

a.) This can occur congenitally as a condition called Mayer-Rokitansky-Küster-Hauser Syndrome. These women do have ovaries and typically ovulate regularly and can provide the egg for a pregnancy.

b.) This can also be the result of surgery for uterine fibroids, uterine or cervical cancer, or from a complicated delivery.

2. Women who cannot carry a pregnancy due to

a.) medical contraindications: Some examples include large uterine arteriovenous malformations, congenital or acquired heart disease,

b.) an incompetent cervix or uterus (due to pelvic radiation or severe scarring known as Asherman's Syndrome).

3. Women who have suffered high numbers of unexplained recurrent pregnancy loss

4. Single male parents or same-sex male couples

Nevertheless, it can be very difficult to find a GS. In the United States it is legal, though expensive, to pay / compensate a gestational surrogate in some states. In Canada, it is not legal to pay/ compensate a GS. Ideally, a GS should have a pristine medical and obstetrical history and should have completed her childbearing in case a complication of pregnancy prevents her from future pregnancies.

Gestational surrogacy is complicated. In Canada, prohibited compensation protects against "uterine trafficking " and financial coercion of potential gestational surrogates. However, it also limits the availability of gestational surrogates for medically indicated cases. Limiting gestational surrogacy to uncompensated carriers also usually limits available carriers to close friends or family members who are willing and want to help. Most patients do not have family or friends who can do this for them. Also, such arrangements do not prevent psychological coercion and potentially complicated relationships.

Gestational surrogacy relationships are managed through legal contracts. However, autonomy over one's body supersedes contractual obligations. If there is a complication of pregnancy and the intended parents and the surrogate differ in their opinions of what should be done, there is little doubt that the intended parents cannot "force" the surrogate into a procedure/treatment course to which she does not consent.

While The Handmaid's Tale foreshadows some of today's struggles with fertility, the Republic of Gilead demotes women and makes many incorrect fundamental assumptions. Firstly, 40 per cent of fertility is due to male factor and not female factor. Secondly, while environmental factors may play a role in current fertility patterns, the incidence of sexually transmitted diseases has decreased. Many people delay starting a family. This has increased the need for and utilization of assisted reproductive technologies such as in vitro fertilization, donor egg and gestational surrogacy.

Also today's "modern family" is unconventional and includes single parents, same-sex parents and transgender parents. Any of these parents may require complimentary gametes (sperm or egg) and in some cases they may need to "borrow" a uterus to have a child. Adoption remains a wonderful way to have a family but availability, timelines, costs often in excess of fertility treatments and uncertainty remain barriers for patients who are open to adoption.

Today's assisted reproductive technologies also include fertility preservation through egg/embryo freezing. Preimplantantion genetic diagnosis prevents the transmission of lethal or morbid single gene defects such as Huntington's disease. Preimplantation genetic screening increases reproductive efficiency by preventing the transfer of chromosomally abnormal embryos that are more likely to result in failed implantation, miscarriage or pregnancies with significant health concerns.

Modern reproduction has advanced to build today's modern families. Margaret Atwood's The Handmaid's Tale was based in fantasy and fiction. Nevertheless, the story held some interesting insights and is perhaps more relevant than ever even if not with regards to traditional surrogacy.

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