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Pre Implantation Genetic Diagnosis and Sex selection

Dr. Kaberi Banerjee, Moolchand Medcity, New Delhi 19 August 2007   The choice of a particular sex for a baby is either made for medical or non medical reasons. The medical reason for undergoing sex selection is to select  a female fetus in order to rule out X linked conditions like Duchenne Muscular Dystrophy and Haemophilia. The non medical reasons are  a couple's preference of one sex over the other. This could be due to cultural / economic reasons or family balancing (the desire to  have a family that includes children of both sexes). While there is virtually no moral or ethical dilemma regarding sex selection for medical reasons, sex selection for non medical reasons is highly debatable. There are two separate social and cultural scenarios where sex selection for non medical reasons may be desired. One is a condition, mainly in the west, where there is no bias towards a particular sex and sex selection is only for family balancing. The other situation is where there is a geographical/society based preference for a particular sex. This is present in South East Asia and China where there is a strong preference for the male child. Allowing sex selection in societies with a bias towards a particular sex is asking for trouble in the long run. Already, in some provinces of India the female-male ratio is as low as 810 females to 1000 males and in some provinces of China it is as low as 677 females to 1000 males. This will eventually irreversibly affect the social structure in these countries. As a concerned old man in a Chinese daily mentioned  ‘Who will my grandson marry?". This will also increase crimes against women. This is already evident in the Northern states of India where crimes against women are rising. It has been reported  that young girls from the eastern states of India are kidnapped and sold into marriage in the neighbouring western states where sex selection is more prevalent. There are various means by which sex selection is performed - sperm sorting, pre- implantation genetic diagnosis (PGD) , ultrasound detection of sex of the fetus followed by termination of the fetus of the undesired sex and finally infanticide. The last two methods are criminal  offences and we shall not discuss them further. PGD for sex selection is considered  advantageous over ultrasound determination of the sex and then feticide. But we cannot ignore the fact that an embryo has life and it is absolutely perfect except for the fact that it does not have the desired sex which the parents want. In this situation, the use of PGD is ethically contentious.  Furthermore, the latest article in the New England Journal of Medicine has conclusively proven that PGD in women under going IVF with increased maternal age does not improve live birth rates. PGD may also reduce pregnancy rates in women undergoing IVF solely for sex determination. IVF with PGD solely for sex selection holds great risk for unwarranted gender bias, social harm and the diversion of medical resources from genuine medical need.  PGD solely for sex selection is banned in many countries.  France, United Kingdom, Canada , Japan, India and Australia being some of them. Though the American Society of Reproductive Medicine has discouraged use of PGD solely for the use of sex selection, it is still not banned in the US for this purpose. Well-off foreign couples are getting around laws banning sex selection in their home countries by coming to American soil - where it's legal - for medical procedures that can give chosen sex of their child.. This kind of practice is reinforcing sexism, diverting resources for actual medical needs and must be strongly discouraged. The issue of sex preference and selection on a societal level needs to be addressed in its root. Clearly if this practice continues and has further progressed via assisted reproductive techniques the exacerbated imbalance will hugely affect many generations to come. However, once there is women empowerment and women are financially strong this gender bias will slowly erase. Let us take for example India. India now has a woman President, a female prime minister before many western countries, and women in cities are doing professionally and financially well in fields like medicine, law, finance and journalism. .Yet women are harassed for dowry and a female child is considered a burden. If a section of society can achieve empowerment then why not all... educating the masses is essential. Boys and girls have to be treated equally, incentives for women education and jobs must be enforced. This will take time ....maybe two or three generations for the mindset to change, but it is not impossible. In my opinion sperm sorting for family balancing in a society where there is no preference for a particular sex is justifiable. However these couples need to know that there is a 25% chance of having a baby of the undesired sex by this method. I would therefore conclude by saying that PGD must be restricted only for identifying medical disorders. Its indication for sex selection must be banned in societies where there is traditional gender bias for the male child. The problem must be addressed at the root and emphasis must be to bring a change in traditional mindset.

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Visitor comments (3) Write a comment Dear Dr Pal This is an interesting article which raises many pertinent social and ethical issues that ART lead to. Although I am in agreement with you about not recommending PGD for sex-preselection as that would be promoting gender biases. However, I would like to question some of the consequences that you fear following sex preselection. You mention that crimes against would increase as the number of females would go down.. but would not it be otherwise that if the number of women are lower then they would be more valued. Humans value what is not available... For example, the west after being materialistically satiated searched for spirituality towards the east. On the other hand, the east looked for materialism.. Consider coal and diamonds - diamonds are valued because they are not available in plenty.. Please note that I am not for PGS.. these are more of 'for the sake of argument'.. -- Secondly, the 'shortage' of marriageable women in the Punjab has led to them arranging for marriages with women from Kerela. Despite the language, culture, food habits differences, these marriages seem to be working. Difficult to sit on judgment whether this is good or not. Geo-politically, it is good as the divisions would diminish but would that also mean 'mixing' of races! -- Thirdly, you mention, 'an embryo has life' which itself a whole lot of questions on when does life begin! Dr. Steinbock recently published an interesting article in Embryo Talk on this issue. 20 August 2007 - Rajvi H. Mehta An interesting and pertinent article. I do not think that sex selection for medical reasons will be objected to by many, and PGD is definitely more acceptable that the other options. However, now that some clinics are offering sex selection for either medical or family balancing reasons, I beleive it will not be long before this technique is much more widespread. Both in order for the clinics to be competitive and often because 'it is what the patient wants'. I also think that, as is common with new technology, public opinion will eventually change from dissent to apathy and sex selection will eventually be less of a moral issue. Also, it is difficult to ban a clinic or country from a technique such as this when other clinics/countries are routinely using it, and with IVF tourism becoming such big business. I agree with Dr. Rajvi H. Mehta that in time, in countries where there is a preference for a particular sex, ultimately the other sex will be more valued. Especially now that there is so much work which is intellectually based as oposed to the historically physically based work (farming, etc.). It is curious that these countries tend to be over populated and the preference for a particular sex should limit the ability to reproduce. Ultimately the male youth in these countries will want to marry a woman, and want their male children to marry, and there should be a shift in thinking. Some of these countries (China and India) are also going through an economic boom meaning the population has more money and opportunities than they have ever had before. As Dr. Rajvi H. Mehta says it is human nature to value that which is rare, and with government action in these countries I hope for a more balanced outlook. Perhaps sex selection could be permitted in these countries if patients wanted to select, for example, girls where there is a societal preference for boys. I looked forward to opinions from other readers. 24 August 2007 - Thomas Elliott Very interesting article. If the couple already have a child of one gender and want to have another child of another gender then they should have the right to do so. This could be done with proper counseling. Sperm selection and ICSI has a good potential here. But this needs debate and concensus. 30 August 2007 - Mr. M. D. Kini.