This post was co-authored with Gamal Serour, M.D.
Earlier this month Argentina joined the list of countries that subsidize in vitro fertilization (IVF) for its citizens. Overwhelmingly passed by the Chamber of Deputies and previously approved by the Senate, IVF is now available to heterosexual couples, single women, and gay couples, whose unions are legal thanks to the passage of the first gay marriage law in Latin America in 2010. President Cristina Kirchner summarized this development as "more rights, more inclusion, better country."
The law's basic tenet is that every adult, regardless of marital status, sexual orientation, gender expression, or economic situation, has a right to reproduce. Now Argentina, like the United Kingdom, Belgium, Germany, Israel, and the province of Quebec, is committed to providing IVF as a matter of universal health care and services.
The United States remains one of the holdouts on all fronts - IVF still costs an average of $15,000-$30,000 per cycle -- a sum beyond the reach of many families who do not have savings, are not able to take out a second mortgage, nor borrow such a hefty sum. Some insurance plans cover IVF and some states provide support for the first steps of the process but consistent and full coverage remains elusive.
By incorporating IVF into health services as a matter of human rights, Argentina has an unprecedented opportunity to attain reproductive justice with a technology that is an unthinkable luxury for many infertile parents around the world. Its new IVF law is predicated on non-discrimination and an acknowledgment that infertility is a medical condition deserving of treatment. Strikingly, Argentina is bucking the trend in Latin America, where there is scant medical assistance for IVF, and until overturned by the Inter-American Court of Human Rights last fall, was the hemispheric home to the only nation in the world, Costa Rica, with an outright IVF ban.
Many Argentines are proud of the IVF law, which distinguishes it, in the words of César Cigliutti, an Argentine gay rights leader, as the "country that most respects diversity in Latin America."
The law prohibits the commercialization of eggs, sperm, and other embryological or genetic material. In addition, it covers the cryopreservation of embryos and the storage of eggs and sperm for persons undergoing treatment for cancer who hope to reproduce in the future. Undoubtedly there will be demand for these services. Argentina has a robust and growing use of IVF, accounting for 25 percent of all attempted cycles in Latin America in 2009, and experts soon anticipate up to 40,000 cycles per year.
The IVF law follows on the heels of a similar, although less capacious law, passed three years ago in the province of Buenos Aires. From the perspective of Sebastian Gogorza, current president of the Argentine Society of Reproductive Medicine (SAMeR) the IVF law constitutes "a great medical and social advance, undergirded by a laudable commitment to access and inclusion." Gogorza is very optimistic about the new law; however, he notes there are many critical issues -- practical, ethical, and clinical -- that will need to be worked out carefully during its implementation and regulation.
Alejandra Koreck holds a similar opinion. A Buenos Aires psychiatrist who counsels patients struggling with infertility, Koreck has witnessed many times the "frustration of potential parents who could not access IVF for economic reasons." In her estimation, this law is a "very important step for our country," but she underscores that IVF remains a sensitive topic that "requires an ongoing transdisciplinary dialogue among physicians, lawyers, ethicists, psychoanalysts, and patients."
Indeed, there are real challenges to achieving the law's lofty goals.
At least in its initial articulation, the law optimistically presupposes that Argentina has the finances and medical infrastructure to support IVF and attendant ART (Assisted Reproductive Technologies) on a broad scale. While state-of-the-art IVF clinics can be found in metropolitan areas like Buenos Aires or Córdoba, how can IVF be provided in less resourced and more remote parts of the country?
One promising option would be the roll out of more economical services, as promoted by the Low-Cost IVF Foundation based in Switzerland. Soft stimulation protocols, wider use of modified natural cycles or natural cycles in young patients with regular ovulation are other alternatives. Certainly more research is needed, particularly studies of in vivo fertilization in IVF programs to reduce the cost and technology of the embryo lab. International drug companies will have to reduce the price of ovarian stimulation drugs in developing countries to substantially reduce the cost of IVF cycles.
Furthermore, many mechanisms and safeguards for these procedures are not spelled out in the law, nor is the number of IVF procedures that will be covered by the national health plan. As a point of reference, Israel covers assisted reproduction for up to two "take-home" babies. The Canadian province of Quebec pays for up to six cycles of IVF, on the condition that only one embryo is implanted per cycle. Nor does the law stipulate any upper age limits for IVF use or precisely clarify acceptable research involving un-implanted embryos, although a high court recently ruled they could not be destroyed, but instead must be cryopreserved or donated in order to preserve "right to life and dignity." In a predominately Catholic, although not necessarily observant country, where abortion remains illegal such moral and theological discourse will continue to be part of any debate around appropriate uses of stored or discarded embryos.
There are small but real risks associated with IVF, particularly when women are given high doses of fertility stimulating hormones to increase egg production, a practice that is common in the United States and the United Kingdom; most concerning is the potential of developing severe ovarian hyperstimulation syndrome (OHSS). Because of the risks associated with high doses of hormones, a growing number of clinics in Europe and Japan are utilizing low dose IVF as a safer if slower alternative. According to Liliana Blanco, past president of SAMeR, "Argentine physicians to date have rejected high dose IVF," and she is hopeful this best practice will continue.
The principles of access and non-discrimination that Argentina's new law enshrines certainly justify the celebrations that have greeted the news.
Yet as Marcy Darnovsky of the Center for Genetics and Society, reminds us, "assisted reproduction raises additional issues of justice that have yet to be addressed in Argentina - or in most other countries." Some of the questions that she and colleagues affiliated with the Pro-Choice Alliance for Responsible Research have asked in the context of the United States are applicable to Argentina today, such as whether or not gamete donors will be allowed to remain anonymous, or if "donor offspring" will be able to learn the identity and medical status of their biological parents. One significant issue, especially given a potential concomitant rise in prenatal testing in Argentina, is whether the counseling mandated in the new law will be sensitive to people with disabilities in terms of expanding possibilities to select against certain genetic variations, and whether parents will be allowed to select the kind of children they will have, up to and including their sex and other clearly non-medical traits.
As Argentina's law moves from federal decree to clinical implementation, the country has the opportunity to follow, and hopefully follow through on, a rights- and justice-based model of IVF provision.
Gamal Serour, M.D., is Professor of Obstetrics and Gynaecology, Director of the International Islamic Center For Population Studies and Research, Al Azhar University (IICPSR), and past president of the International Federation of Gynecology and Obstetrics. Dr. Serour has authored and co-authored 371 papers published in international, regional, and national journals and 28 chapters in international books, and edited and co- edited 18 books. He has been an invited speaker and keynote speaker at national, regional and international conferences organized by ESHRE, IFFS, ASRM, RCOG, FIGO, IAB, WHO, UNFPA, UNICEF, UNESCO and other societies of Ob/Gyn around the world.