“I did everything humanly possible”: the process of making reproductive decisions in the context of assisted reproduction in Chile

ABSTRACT

The options for intervention opened by assisted reproductive technology (ART) oblige its users to make decisions that drag them into a “moral odyssey.” This paper explores the decision-making of mothers and fathers in Chile who opted to use ART as a means of having a child. Methods: The results are based on a qualitative study. Thirty-two in-depth interviews with mothers and fathers who had children through ART were analyzed using thematic content analysis. Results: The participants would have liked to be guided by the doctors and not be forced to make decisions. However, when treatments fail and become more complex, they are obliged to make decisions on matters they perceive as akin to science fiction. On the one hand, they feel they must do everything possible to have a child but, on the other, they believe they must establish limits to determine how far it is morally acceptable to go. To identify these limits, they ask themselves what is natural and what the divine will is. Conclusion: The need to exhaust all the possibilities to have a child means always asking oneself where to set the limits of what is morally acceptable. People view the creation of human life and ties of kinship as things that should be beyond human will. Parents want to be sure they will have children but also want to be able to leave things in “the hands of God” or “the hands of nature.”

RESUMO

As possibilidades de intervenção abertas pelas técnicas de reprodução assistida (TRA) fazem com que as pessoas que passam por elas enfrentem a necessidade de tomar decisóes que as arrastam para “odisseias morais.” Este artigo explora o processo de tomada de decisão de mães e pais que optaram pela TRA para ter um(a) filho(a) no Chile. Métodos: Os resultados são baseados em um estudo qualitativo. Foram analisadas 32 entrevistas em profundidade com mães e pais que tiveram filhos através da TRA. Foi utilizada análise de conteúdo temático. Resultados: Os(as) participantes gostariam de ser orientados pelos médicos e não precisarem tomar decisões. No entanto, à medida que os tratamentos fracassam e se tornam mais complexos, eles e elas são forçados a decidir sobre tópicos que parecem próximos à ficção científica. Por um lado, sentem que devem fazer todo o possível para ter um(a) filho(a) e, por outro, acreditam que devem estabelecer limites para identificar até que ponto é moralmente aceitável ir. Para identificar esses limites, eles se perguntam o que é natural e qual será a vontade divina. Conclusão: A necessidade de esgotar todas as possibilidades de ter um(a) filho(a) significa sempre se perguntar onde colocar os limites do que é moralmente aceitável. Para as pessoas, a criação da vida humana e os laços parentais devem estar além da vontade dos indivíduos. Os pais querem ter certeza de que terão filhos(as), mas eles e elas também desejam ser capazes de deixar as coisas “nas mãos de Deus” ou “nas mãos da natureza.”

RESUMEN

Las posibilidades de intervención abiertas por las técnicas de reproducción asistida (TRA) hacen que las personas que se someten a ellas se enfrenten a la necesidad de tomar decisiones que los arrastran a “odiseas morales.” En este artículo se explora el proceso de toma de decisiones de madres y padres que optaron por las TRA para tener un(a) hijo(a) en Chile. Métodos: Los resultados están basados en un estudio cualitativo. Se analizaron 32 entrevistas en profundidad a madres y padres que tuvieron hijos(as) a través de TRA. Se utilizó análisis de contenido temático. Resultados: Los(as) participantes desearían dejarse llevar por la guía de los médicos y no tener que tomar decisiones. Sin embargo, a medida que los tratamientos fracasan y se complejizan, se ven forzados a decidir sobre temas que les parecen cercanos a la ciencia ficción. Por un lado, sienten que deben hacer todo lo posible para tener un(a) hijo(a) y, por otro, creen que deben establecer límites para identificar hasta donde es moralmente aceptable llegar. Para identificar estos límites se preguntan qué es lo natural y cuál será la voluntad divina. Conclusión: La necesidad de agotar todas las posibilidades para tener un(a) hijo(a) conlleva estar siempre preguntándose dónde poner los límites de lo aceptable moralmente. Para las personas la creación de la vida humana y de los lazos parentales deben estar más allá de la voluntad de los individuos. Los padres/madres desean tener la seguridad de que tendrán hijos(as) pero también anhelan poder dejar las cosas “en manos de Dios” o “en manos de la naturaleza.”

KEYWORDS:

• Assisted reproduction technologies
• reproductive decisions
• qualitative methods
• Chile

PALAVRAS-CHAVE:

• Técnicas de reproduçao assistida
• decisoes reprodutivas
• métodos qualitativos
• Chile

PALABRAS CLAVE:

• Técnicas de reproducción asistida
• decisiones reproductivas
• métodos cualitativos
• Chile

Introduction

Assisted reproductive technology (ART) has expanded the range of what is possible in human reproduction, posing new ethical challenges. What is considered acceptable has changed over time and varies across countries. Around the world, regulatory systems also differ greatly (Richards 2014). ART is not transferred neutrally but is translated into local practices and languages (Raspberry 2007). According to Asplund (2020), assisted reproduction involves a complex interaction between rapid scientific-technological development and changes (and continuities) in societal values. The use and regulation of ARTs raise questions about what constitutes human life, what elements determine parenthood, and to what extent it is legitimate to intervene in reproduction. People who use ARTs are forced to ask these questions.

The research on which this paper is based corresponds to the field of reproductive studies, which examines how babies are procreated and analyzes the cultural impact of ARTs (Faircloth and Gürtin 2018). Research in this field has shown sustained growth since the birth of the first baby through in vitro fertilization (IVF) in 1978. It has emphasized the family configurations made possible by reproductive technologies (homoparenthood, co-parenting, elective single-parenting). It has explored how the different actors (mothers, fathers, donors,¹ surrogates, health professionals) react to the new possibilities of intervention offered by technologies such as IVF, the donation of gametes and embryos, surrogacy, the preservation of fertility and prenatal diagnosis (Faircloth and Gürtin 2018; Franklin 1997; Graham and Braverman 2012; Herrera 2009; Herrera et al. 2018; Jociles, Rivas and Álvarez, 2017; Lupton 2012; Mozersky et al. 2017; Rapp 1999; Smietana 2013, 2016; Thompson 2005). It has also reflected upon the ethical challenges raised by the use of ARTs (Asplund 2020).

The tensions that individuals face in today’s world are mirrored in assisted reproduction practices: the quest for autonomy and meaning, the experience of uncertainty and the desire for certainty, the ability to choose, and the weight of one’s own decisions. Franklin (1997) indicates that, for couples, infertility is an obstacle, in what is considered the “normal” and “natural” progression from marriage to parenthood, standing between them and the life they expected to lead. In the past, the natural facts of human reproduction provided certainty. By comparison, the attention now paid to reproductive risks and the development of technology have transformed reproduction into a source of uncertainty (Franklin 1997; Silva and Machado 2010).

People who undergo assisted reproduction treatments are not only seeking to have a child, they are also seeking an answer to the uncertainty caused by infertility. According to Franklin (1997), women need to feel they have done “everything possible” to become a mother. Assisted reproduction appears to offer a solution to reproductive uncertainty: either they will have a child or they will have exhausted all the options. However, this promise often fades as they come up against the surprising complexity, difficulty, and ambiguity of the treatments. Even so, the possibilities seem inexhaustible and one decision leads to another, making it very difficult to abandon the treatments (González-Santos 2016; Peddie, Van Teijlingen, and Bhattacharya 2005). Doing everything possible to “create a child together” inevitably entails decisions about what is morally acceptable in a field that, for the couple, is strange and unfamiliar (Nordqvist and Smart 2014).

According to Bauman (2000), uncertainty and insecurity are distinguishing features of the world in which we live. People try to grasp the promise of certainty through consumption and the possibility of choice, that give the illusion of control over reproductive uncertainty. ART offers different treatments at different prices. Those who can pay initially feel they are about to achieve reproductive security. However, as Bauman points out, the prized possibility of choosing has its drawbacks and tends to bring new uncertainties. Moreover, in unequal societies, not everyone has the opportunity to choose. Reproductive studies have also drawn attention to the inequality of the “global landscape of reproduction” (Franklin 2011). In other words, reproductive decisions take place on an uneven terrain where inequalities in economic, racial, ethnic, religious, class, and gender terms play a decisive role (Göknar 2013; Inhorn and Van Balen 2002; Inhorn and Wentzell 2011; Thompson 2005).

The new options for intervention mean that ordinary people have to make decisions that, as pointed out by Beck and Beck-Gernsheim (2002), drag them into a true “moral odyssey.” The freedom to make choices and decisions increases the uncertainty of the reproductive process. Technology means that nature, instead of seeming fixed, becomes malleable (Franklin 1997).

For example, the information provided by prenatal diagnostic technologies – ranging from ultrasound to preimplantation genetic diagnosis (PGD) – can be used to make decisions and intervene in the reproductive process. Since mothers and fathers want to give their children the “best possible start in life” (Beck-Gernsheim 2002), they want to avoid the birth of children with disabilities or serious illnesses (Rapp 1999). Some of the decisions taken by the actors involved (mothers, fathers, health professionals) to control reproduction and ensure the birth of “desirable babies” consist of selecting donors with specific characteristics, selecting embryos or terminating pregnancies if the baby is not expected to be healthy. The people who may use PGD want to have healthy children but are concerned about the moral and ethical implications of discarding embryos (Genoff et al. 2018; Hershberger and Pierce 2010).

Areas that were previously considered morally neutral, therefore, become moral objects when human choice is involved (Bestard 1999). Rapp (1999) asserts that in the field opened up by reproductive technologies, pregnant women have become “moral pioneers.” Bernasconi (2015) proposes expanding the conception of the moral from the sphere of norms and what is correct to the sphere of value so that social studies can include the question of what is good or what is the “good life” to which people commit. Moral coordinates are a resource or a cultural tool that people can use to intervene in situations in which they find themselves and to give meaning to their experiences and decisions. These coordinates become explicit when people’s beliefs or stances are challenged (Bernasconi 2015). This is the case with ART. For example, Raspberry and Skinner (2011a, 2011b) describe how women diagnosed with fragile X syndrome have to review their reproductive imageries and decide what it means “to do what’s right”: does it mean to be “genetically responsible” and not have children who could inherit the gene?

Morality, understood as a cultural tool, is based on a historically variable set of ideas of what is good and just. It, therefore, takes specific forms depending on the local and historical context (Bernasconi 2015). For example, according to Roberts (2006), in the “moral landscape” of doctors in Ecuador, religion is not separated from the scientific practice of medicine while Raspberry (2007) argues that, unlike their peers in Ecuador, doctors in Argentina keep medicine and science separate from religion and society. This transforms them into moral guardians who decide when and how human life should be protected.

Studies of ART in Latin America

Ariza (2016) indicates that empirical studies of users’ experience of ARTs and medical practices are scarce in Latin America, while González-Santos (2016) notes the scant interest that academia in the region has shown in how biotechnologies associated with reproduction are assimilated and transformed. Some of the studies that have been carried out analyze the relationship between science, technology, nature, religion, and the transcendental in the field opened by ARTs (Ariza 2010; González-Santos 2013; Herrera 2011; Raspberry 2007; Roberts 2006).

According to Ariza (2010), women in Buenos Aires suffering from infertility view technological intervention as a deviation from the idealized natural path. Nature is associated with something that is good in itself (it is fertile and productive). As these women encounter difficulties in conceiving, they come to see this natural path as ever more elusive and reproduction becomes “denaturalized.” To avoid this “denaturalization,” treatments are understood as “a helping hand for nature” (Ariza 2010). In this way, procreation is seen as a process that can be improved and controlled by technology but can still be thought of as a natural process because ART enables biological reproduction (as opposed to how adoption is understood) and its practices imitate – and restore – “what is natural” (Ariza 2010). The question of when procreation ceases to be natural goes hand-in-hand with the question of when technological intervention is considered morally questionable.

González-Santos (2013) analyzes how assisted reproduction is represented and understood in medical discourse and by users in Mexico. In medical discourse, ARTs imitate nature but also improve it because nature is seen as inefficient and imperfect. In users discourse, we can observe that what is natural and artificial is used as a criterion for evaluating ARTs. In this process of constant evaluation, users adjust their religious beliefs to make them compatible with the use of ARTs to conceive a child. To this end, they involve God in reproductive procedures. If they are successful, it is because this is what God wanted.

Raspberry (2007) reports that, in Argentina, medical professionals in the field of reproduction try to depict ARTs as merely a biomedical treatment through which to bypass nature’s failings. In this way, they purify science, separating it from a social order where religious beliefs, economic considerations, and social values carry great weight. ART represents a doubly “purified” science since it is considered neither social nor natural.

The situation described by Roberts (2006) in Ecuador is different. There, reproductive medicine professionals combine the domains of the scientific/technological with the spiritual. They invoke the divine will to give meaning to the treatments’ results and legitimize their practices.² Here, there is no contradiction between scientific modernity and the miraculous and personal intervention of God. For doctors and laboratory workers, being modern subjects does not imply being secular subjects. At different moments in the treatments, the professionals declare that their success is in the hands of God. This position of humility allows them to argue that they are not responsible for the creation of human life.

In Chile, there have been very few studies of ARTs and their implications. One survey³ in Santiago found that 88% of the city’s inhabitants approve of using medical support to conceive and that there is strong support for the use of IVF by heterosexual couples and single women (Herrera et al. 2013). Only 17% agreed with the statement “The use of in vitro fertilization is not correct because it is ‘playing God’,” and 28% with the statement “It is not correct to become pregnant in this way because it is not natural.” People who are in favor of ARTs tend to be young, not religious, and of a medium-high socioeconomic level. A qualitative study (with interviews and focus groups⁴) found that the arguments most commonly used to justify the rejection of ARTs are that they involve the manipulation and commercialization of human life and that God’s will must be obeyed (Herrera, Teitelboim, and Zegers-Hochschild 2015). When analyzing the perceptions of men and women with cryopreserved embryos, Velarde et al. (2018) found that these embryos are considered a child (53.2%) or a potential child (40.7%). Most respondents rejected the option of discarding them or using them for research while around half indicated that they would be willing to donate them to another couple for reproductive purposes (associating this with adoption).

This paper seeks to contribute to scientific and technological research from the standpoint of reproductive studies. According to Ariza (2016), the aim of scientific studies

is to understand the practices through which scientific knowledge is produced, the connections between science, technology, the state, the economy, industry or law and the ways in which the different players participate in the formation of scientific objectives and evaluate their results. (2016, 365)

Here, we explore how people who have used scientific and technological advances in the reproductive sphere try to make decisions about what is legitimate and good or, in other words, how they determine the moral limits of the intervention of science and technology in processes such as the creation of human life and ties of kinship. To address this question, I analyze the biographical accounts of mothers and fathers who had children through ART. According to Bernasconi (2015), in their biographical narratives, individuals reveal their ideas of what is good, just, and right because their personal identity and moral compass are intrinsically related.

Assisted reproduction in Chile

Assisted reproduction practices in Chile occur in the context of the Catholic Church’s historical influence,⁵ women’s growing workforce participation, a declining fertility rate (Larrañaga 2006a, 2006b), high inequality, the concentration of wealth and the privatization and deregulation of basic forms of social security (UNDP 2017). The child occupies an ever more central place in the family, ceasing to be a means of contributing to the family’s livelihood and becoming the main object of the parents’ economic and affective investment (Valdés et al. 2005). In this context, infertility is experienced as a drama to which it is necessary to find a solution.

In Chile, the number of ART procedures registered has shown a sustained increase since the birth of the first child through in vitro fertilization (IVF) in 1984. According to the National Register of Assisted Reproduction Techniques,⁶ 39,593 procedures using ARTs took place between 1990 and 2016, leading to the birth of 11,600 babies. Out of these births, 16.8% corresponded to ovule donation (OD) and 17.7% to frozen embryo transfer (FET). OD increased from 12% of total procedures in 2000 to 20% in 2016, while FET increased from 9% to 27.2%. The percentage of older women (over 40) has also shown a sustained increase, rising from 9% in 2000 to 22% in 2016. The number of embryos transferred has been decreasing (in 1996, the average was 4.1 but by 2016 it had dropped to 1.79) (SOCMER 2019; Zegers-Hochschild et al. 2019). Although semen donation began in Chile over 40 years ago, there is no register of procedures.

Assisted reproduction treatments are very expensive⁷ and out of the reach of most infertile couples in Chile. The National Health Service has an assisted fertilization program under which some free cycles of low and high-complexity assisted fertilization are available each year to married or stable couples who are users of the public health system.⁸

Despite the great development of the assisted reproduction industry in Chile, it is not regulated by law but only by the ethics committee of each medical center. Some private clinics have norms of self-regulation on, for example, the management of embryos. The only legal provision at the national level is an article of the Civil Code that stipulates that the father and mother are presumed to be the persons who voluntarily used a method of assisted reproduction and that their status cannot be impugned. There is no age limit on the use of ARTs and no regulation on whether the donation of eggs and sperm must be anonymous or whether it can be remunerated. The mother is understood to be the woman who gave birth to the child and the father the man to whom she was married. This leaves surrogate pregnancy outside the legal framework. In the absence of marriage, paternity must be established voluntarily. Chilean legislation prohibits the deliberate destruction of embryos or research that may affect an embryo’s survival (Law N° 20.120 introduced in 2006). This lack of regulation of ARTs places the moral dilemmas they pose even more firmly in the personal sphere (Ariza 2010; Luna 2002).

Methodology

The findings presented here are based on interviews carried out as part of three qualitative investigations conducted in Santiago, Chile between 2008 and 2019, financed by the National Fund for Scientific and Technological Development (FONDECYT) (Projects N° 3080018, N° 11110287, and N° 1150554). In the framework of these projects, in-depth interviews were conducted with 64 people who had undergone ARTs or had participated in adoption processes in order to become parents (some had not been successful at the time of the interview). For this particular paper, special attention was paid to the 32 interviews with mothers and fathers who had had children through ARTs (artificial insemination, IVF/ICSI, gamete donation).⁹ The studies were approved by the Ethics Committee of the Diego Portales University. Pseudonyms are used to protect the identity of interviewees.

All the participants were asked to recount how they experienced the process of becoming a parent, starting from the first time they thought “I want to be a mother/father.” This prompted a free narration, a biographical account in which interviewees organized and gave meaning to their experiences (Mason 2002; Weeks, Heaphy, and Donovan 2001). Bernasconi argues that, in biographical accounts, “the narrators negotiate their understanding of who they are in spaces organized around questions about what is good, just and right” (2015, 317). People structure their accounts around the adoption of moral positions (Bernasconi 2015). This is particularly evident when they talk about the dilemmas they faced when undergoing ART. The structure of the interviews was flexible and fluid, allowing the points of view of the interviewees to emerge and unexpected topics to develop (Mason 2002). It is important to bear in mind that the accounts of people interviewed represent a reconstruction and reinterpretation of “yesterday” from the standpoint of “today.”

The participants were recruited through two specialized ART clinics, an adoption foundation and the researcher’s personal networks (followed by the snowball technique). People who undergo ARTs often “go on a pilgrimage” from one medical center to another over the course of their treatments and, in their interviews, therefore, they refer to their experiences in different clinics.

It was more difficult to find men willing to participate in the study than women, probably because of the association of fertility with virility (Nordqvist and Smart 2014; Silva and Machado 2010; Webb and Daniluk 1999). Women and men experience and address infertility and ARTs differently (Becker 2000; Franklin 1997; Greil, Slauson-Blevins, and McQuillan 2010; Inhorn and Van Balen 2002; Thompson 2005). Men’s experience of infertility and reproduction has been studied less than that of women (Dolan and Coe 2011; Herrera 2013; Throsby and Gill 2004). However, this paper does not distinguish between the experiences of women and men because (1) in the specific topics addressed here, no obvious differences were detected; and (2) the paper’s length does not permit discussion of the most subtle differences.

People with different profiles were contacted in order to cover the variety of experiences of fathers and mothers who have conceived children through ARTs. For this paper, I examined the cases of people who were in heterosexual relationships,¹⁰ analyzing 20 interviews with women, 10 with men, and 2 with heterosexual couples. The age of the interviewees at the time of the interview ranged from 30 to 60 years. Some were in a financial position to pay for several IVF cycles a year but most had borrowed to finance the high costs of the treatments. A few had access to ARTs through the free places offered by state programs. Similarly, the interviewees included people with postgraduate education, only undergraduate education, technical training, and complete school education. Most of the participants identified themselves as believing in God (Catholics, some from other religions and others who, albeit believing, did not identify with any religion). An important percentage of the mothers and fathers were married at the time of the interview. However, separated, single, and cohabiting people were also contacted. For each person cited in the results section, information is provided about the number of children, the treatments undergone, educational level, religion, relationship situation, and age range at the time of the interview. No further information is provided to minimize the risk of revealing their identity.

The interviews lasted an hour on average and were conducted by the author and a research assistant (sociologist). They took place in the participants’ homes or workplaces or in a public place (such as a café or public square). The interviews were recorded and then transcribed.

The material was analyzed using thematic content analysis. The most significant segments of the material were identified and selected according to the topic of interest in this paper: the reproductive decision-making process of people who have undergone ARTs in order to have children (Atkinson and Coffey 2005; Ruiz 2009). For this, a mixed system of categories or codes created prior to reading the transcripts (deductively) and emerging codes (arising inductively from their reading) was used. This process was carried out using Nvivo qualitative data analysis software.

Results

Taking reproductive decisions

The impossibility of taking the expected route to have children (sexual relations) puts the future parents in a particular situation. The illusion of control over their reproductive process is shattered and they find themselves obliged to make decisions on matters in which it is not normally possible to intervene. The participants report that, in this situation, they prefer to trust the doctor and not stop to think too much about the consequences of their decisions. “I did everything the doctors told me,” says Javiera (one son and one daughter, IVF/ICSI, university education, Catholic, 31–40 years, married). “I had no idea what they were doing to me, that they were putting hormones in me, or were going to grow the eggs, nothing like that, I had no idea,” says Ana (four children from two pregnancies, IVF, technical training, Catholic, married). Claudio recounts how he and his wife followed their doctor’s advice step-by-step:

Because, in general, one says if the doctor tells you something, then it’s the solution; I think that, for almost all of us, what the doctor says is almost sacred so one does not put oneself in the situation that it won’t work but believes that it is the solution (twins (one daughter and one son), IVF/ICSI, technical training, believes in God, 41–50 years, married).

As in the study by Chan et al. (2019), the participants in our study decided to put themselves in the position of patients and be guided by the doctors. However, the options offered by ARTs oblige them to make decisions on matters with which they are often not familiar and find uncomfortable and problematic. As Matías says, they have to decide on things that seem to them to be out of a science fiction film: “If they are able to choose a specific ovule, a specific sperm, what can they produce next? In the end, they can do things like in those science fiction films that are not so science fiction at all” (Matías, no children, still in treatment, university education, believes in God, 31–40, married). The participants in the study by Ariza (2010) also indicated that the decisions they had to make during treatments seemed like science fiction. In the case of IVF treatments, for example, they have to decide what to do with the eggs that are not required for the cycle, how many embryos to implant, whether to cryopreserve embryos and what to do with the embryos they will not use. They also have to decide how far to go to obtain the desired biological child. If artificial insemination and IVF do not work or the eggs or sperm are found not to be viable, are they willing to use third-party gametes to become mothers/fathers? What position will they take on surrogacy?

Claudia and her husband had their two children using IVF. In the following excerpt, she reflects on the choices related to fertilization, cryopreservation, and implantation in an IVF cycle. She begins by describing the doctors’ decision about how many eggs to fertilize but then goes on to talk about the decisions she will have to make as a result of this decision. Several issues come into play: When does human life begin? What is the morally right decision about the embryos? How far should one be willing to go for the treatments to be successful?

So they (referring to the doctors) said, “we are going to put seven [eggs] to fertilize so that, hopefully, four get fertilized, so as to have two to put in now and two to save and put in a second time.” What’s going on? If at the first try, with these two, you get pregnant and, for example, have twins and later decide not to have any more children, you will have to know what you are going to do with those other two. These two fertilized embryos are two babies, they are two … They can be unfrozen and there’s always the opportunity and the possibility of using them. But if you decide not to have any more children, you have to decide what to do with them, and you can’t kill them, you can’t throw them in the trash like they do in the United States because there’s the whole discussion of whether it’s an abortion or a homicide. So you have to decide either to put fewer to fertilize so there aren’t any left over or, if you don’t use them, you have to give them in adoption to another couple who can’t have children. Already there you have to make a decision because if, for example, you decide not to freeze, it’s very difficult for the doctor and you to decide how many to put to fertilize because if you put three to fertilize, for example, it may be that none gets fertilized and you have lost the four million pesos (approximately US$5,000 or 24 minimum monthly wages) that this cost you. (two children, IVF, higher education, Catholic, 31–40 years, married)

Claudia’s account shows that, even when people decide to be guided by their doctors, there are still decisions they have to make. In this case, she describes how difficult it is to balance what is morally acceptable with efficient use of the expense involved in the treatments.

The decisions made during the treatments are guided by two concerns that are at odds with each other. On the one hand, people feel they must do everything possible to have a biological child while, on the other, they consider that they must be careful to identify the acceptable limits of human and technological intervention in their reproductive process. These concerns are analyzed in the next two sections.

Doing everything possible to have a child

When making reproductive decisions, participants evaluate the alternatives available to them or, in other words, what is “possible” in their particular circumstances in order to become mothers/fathers. They think they must exhaust all the possibilities. Claudio uses a sports metaphor to explain that he felt he had to do everything in his power to become a father:

I have to give my hundred percent, then if I don’t come out champion, it’s because of other circumstances of life, so if I want to have children, I have to do everything in my reach; if it’s in my reach to do these processes (referring to ART) and to do it all, I have to do it and, if the doctor says that we have to keep going and there are possibilities, we have to keep going. (two children, IVF/ICSI, technical training, believes in God, 41–50 years, married)

Amalia was treated at several clinics and underwent different treatments (artificial insemination, IVF, ICSI, egg donation) but was unable to have a biological child. At the time of the interview, she said she was at peace because she felt she had exhausted all the options for becoming a biological mother. “There is the frustration that it didn’t work but I am sure I did everything humanly possible to be a mother. Biologically” (no children, artificial insemination, IVF, ICSI, technical training, 41–50 years, Jehovah’s Witness, married).

“Doing everything possible” usually means exhausting all the possibilities offered by ARTs since this is perceived as the natural step in the case of difficulties in conceiving. According to interviewees’ accounts, doctors often present reproductive treatments as “a little push” to make nature do what it should have done from the beginning. Most participants went to several medical centers and underwent several cycles before being successful. Daniel says that he and his wife knew that assisted reproduction existed and that it was a viable option for them: “It was simply an element that science gives you and it was within our possibilities, there was no sitting down to discuss it, it was just another procedure, you had to go there” (three children, one through ICSI, university education, non-believer, 41–50 years, married).

When Daniel says that ART was within their possibilities, he means they could pay the high cost of the treatments. “Here, those who have the money can do the treatment; those who don’t, can’t,” he says. What a person can afford is a central aspect of defining what is possible or not. The economic criterion applies throughout the reproductive process. For example, it is used to make decisions about which path to follow to have a child, what treatments to undergo and when it is necessary to give up. Javiera says that: “My limit was going to be when my husband and I were going to say ‘you know what, we no longer have the money for our treatment’” (one son and one daughter, IVF/ICSI, university education, Catholic, 31–40 years, married). Marcela reports that, when the doctors told her that her chances of getting pregnant were low, “my husband and I never set a maximum number of attempts or anything like that (…) I would have carried on as long as we could have paid, I would have carried on doing it” (three children, ICSI, university education, non-believer, 31–40 years, married).

Defining when the possibilities of having a child have been exhausted is a personal matter. For some, doing everything possible to have a child includes adoption. For others, the options end with ARTs because they want to have a biological child.¹¹

The limits: the natural and the divine

Like the participants in the study of Ariza (2010) in Buenos Aires, the interviewees in our study wanted the way their child arrived to be “as natural” as possible. As discussed above, ARTs are viewed as a way of giving nature “a little push” or “a helping hand.” This argument “renaturalizes” reproductive technologies (Franklin 1997). However, this naturalization has its limits.

In reproduction, “natural” can have different meanings. It can be understood as conceiving through sexual relations with one’s partner. Javiera remembers regretting not being able to conceive “naturally” and in a “spontaneous” way: “They told me about assisted treatment and I said  …  all the same, it’s a bit upsetting that it’s not natural, that it didn’t happen naturally, like much more spontaneously” (one son and one daughter, IVF/ICSI, university education, Catholic, 31–40 years, married). Interviewees tend to play down the role of the “artificial” and technology in conception – the laboratory, the hormones, the transfers. They avoid the issue that their child will not be the product of a sexual relationship.

“Natural” can also be used to mean that the father and mother have a biogenetic link with the child. In this case, producing a child must be the result of the union of the gametes of the father and the mother (Thompson 2005). In ARTs without a donor, the conjugal couple and the parental couple (in the sense of the couple who procreate and the parents who raise the child) are the same, thereby respecting a crucial element of our ideology of kinship (Cadoret 2003). In this case, the use of ART-D or adoption as a means of becoming a mother or father is relegated to second and third place. This is expressed by Valentina:

I think adopting can be good, it can be nice, it can end up being almost the same as having a child of your own, but if you have the possibility of having your own, even if only one – aaah, it’s better that your child has your blood and your husband’s blood, hopefully, the child is yours alone, 100%. (twins, artificial insemination, technical training, Catholic, 31–40 years, married)

The criterion of “natural” is used as opposed to the level of technological intervention required by the reproductive process (with the latter understood as biomedical intervention). The more intervention, the less natural and therefore the treatment is considered more artificial. In a way similar to that described by González-Santos (2013), this criterion is used to make reproductive decisions.

For the interviewees, not everything that science permits is acceptable and there are lines that should not be crossed. These lines symbolize the point where technological intervention renders the reproductive process “anti-natural.” Mothers and fathers feel that some aspects of reproduction ought not to be a matter of human decision. Their accounts show them establishing limits between what should and should not be done in the treatments

In this way, the participants tend to set a point where they decide that technological intervention is excessive and, therefore, morally reprehensible (Bestard 1999). This point is personal and can vary greatly between different people. For example, Amalia underwent IVF cycles with egg donation and, when asked about having children with a donated embryo, said, “It is very strange because, with the donation of eggs, there’s my husband’s sperm, but it was like digging too much, going against nature, it’s too much, it frightens me” (no children, artificial insemination, IVF/ICSI, egg donation). As we saw above, Amalia also says that she is at peace because she did everything possible to have a biological child. Here, she indicates that, for her, the donation of embryos goes beyond what is acceptable since it goes “against nature.”

In other words, the “renaturalization” of procreation has a limit beyond which the participants view technological intervention as twisting the arm of nature or going against divine will. When, in their accounts, they talk about setting limits, they often refer to nature and God. When Bárbara was interviewed, she had cryopreserved embryos and this was problematic for her because her husband did not want more children. She wonders if these embryos are tiny people and believes that, if they are, having them frozen or eliminating them is against the laws of God because it is anti-natural: “Although I am not that religious, I do believe in God … it’s sort of anti-natural” (one daughter, IVF, university education, believes in God, 31–40 years, married).

Respect for divine will is identified with respect for what is “natural.” As González-Santos (2016) asserts, nature and God appear on the same side of the argument. In her account, Ana describes how, when she moved from artificial insemination to IVF, she wondered if God would agree with this method. The question of God’s moral position is related to the fact that conception will take place outside the woman’s body and would, therefore, not be natural.

then later, as it (artificial insemination) didn’t work, they told me “now we are going to treat you as a candidate for in vitro because there is no other option for you” (…). I knew what it involved, that, in the end, an egg and a sperm are put together outside and that was not natural, that they were going to put it in you all ready, so I said “goodness, will God agree or not?” (four children from two pregnancies, IVF, technical training, Catholic, married).

Moveable limits

The limits of what is acceptable or not and what is natural or not can shift over the course of the reproductive process as the complexity of treatments increases. An intervention that, compared to a less complex method, was considered unnatural (for example, IVF compared to artificial insemination) can become “natural” and acceptable compared to another more complex method (for example, the donation of eggs or embryos). Alba’s account shows how she tries to establish the line that should not be crossed and how this moves:

My biggest apprehensions had to do with egg donation. One thing is manipulating your eggs and your husband’s sperm, but going and getting eggs from someone else to inseminate and then implant them, I found that rather too much. That’s what I said … and then I thought I’d better go and get a womb for rent and for someone else to have the baby for me, because why am I going to get fat, I said. No, this is like … here we are overstepping the limit, between this and adopting, there is no difference. I said, “no, it’s not for me”. But as time goes by, you mature things and you say “I have nothing and I still have this option, what do I have to lose?” (A one-year-old daughter, IVF and egg donation, university education, Catholic, 30–40 years, married).

In this account, the limit of the acceptable shifts. Initially, Alba’s limit was not to use third-party gametes but then she draws another line in which she will not get pregnant (surrogacy). In this case, she gives as an example a motivation with superficial and selfish connotations (“not to get fat”) to reinforce the argument that using surrogacy would be morally reprehensible. She also indicates that there is no difference between surrogacy and adoption because she would not experience the pregnancy in either case so adoption appears as the morally acceptable path. However, Alba does not see adoption as a viable alternative since, as she says at another point in the interview, “one does not know the stories behind those babies” and she fears “something bad in the DNA.” Finally, after not being successful with her gametes, she decides to accept the possibility of egg donation. This illustrates how the tension between doing everything possible to have a child of one’s own and not crossing the line of what is considered morally appropriate leads to constant review of these limits.

Despite the decisions made and all the technological intervention involved, many interviewees indicate that the success of the treatments “is in the hands of God” or some power that transcends human will. Once they have had a child/children, they justify the path traveled by invoking a transcendental authority. Anita (triplets using IVF, technical training, Catholic, 51–60 years, married) believes that her desire to have two daughters and a son was so great that God sent her two girls and a boy. Similarly, Carmen (twins using IVF, university education, Catholic, 31–40 years, married) believes it was so difficult for her to get pregnant because her children were meant to be born just after her father’s death in order to ease her grief and that of her mother.

Discussion

This paper has examined how people using scientific and technological advances in reproduction try to make decisions about what is legitimate and good in a field that is new and unfamiliar to them. To identify the moral limits of technological intervention in the creation of human life and ties of kinship, they invoke the domain of what transcends human will. In a way similar to that seen in the study in Ecuador by Roberts (2006), the participants in our study combine the scientific/technological and spiritual domains to make sense of their reproductive experiences.

They would have liked not to have to make decisions about their reproductive project and, like those interviewed in the study of Ariza (2010), would have preferred procreation to be natural and spontaneous. They indicate that, when faced with infertility, they would prefer to leave decisions to the doctors. However, they find themselves obligated to make decisions about which methods to use: embryos to implant, cryopreservation, gamete donation, etc.

The initial illusion of certainty promised by ARTs gives way to perplexity and frustration since each stage of the treatments involves new decisions and tensions (Franklin 1997). To their bewilderment, the future parents realize they do not have control over their reproductive process and have to intervene in matters they view as the domain of God and nature. They perceive these decisions as akin to science fiction in that they involve navigating uncharted territory where the manipulation of nature by technology seems like something out of the future. For the participants, it is not yet clear what is right and what is wrong or how far it is legitimate to go to achieve the desired goal of becoming a mother/father.

The desire to do everything possible to have children is difficult to reconcile with concern about respecting the limits of what is morally acceptable. In this exercise of identifying the limits, the participants use the figures of the divine and nature as belonging to the same domain of the transcendental: what is beyond human will. In this way, even when a pregnancy is achieved through medical intervention and an active quest on the parents’ part, the result – that is, the child – is signified as the product of a divine or transcendental decision.

Beck-Gernsheim (2002) argues that developments in medicine, biology, and genetics have made the deliberate construction of parenthood ever more possible. In the modern world, this is no longer a natural condition but, according to Beck-Gernsheim, a “planning project” that is the object of constant effort and optimization. New possibilities bring new questions and conflicts in the context of a weakening of the traditions that used to provide answers and certainties.

However, mothers and fathers do not see parenthood as a project they can build but as something that must be beyond individual choice and will. The need to intervene and the possibility of making decisions in assisted reproduction processes disconcert them because they are at odds with this idea of the parental relationship as something that must be bestowed. People long for the process of becoming a mother or father to be validated by something transcendental (Herrera 2011; Mason 2008). In the Chilean case, the traditional frameworks continue to operate. Mothers and fathers want to be sure they will have children and feel they must do everything possible to achieve this but, at the same time, long to be able to leave things in “the hands of God” or “the hands of nature.” In other words, they want God or nature to send them a child, and not to be the ones who go out to seek, design, and select it. They want to be able to construct a biographical narrative in which they are good people, who made the right decisions and respected the limits of the natural and the divine.

The quest for autonomy and the search for meaning in the framework of ARTs configure a relationship in which there is constant feedback. On the side of autonomy, there is the human exercise of doing everything possible to achieve motherhood/fatherhood and maintain control of the reproductive process while, on the side of meaning, there is the longing for something transcendental to give legitimacy to the path traveled. The danger is that, if intervention is taken too far, going “against” nature or God, this legitimacy becomes unattainable. The need to exhaust all possibilities to have a child means always asking oneself where to put the limits of what is morally acceptable or, in other words, what can still be understood as “natural” or “the will of God.” However, with ARTs, new possibilities are always emerging and must be reviewed, and what was initially rejected is re-evaluated. In this relationship between control and what is transcendental, what is natural and what is acceptable are continually resignified.

This study has the following limitations: (a) the people and couples were not followed throughout their reproductive treatments; (b) people with non-heterosexual orientations are not included; and (c) the reproductive experiences of people from other minorities such as migrants and people with disabilities are not included. The contributions this article makes include: (a) it investigates how people not linked to the world of science and technology make sense of scientific and technological interventions in their own reproductive processes; (b) it analyzes biographical narratives in which people deploy their moral agency, that is, their capacity for reflection and mobilization based on a value they consider good, fair or right (Bernasconi 2015); (c) the research was undertaken outside the Euro-American framework and dialogs with both the literature on ARTs in Europe and the United States (Beck-Gernsheim 2002; Bestard 1999; Franklin 1997; Jociles, Rivas, and Álvarez 2017; Raspberry and Skinner 2011a, 2011b; Silva and Machado 2010) and studies carried out in Latin America (Ariza 2010, 2016; González-Santos 2016; Herrera 2011; Herrera, Teitelboim, and Zegers-Hochschild 2015; Raspberry 2007; Roberts 2006); and (d) it includes the male perspective whereas most studies of infertility, reproduction, and ARTs focus on women’s experience (Culley, Hudson, and Lohan 2013; Herrera 2013; Throsby and Gill 2004).

Acknowledgments

I would like to thank the people who trusted us and generously shared their experiences with us. I would also like to thank Fabián Urrutia for his help in carrying out the research and Ruth Bradley for translating into English the original manuscript. Finally, I am indebted to the two anonymous reviewers whose comments helped to improve this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes on contributor

Florencia Herrera studied sociology at the Catholic University of Chile and holds a PhD from the University of Barcelona. Lecturer at the School of Sociology of the Universidad Diego Portales. Her research interests are related to the different forms families take, particularly non-hegemonic types of parenting, reproduction, gender and qualitative methods. She has published articles on these subjects in journals in Chile and other countries. The main studies she has undertaken are: (1) “Being and forming a family: the lesbian view of intimate relationships,” PhD thesis (2002–2006); (2) “Social construction of the parental bond: Adoption and assisted reproduction in contemporary Chile,” National Fund for Scientific and Technological Development, (FONDECYT) (2008–2010); (3) “Assisted reproduction in Chile: Analysis of the cultural repertoires used to evaluate what is correct, moral and legitimate in the field opened up by new reproductive technologies,” FONDECYT (2011–2014); and (4) “Becoming a father today: Male experiences of transition to paternity in Chile,” FONDECYT (2015–2019). Most recently, her experience as a researcher and a mother with a visual disability has drawn her to be interested in the parental experiences of people with disabilities in Chile.

Additional information

Funding

This paper was written with financial support from Chile’s National Agency of Research and Development (ANID) (FONDECYT N° 3080018, N° 11110287 and N° 1150554; REDI170133) and institutional support from the Universidad Diego Portales.

Notes

1 Donor is understood as the person who donates gametes or embryos; surrogate is understood as the woman who lends her womb for the process of surrogate pregnancy.

2 Roberts (2006) distinguishes between Baroque Catholicism and enlightened Catholicism: “Baroque Catholicism, for the purposes of my analysis here, signifies outwardly focused devotion entered on personalistic exchanges with God and saints, with relatively little attention paid to Church doctrine. Enlightened Catholicism denotes a cultivation of the individual self as inwardly focused, temperate, and rule-oriented” (2006, 513). Health professionals and patients proclaim the presence of God in the laboratory, positioning them closer to Baroque Catholicism.

3 This survey took a random sample of 1500 people, representative of the population aged between 18 and 65 years in Greater Santiago.

4 Twenty-five semi-structured interviews and six focus groups (with eight participants in each) were conducted. The interviewees and participants in the focus groups were selected through purposeful theoretical sampling, using as the selection criteria the variables that, according to the survey, influence opinions about ARTs: age, gender, religion, socioeconomic group, and political position.

5 The Catholic Church has strongly opposed ARTs (Asplund 2020).

6 This Register has been kept by the Chilean Society of Reproductive Medicine and the Latin American Register of Assisted Reproduction since 1990. Medical centers voluntarily submit information about the assisted reproduction procedures they carry out each year.

7 A cycle of IVF can cost around 13 times the minimum monthly wage (this is an estimate because the cost varies widely depending on the clinic, the medical team and a person’s health insurance).

8 There is a low and high-complexity assisted fertilization program for beneficiaries of the National Health Fund (FONASA). Couples who opt for the low-complexity assisted fertilization program (artificial insemination) must have been unable to achieve a clinical pregnancy after at least 12 months of sexual relations. The maximum frequency of the low-complexity treatment is three cycles in a year. Couples do not need to be married but must show that they have lived together for at least two years. The prioritization criteria for high-complexity treatments (IVF, ICSI) include: months on the waiting list, having no children and ovarian reserve (rather than the woman’s age). The selected couples receive a complete cycle and the couples who achieve pregnancy in the first attempt and have cryopreserved embryos have access to a second attempt (only once). (For further information (in Spanish), see https://www.chileatiende.gob.cl/fichas/23778-programa-de-fertilizacion-asistida-de-baja-y-alta-complejidad-en-la-red-publica-o-red-preferente-mai-de-fonasa).

9 Interviews with people for whom ARTs was not successful and/or had children through adoption received less attention.

10 The cases of participants in homosexual relations or who had children without a partner were not considered since their reproductive journey is very different to that of heterosexual couples (for example they do not necessarily have fertility problems and know from the outset that third-party participation will be required) (Herrera 2009).

11 The concept of biological child is understood in different ways by the participants: it can be understood as a product of the union of their gametes (genetic) or as a product of the mother’s pregnancy.