ART and culture? Or a culture against ART?

Dovidena, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons / no changes made

Why choice and autonomy are paramount in the argument for Assisted Reproductive Technologies for those who cannot conceive without medical intervention, and for abortion.

People of a university age are more likely to seek contraception[1] or abortion services[2] than they are to consider having children. Yet, whether people will have affordable access to assisted reproductive medicine* is a question of equal importance. Choice, in both dimensions, is paramount to ensuring a just and equal society in which people are enfranchised to receive care and the best possible quality of life, look after themselves, and plan their futures. Infertility affects approximately 3.5 million people in the UK[3] and according to NHS figures, 1 in 7 heterosexual couples may have difficulties conceiving[4]. For those who have been trying to conceive for more than 3 years without success, the likelihood of getting pregnant in the next year is 1 in 4, or less[5]. The peak abortion ages (early 20s)[6] overlap with the ages at which many women are first diagnosed with PCOS* (~10% prevalence)[7], endometriosis* (~10% prevalence)[8] and for both men and women STI* incidence (chlamydia diagnoses concentrated in ages 15-24) is highest[9]. While a large proportion of people undergoing abortions in the UK are in the ‘university age’ bracket, among the same demographic, fertility-compromising conditions are common. These overlapping age patterns mean that reproductive health policy must treat abortion, contraception, STI prevention/ treatment, early diagnosis of gynaecological conditions and fertility as interconnected issues, not separate or differing in importance. Treating abortion and fertility care as separate policy issues risks missing how interlinked and common these needs are for young people. Considering how many young people are affected by these issues, and as they concern the same principles of choice, ending or beginning a pregnancy deserve considerable and consistent consideration.

An intersectional understanding is crucial when comparing reproductive technologies such as IVF*, with abortion. As Bell (2009) shows, IVF is frequently represented as a procedure reserved for affluent, white, middle-class women[10], whereas abortion rates in the US remain highest among unmarried, low-income, African-American women[11]. These demographics reveal debates around reproduction as not only moral or medical but deeply structured by race, class and social privilege. Nevertheless, I argue that the notion of choice operates as an overarching and enfranchising principle across these contexts. Whether exercised in the choice to pursue an IVF pregnancy or the termination of pregnancy, reproductive choice represents a shared claim to bodily autonomy and self-determination. Choice is therefore a tool with which individuals can assert agency over their reproductive lives in every context.

Positive rights and positive enforcement

Where rights such as the ‘right to life’ and ‘prohibition from torture’ feature as so-called ‘first-generation’ rights[12] in doctrine such as the ECHR*[13] and Bill on Human Rights*[14], the question of whether positive assistance with reproduction can attain the status of a right must be assessed. The moral claim to assistance is fundamentally different from whether this assistance is a fundamental right. Yet the relationship between them and how the strength of the moral claim informs the status of ‘right’ is one which I argue correlates. Where people have a moral interest in deciding whether and how[15] to have children, infertility interferes with the expression of this autonomy. Assisted reproductive technologies (ART) therefore restore the individual’s capacity to exercise it. Moral claims often precede recognition of codified rights (this preceded how contraception and abortion became codified), yet ART is still at the ‘progressive realisation*’ stage of the right to health – not yet legally enshrined. In order for a state to provide the maximum welfare towards social democracy and the true freedom to choose when it comes to reproductive rights, both first generation rights (political and civic) and second (such as the right to education, social care, work, housing)[16] must be addressed. Therefore, we must ask ourselves whether access to (ART) is a concern of sufficient magnitude to make it a positive right*. Where the number of children born from IVF amounted to approximately 1 child in every classroom in 2023[17], and those born from IVF more than doubled from 2000 to 2023[18], it is clear this issue affects many of those making the decision to become parents. It is also interesting to note that the rate of single patients using both IVF and donor insemination (DI) increased 83% from 2019 to 2023. Despite this uptake, the proportion of NHS-funded IVF cycles declined in the UK from 35% in 2019 to 27% in 2023 – the decrease most evident in England[19]. This demonstrates that not treating ART as a policy matter of legal importance fails to reflect pragmatic and social needs of those seeking this form of assistance.

Can ART be a right if it’s not easily accessible?

Where infertility affects around one in six people of reproductive age worldwide[20], it must be acknowledged that the treatments to address it are multifaceted. In 2022, the pregnancy rate from IVF among patients aged 18-34 was 42%[21]. Patients aged 40-42, this rose from 10% in 2012 to 16% in 2022[22]. While there is therefore evidence of efficacy, this disappointing decrease in funding, on top of well-known disparities in access to care such as marginalised ethnic groups, those in same-sex relationships and the geographic ‘postcode*’ lottery shows systemic barriers persist, placing hurdles in the way of accessing ART. Black and Asian patients have lower birth rates[23] and higher instances of treatment complexities[24], funding is less likely for female same-sex couples[25] and those living in a deprived area are 30% less likely to have a fertility clinic nearby[26]. When asking what makes something a ‘right’, the difference between formal and substantive legislation comes to the fore. Concerning ART: when access to ART relies on privilege, substantive legislation is undermined by inequality. The legislature itself makes this process tricky – whereas fundamental rights are seen as basic and universal (prima facie) irrespective of courts’ recognition, positive laws only become valid when enacted and enforced by the state[27]. Therefore, legislative and political acknowledgement of the disadvantage of certain groups is prerequisite to effective implementation of technologies like IVF.

Further hidden barriers post implementation

The system and legislation for accessing IVF and other forms of assisted reproductive technology centres around the 3 loci of mother, medical professional and child. Where the latter is concerned, section 13(5) of the Human Fertilisation and Embryology Act of 2008 states that license holders are required ‘before providing treatment services, to consider the welfare of a child who may be born as a result of the treatment (including the need of that child for supportive parenting) and the welfare of any other child who may be affected by the birth.[28] This means the ‘welfare’ becomes rather subjective as to the medical professionals’ perspective and leaves some of these systemic barriers to persevere at the discretion of the individuals involved. The bracketed part used to read ‘including the need of that child for a father’ – implicitly questioning the ability of same-sex female partners and single women to parent.

‘Embryonic politics’ - the crossover with IVF and abortion

Our understanding of how religion (particularly Evangelical Christianity) influences attitudes about IVF is more limited than our understanding of how it influences abortion. In a paper by Heather Silber Mohamed on ‘Embryonic Politics’[29], ESC* research, IVF and abortion are looked at with data from the Pew Research Center[30] on morality and destruction of embryos, religion is found to shape attitudes most strongly towards abortion, and least towards IVF[31]. According to the paper, this is most profound because fundamentally, IVF is not seen as a moral issue – nearly half of those who decry abortion as morally wrong described IVF as ‘not a moral issue[32]’, and because of this foundation, 57% of respondents view abortion as ‘morally wrong’ compared with just 13% for IVF[33]. According to the Human Fertilisation and Embryology Authority (HFEA), only 30-50%[34] of fertilised eggs typically reach the blastocyst stage* (a more viable form). Only some of the embryos that reach this stage are transferred to the uterus[35] . Not even all of the transferred embryos will implant and lead to a live birth[36]. This shows that when ‘personhood’ laws – which aim to restrict abortion by defining life as beginning at fertilisation[37] – are supported by legal proposals like Jody Hice’s 2017 bill[38], the issue of how these laws relate to IVF becomes even more complicated and unclear.

Conclusion

It is one of the reasons that IVF is treated as ‘less of a moral issue[39]’ that circles back to my motivation for writing this article and shall draw it to a close. For some, it is the medical or therapeutic framing of IVF – seen as a treatment for infertility – that lifts it out of the morality politics framework – restoring a ‘lost capability[40]’ rather than ending pregnancy.

This goes back to two issues – medical care and choice. In the 1994 International Conference on Population and Development (ICPD) Programme of Action, reproductive rights are defined as “the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so”[41]. In the UNFPA*’s 2024 report “The Future of Sexual and Reproductive Health and Rights,” it states that the ICPD roadmap remains “universally applicable” and describes follow-up commitments since 1994[42]. This frames both abortion access and IVF access within the same international human rights framework overarchingly encapsulated by choice. As the WHO (World Health Organisation) and UN committee on Economic, Social and Cultural Rights (CESCR) puts it - general comment No. 14, 2000: The right to health includes “control over one’s health and body, including sexual and reproductive freedom[43].” IVF and abortion are connected directly: both are expressions of the right to bodily integrity and reproductive self-determination. Whereas abortion protects the right to avoid involuntary motherhood, IVF protects the right to overcome involuntary childlessness. In both cases, reproductive choice functions as an expression of human dignity and self-determination. Where the ‘right to health’, and concept of ‘reproductive autonomy’ are at stake, does it not follow that allowing individuals choice harnesses medicine in pursuit of a life that aligns with conceptions of wellbeing and a brighter, self-directed future?

Notes

1. Office (2024). Abortion statistics, England and Wales: 2022. [online] GOV.UK. Available at: https://www.gov.uk/government/statistics/abortion-statistics-for-england-and-wales-2022/abortion-statistics-england-and-wales-2022.

2. Statista. (2022). Contact with reproductive health services for contraceptives in England 2022/23, by age | Statista. [online] Available at: https://www.statista.com/statistics/573180/reproductive-health-services-contact-for-contraception-england-by-age/[Accessed 6 Oct. 2025].

3. Fertility Network UK (2019). Fertility Network | Fertility Network UK is the UK’s leading charity providing information, support and advice to all those struggling to conceive. [online] Fertilitynetworkuk.org. Available at: https://fertilitynetworkuk.org/.

4. NHS (2023). Overview - Infertility. [online] NHS. Available at: https://www.nhs.uk/conditions/infertility/.

5. Ibid.

6. Office (2024). Abortion statistics, England and Wales: 2022. (1)

7. Deswal, R., Narwal, V., Dang, A. and Pundir, C.S. (2020). The Prevalence of Polycystic Ovary Syndrome: A Brief Systematic Review. Journal of Human Reproductive Sciences, 13(4), pp.261–271. doi:https://doi.org/10.4103/jhrs.JHRS_95_18.

8. Endometriosis UK (2020). Endometriosis Facts and Figures | Endometriosis UK. [online] Endometriosis-uk.org. Available at: https://www.endometriosis-uk.org/endometriosis-facts-and-figures.

9. UK Parliament (2023). The prevalence of sexually transmitted infections in young people and other high risk groups - Women and Equalities Committee. [online] Parliament.uk. Available at: https://publications.parliament.uk/pa/cm5804/cmselect/cmwomeq/463/report.html.

10. Bell, A.V. (2009). ‘It’s Way out of my League’. Gender & Society, 23(5), pp.688–709. doi:https://doi.org/10.1177/0891243209343708.

11. Finer, L.B. and Henshaw, S.K. (2006). Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38(2), pp.90–96. doi:https://doi.org/10.1363/3809006.

12. Manual for Human Rights Education with Young people. (2025). The evolution of human rights - Manual for Human Rights Education with Young people - www.coe.int. [online] Available at: https://www.coe.int/en/web/compass/the-evolution-of-human-rights.

13. Council of Europe (1950). European Convention on Human Rights. [online] Available at: https://www.echr.coe.int/documents/d/echr/Convention_ENG.

14. Nations, U. (2023). Universal Declaration of Human Rights | United Nations. [online] United Nations. Available at: https://www.un.org/en/about-us/universal-declaration-of-human-rights

15. Robertson, J.A. (1994). Children of Choice: Freedom and the New Reproductive Technologies. [online] JSTOR. Princeton University Press. Available at: https://www.jstor.org/stable/j.ctv1h9dhsh.

16. Renucci, J.-F. (2005). Introduction to the European Convention on Human Rights The rights guaranteed and the protection mechanism. [online] Available at: https://www.echr.coe.int/documents/d/echr/Pub_coe_HFfiles_2005_01_ENG.

17. Human Fertilisation & Embryology Authority (HFEA). (2023). Human Fertilisation and Embryology Authority. [online] Available at: https://www.hfea.gov.uk/about-us/publications/research-and-data/fertility-treatment-2023-trends-and-figures/.

18. Ibid.

19. Ibid.

20. World Health Organization (2023). 1 in 6 People Globally Affected by Infertility. [online] www.who.int. Available at: https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility.

21. HFEA (2024). Key facts and statistics | HFEA. [online] www.hfea.gov.uk. Available at: https://www.hfea.gov.uk/about-us/media-centre/key-facts-and-statistics/.

22. Ibid.

23. www.hfea.gov.uk. (n.d.). Ethnic diversity in fertility treatment 2021 | HFEA. [online] Available at: https://www.hfea.gov.uk/about-us/publications/research-and-data/ethnic-diversity-in-fertility-treatment-2021/.

24. www.hfea.gov.uk. (n.d.). Fertility treatment less successful for ethnic minority patients, new figures reveal | HFEA. [online] Available at: https://www.hfea.gov.uk/about-us/news-and-press-releases/2021/fertility-treatment-less-successful-for-ethnic-minority-patients-new-figures-reveal/.

25. www.hfea.gov.uk. (2020). Family formations in fertility treatment 2018 | Human Fertilisation and Embryology Authority. [online] Available at: https://www.hfea.gov.uk/about-us/publications/research-and-data/family-formations-in-fertility-treatment-2018/.

26. Jones, B., Peri-Rotem, N. and Mountford-Zimdars, A. (n.d.). Geography lottery: it sadly matters where you live when you want to start a family through fertility treatment | HFEA. [online] www.hfea.gov.uk. Available at: https://www.hfea.gov.uk/about-us/our-blog/geography-lottery-it-sadly-matters-where-you-live-when-you-want-to-start-a-family-through-fertility-treatment/.

27. Sieckmann, J.-R. (2025). The Foundation of Fundamental Rights. [online] Philpapers.org. Available at: https://philpapers.org/rec/SIETFO-2 [Accessed 6 Oct. 2025].

28. Department of Health (2024). Human Fertilisation and Embryology Act 2008 - Explanatory Notes. [online] Legislation.gov.uk. Available at: https://www.legislation.gov.uk/ukpga/2008/22/notes/division/6/1/14/2.

29. Silber Mohamed, H. (2018). Embryonic Politics: Attitudes about Abortion, Stem Cell Research, and IVF. Politics and Religion, [online] 11(03), pp.459–497. doi:https://doi.org/10.1017/s175504831800010x.

30. Pew Research Center. (2013). Survey of Aging and Longevity Archives. [online] Available at: https://www.pewresearch.org/dataset/survey-of-aging-and-longevity/ [Accessed 6 Oct. 2025].

31. Silber Mohamed, H. (2018) (ref. 29 - Ibid).

32. Ibid.

33. Ibid.

34. HFEA (2024). Key facts and statistics (ref. 14 - Ibid).

35. ARGC | The IVF Clinic London. (2025). Understanding Success Rates | ARGC | The IVF Clinic London. [online] Available at: https://argc.co.uk/en/understanding-success-rates [Accessed 6 Oct. 2025].

36. Human Fertilisation & Embryology Authority (HFEA). (2023) - (ref 11, Ibid).

37. R-GA-10, J.B. (2017). Cosponsors - H.R.586 - 115th Congress (2017-2018): Sanctity of Human Life Act. [online] Congress.gov. Available at: https://www.congress.gov/bill/115th-congress/house-bill/586/cosponsors [Accessed 7 Oct. 2025].

38. Ibid.

39. Silber Mohamed, H. (2018) - Ibid (29).

40. Franklin, S. (2013). Conception through a looking glass: the paradox of IVF. Reproductive BioMedicine Online, [online] 27(6), pp.747–755. doi:https://doi.org/10.1016/j.rbmo.2013.08.010.

41. United Nations (1994). Programme of Action Adopted at the International Conference on Population and Development. In: UN Economic and Social Affairs. [online] Available at: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_1995_programme_of_action_adopted_at_the_international_conference_on_population_and_development_cairo_5-13_sept._1994.pdf.

42. United Nations Population Fund. (2022). The Future of Sexual and Reproductive Health and Rights. [online] Available at: https://www.unfpa.org/publications/future-sexual-and-reproductive-health-and-rights.

43. Un.org. (2025). Document Viewer. [online] Available at: https://docs.un.org/en/E/C.12/2000/4.

Glossary of key terms / acronyms

Assisted reproductive medicine - grouped under ART in this article: Assisted Reproductive Technologies

Blasocyst stage - In IVF, the ‘blastocyst stage’ refers to a rapidly dividing ball of cells, approximately 5 to 6 days after fertilisation. These have a complex structure containing an internal cell mass (which forms the fetus) and an outer layer called the trophectoderm (which forms the placenta). Embryos are often cultured to this stage in the lab to identify those with the highest potential for implantation and a healthy pregnancy.

Bill on Human Rights - refers to the International Bill of Human Rights, which includes the Universal Declaration of Human Rights (UDHR)

ECHR - European Convention on Human Rights

Endometriosis - a chronic inflammatory condition where tissue similar to the lining of the uterus, known as the endometrium, grows outside the uterus, typically in the pelvic region, causing pain, inflammation, and scarring – affects many women of reproductive age, potentially impacting fertility

ESC research - embryonic stem cell research

IVF - In Vitro Fertilisation – fertility treatment where an egg is fertilised by sperm in a laboratory (‘in vitro’) and then the resulting embryo is transferred to the woman's uterus to grow

PCOS - or polycystic ovary syndrome, is a common hormonal disorder affecting women of reproductive age that involves hormonal imbalances, irregular periods, and can lead to the development of cysts on the ovaries – can impact fertility

Positive Right - an entitlement to receive something or be provided with a service, which requires another party to take action, such as a government providing healthcare or education. This is different from a negative right, which is the right to be free from interference or coercion, requiring only that others refrain from acting against you.

Postcode lottery - a situation in which the level of the quality of health care, education, etc. that people receive is different in different areas of the UK

Progressive realisation - formal, codified concept in international human rights law – widely used in legal literature. It stems from the International Covenant on Economic, Social and Cultural Rights (ICESCR), 1996.

Article 2(1) states:

“Each State Party… undertakes to take steps… to the maximum of its available resources, with a view to achieving progressively the full realisation of the rights recognised in the present Covenant…”

It is the legal mechanism for how states are expected to move towards the right to health – a step towards full implementation.

STI - sexually transmitted infection

UNFPA - United Nations Population Fund