A Realpolitik of Ethics. Behind the Specificity of the French ART System (1972–1994)

What Did Differences Lay On?

For David, Netter and Geller alike, AID was a male infertility remedy, certainly not a new way to make children for any kind of intended parents. Secrecy and anonymity were undiscussed, self-evident premises. “Social” indications, such as insemination for single women, were hardly a topic of discussion. What is more, they all felt it necessary to confer an axiological justification upon cryonservation and non-husband insemination, in other words to provide these unusual activities with “respectability”. ⁴⁰ One shared argument was that AID was an expression of conjugal love and a medical tool for converting pain into happiness; it would in no way be used to “manipulate life” for dubious purposes. Retracing the steps of his own conversion to AID, from hostility to doubt and doubt to acceptance, Netter made the case that doctors, whatever their personal opinions, could no longer remain deaf to patients’ demands for an alternative to adoption. ⁴¹

The outlines of David's credo, revealed as early as October 1972, ⁴² were formalized as a chart for Bicêtre's CECOS and then became the backbone of the protocol for private gynecologists using CECOS semen samples. Both his Catholic background and his fear of a religious bridging explain David's attempt to “ennoble” (as Irène Théry wrote) AID. In the face of societal change, medical customs and norms should adapt, but without going too fast, and certainly not without official support. David's rhetoric of “gift”, directly traced from blood donation and underpinned with the help of modernist religious consultants, ⁴³ went hand-in-glove with his rejection of any monetary compensation, which he refused to dissociate from commodification or market-based relations. Referring to practices in Brussels and Copenhagen, Netter and Geller chose to compensate (or defray) sperm donation, without terming it remuneration or contesting the free-of-payment philosophy. However, this minimal money transaction ⁴⁴ was, at the very start, the main disagreement between David and them. Another divergence was that the CECOS, in order to preserve mainstream family values and to neutralize the “adultery” objection, designed donation as a couple-to-couple gift. It is likely that the application letters sent by unmarried donor candidates when the Bicêtre bank was first launched strengthened David's convictions: these unsolicited candidates, who had a very basic (if not vulgar), androcentric and self-centred view of sperm donation, were the opposite of what David imagined in his project to symbolically elevate AID. ⁴⁵

It might nonetheless be misleading and anachronistic to overestimate these initial divergences, and to analyse only in “ethical” terms a combination of morals and mores, ethics and ethos, normative behaviors and styles of thinking. A synthesis of his own mixed profile—partly a clinician, partly an experimentalist, but also a doctor with a deep-seated belief in social medicine—Georges David's credo lay on a biomedical modernism and a bet on interdisciplinarity. Based on laboratory work, CECOS centers brought together an extended range of medical specialisms and even resorted to humanities to treat all the aspects a doctor and a couple could not resolve by themselves. Moreover, it was not separable from David's deep faith in public service and universal access to care, with explicit, transparent, non-negotiable rules. Netter and Geller's “framework”, on the contrary, referred to the private doctor's moral code, which they considered the only valuable and acceptable safeguard against all potential abuse. What was avant-garde in their conception was—unlike David—the abandonment of medical paternalism ⁴⁶ : as their interwar American forerunners (Koerner, Seymour, Guttmacher) might have stated, and somehow as young liberal gynecologists would argue about contraception or abortion, a doctor should remain a neutral, judgement-free service provider, ⁴⁷ whose only duty is beneficence. ⁴⁸ David, for his part, conceived his own liability and the consequences of his acts on the scale of the whole of society. Thus, his strategy could not be confined to the medical field. After being granted the tacit support of the Paris hospitals trust (Assistance publique-Hôpitaux de Paris) ⁴⁹ in as early as 1972, he was determined to obtain the support of the state itself, so that he could be confident that no obstacle would be put in his way. Only under these circumstances could the CECOS “experiment” be rolled out and duly assessed. In the longer term, David hoped, the government should “take an explicit stance on AID”. ⁵⁰

Knocking at government doors resulted in an under-publicized but steady and efficient circuit of discussions that brought together CECOS representatives and a handful of state decision-makers. The Health Minister, Simone Veil, immediately became an indefectible ally. Although not verbatim, the archive records of these round tables witness the affinity between the latter, the representatives of the ministerial directions centrales and Georges David. All were reformists in the double meaning of the word: they pushed for change, but through compromise and legalism. ⁵¹ Veil, who faced violent political hostility in her struggle for abortion rights, did not want to embrace an additional hot topic. ⁵² She shared David's wish that the CECOS experiment remained as quiet as possible until it underwent a rigorous assessment. Reading between the lines, another major fear can be discerned: that of triggering political and parliamentary debate. ⁵³ Putting AID in the democratic forum would not only provoke a conservative backlash, it might also encourage feminist claims and potentially give single women the opportunity to ask for the right to motherhood.

Simone Veil suggested that, in its probationary phase, the CECOS site at Bicêtre—and, from 1974, the numerous CECOS sites created at provincial university medical centers—should retain a non-profit status (association under the Law of 1901), rather than seek formal attachment with the public hospital sector. This option allowed governance to remain in the hands of the association's directorate (conseil d’administration) and released hospital authorities from any liability. The composition of the directorate had to offer the best possible protection against hypothetical criticisms. To this end, Georges David played a precious card he had inherited from his medical student years. ⁵⁴ The revered pediatrician, social hygienist, and hospital reformer Robert Debré, who embodied the French biomedical and hospitalo-universitaire establishment, was appointed Honorary Chairman, bringing with him his symbolic capital of medical and moral authority. ⁵⁵ Ex-officio representatives of CECOS Paris’ institutional environment (ministerial directorates, APHP, provincial teaching hospitals, French Order of Physicians) provided the organization with the legitimacy of a “parapublic” body. As a token of pluralism, two Catholic and notoriously anti-AI physicians, Drs Monsaingeon and Monod-Broca, sat on the directorate. ⁵⁶

This co-option strategy illustrates the “controlled openness” that characterizes David's cautious way to adapt to societal change. A decade before the Comité national d’éthique was established, the CECOS initiated this way of regulating life technologies by entrusting problem solving and decision-making to pluralistic but elitist “committees” (commissions) of “wise” people. By embracing experts, religious leaders, and moral thinkers—rather than political parties or social movements—these committees objectivized the preference for areopagus rather than agora. Nevertheless, the CECOS’ cleverness was in promoting discussion and collegial practices, especially about issues that could not be resolved by the practitioner's own conscience: unconventional requests, or screening and selection possibilities that touched on the uncertain borderlines between medical genetics and eugenics.

David's organization, therefore, was much more than a symbolic package of “values” or an “ethical construct” regarding the body, sexuality, parenthood, or the doctor-patient relationship. It was a comprehensive and integrated system—an economy in the early-modern meaning of the word—embracing every side of this biomedical activity, anticipating every potential obstacle. David placed AI/D and sperm banking at the core of a sophisticated disciplinary architecture combining reproductive biology, epidemiology, and public health, with frequent references to philosophy, psychology, anthropology, sociology, theology. Of great significance is the centrality of statistics in this design. A member of the CECOS directorate was the researcher at the Institut national de la santé et de la recherche médicale, the introducer of modern quantitative epidemiology in France, and Robert Debré's nephew Daniel Schwartz, ⁵⁷ whose work was of primary importance for the CECOS research, assessment, macro-scale organization, and resources management. ⁵⁸ Letters sent by infertility doctors and gynecologists who asked to become CECOS partners ⁵⁹ suggest that the nature of this economy, although inseparable from David's charisma and affability, received positive feedback from professionals. ⁶⁰

The David/Veil partnership led to a first major outcome: the granting of subsidies to facilities for their running expenses. As early as 1975, Simone Veil, who had the double responsibility of Public Health and Social Security, also believed that the national health insurance system (assurance maladie) should urgently provide infertile households with full coverage for diagnoses and treatments. ⁶¹ She received letters from couples who could not afford semen samples ⁶² and she examined several juridical options to overcome this financial issue, despite some ministers’ refusal to spend money on such a marginal condition. ⁶³ In 1978, she subtly inserted AI into a bill (projet de loi) on mother-and-child protection, which became a law. ⁶⁴ Since it was placed under the umbrella of insurance issues, no detail alluded to semen banking and gamete donation, but there was no ambiguity. The exclusively therapeutic indications of medically assisted reproduction were tacitly enshrined, although there was growing debate concerning the scope of AID.

Rising Tensions, Dampened Conflicts

Public funding was an (inconspicuous) recognition of AI/D, but it did not resolve the uncertainties and differences of opinion about how to organize sperm donation. It was particularly crucial to decide to what extent formal norms were necessary to make this activity safe for the doctor, the child, the parents, and the donor, and whether several AI/D circuits should exist or just one.

Doctors and juridical experts complained about a “legal vacuum”, that required the provision of the child-to-be with a legal status, to prevent them from non-paternity suits. ⁶⁵ But for Georges David solving this matter of filiation law was not enough: every philosophical option involved in the AID process and access conditions should be codified. Although he used to say that he never had any “monopolistic” agenda, ⁶⁶ he triggered a process that would potentially enforce CECOS norms across the whole assisted-reproduction offer. The conflict that led from the CECOS’ internal rules to the setting of external rules (with the lois de bioéthique) has been written about through the prism of ethical controversies and judicial cases. Such accounts tend to neglect what was behind the sperm-bank contest, starting with a struggle surrounding a scarce resource. The low number of donors—while the decrease in the adoption offer probably stimulated AID demand—made semen shortage a chronic issue. ⁶⁷ Right from the launch of the Bicêtre CECOS, David had to inform many couples and colleagues that his bank could not satisfy a demand that exceeded supply. ⁶⁸ In 1985, only 600 men gave their semen. Around 3000 donors were needed. The waiting list soon emerged as the CECOS’ Achilles heel. ⁶⁹ Minister Veil, along with the wife of then President Giscard d’Estaing, were sent supplications from people for whom the obstacle course to obtaining AID was so difficult that they begged them to convince the CECOS to consider their case. ⁷⁰ This imbalance, aggravated by non-payment and “couple-to-couple” donation, affected every part of the AID economy.

This concerning issue led to set up a consultation circle bringing CECOS leaders and civil servants together, who met from March 1976 to October 1977. ⁷¹ Officially, this working group was supervised by the Directeur général de la santé. Actually, David immediately took the lead. His overall “framing” of the AID-related issues proved even more consensual than the CECOS principles as such. Aligned with what Pierre Bourdieu coined “state thinking” (pensée d’État), ⁷² David's suggestions and requests were in perfect harmony with the inclinations of the hauts fonctionnaires (state administrators): he spoke their language and shared a similar conception of “modernization”. An apostle of the Republican service public, who had deliberately waived a private GP career, David had internalized a bureaucratic rationality that enabled him to envision assisted reproduction at a macro scale, in terms of time (planning) and space (mapping). This was a major asset compared to David's competitors, who framed the issue as, basically, a problem of medical interaction and demand-flow adjustment. Since the CECOS benefited from state subsidies, and in anticipation of social refunding, David was aware that his credibility also depended on budgetary considerations, at a time when administrators were experimenting with the move towards “expense-optimization” and “cost-benefit analysis”, ⁷³ implementing new instruments to govern “medical demography”.

David also insisted that managing the supply issue required sound coordination within the CECOS network ⁷⁴ : CECOS banks had to be regulated both in number and in localization. Such macro-management would not only facilitate the exchange of semen samples and ease statistical harmonization, it would also prevent applicants from having tries at other centers if turned down by their local one—another type of “consumer” behavior incompatible with the CECOS values. Little by little, the idea of introducing some réglementation ⁷⁵ to the whole French sperm banking offer arose. The claimed purpose was twofold: firstly, to establish, in official terms, the conditions that CECOS centers had to respect, and secondly, to avoid the “wild dissemination” (“prolifération sauvage”) of sperm banks in general. ⁷⁶ David dealt with banks, not “traditional” AID. He deemed it illusory to regulate private and infralegal practices, a belief shared by the DGS’ juridical expert. ⁷⁷ Although he was eager to “sanitize” AID, and aware that the informal sector probably captured a number of potential donors, the CECOS patron thought it too ambitious and was convinced that coercive laws would fuel the black market instead of blocking it. De facto, informal AID survived until the 80s at least ⁷⁸ and even some regular partners of CECOS resorted to both systems, depending on their needs. ⁷⁹ Nor did David allude to the Hôpital Necker. In the mid-70s, a peaceful coexistence reigned between Bicêtre's CECOS and Necker's “spermiothèque”. ⁸⁰ Netter was as legitimate as David in the field. In addition, he had retired in 1975 and his successor Prof. Mauvais-Jarvis, who also attended the working group, intended to join the CECOS system. ⁸¹

The expression of “wild dissemination” was actually aimed at Sacha Geller. Unlike the Parisian setting, where the Necker and Bicêtre sperm banks had been established concomitantly, the development of Geller and Dajoux's cryoconservation facility in Marseille occurred where a CECOS site already existed. ⁸² Geller, who was fond of conversation and disputatio, had promoted his activity in public debates in Marseille. Nevertheless, he was careful not to offend David. In April 1977, informed by “the newspapers” that the Marseille CECOS was facing a lack of donors, he invited David to a fair and friendly exchange of views. ⁸³ The way in which the CEFER operated was not—Geller admitted—as “ethically demanding” as the CECOS, but the acceptance of unmarried donors and the fact they were paid for donating made it evidently more efficient. Theorizing a “three D” policy—“de-mystify” (AID is a low-tech procedure), “de-dramatize” (non-husband sperm is just a “biological prosthesis”), and “decentralize” ⁸⁴ —he also contested the relevance of national planning/mapping. Rather than a peak technology requiring a hospital environment and geographic concentration of resources, he considered sperm banking a light and flexible device that allowed reactivity.

The open and peaceable conversation did not occur. Despite his leitmotiv that the CEFER was nothing more than a “complementary” bank, ⁸⁵ Geller soon conceded that he was carrying on a “fair and fruitful”, but determined, joust: that of private practice vs public sector. ⁸⁶ He and Dajoux, though reputed physicians, had both been kept out of university hospital circles. As medical students (respectively in the 1940s and 1960s) with Jewish origins, they had faced prejudices and their route to the agrégation had plausibly been blocked by discrimination. ⁸⁷ Geller, who benefited from a remarkable reputation in endocrinology and contraception—notably working with Scholler at the FRH—had never concealed his desire for “revenge”. ⁸⁸ In a 1977 paper ⁸⁹ that contrasted the CECOS Marseille bank's difficulties with the “success” of the CEFER, with its “74 babies” born in three years, ⁹⁰ Geller proudly presented his bank as a flourishing organization. His patients came not only from the south-east of France, but from every corner of the country. A CEFER branch was to open in Montpellier and a further one was announced in Nice. ⁹¹ When, in 1980, André Mattei, the head of CECOS Marseille, told David of his anger at seeing the CEFER distributing leaflets to the gynecologists of Marseille, the accusation of unfair competition was implicit behind allusions to ethical laxity.

Make new laws or build an institutionalized space for professional reflection? Set up a complicated and fussy framework or simply formulate general guidelines? The working group's hesitations foreshadowed the dilemmas addressed until the making of the lois de bioéthique. The discussion soon focused on the concept of “rules” (réglementation), which could involve a range of possibilities. ⁹² Here again, various options were put on the table. One was to sectorize sperm banking facilities on a national scale (based on the idea of a carte sanitaire—health service map), in order to prevent the establishment of new banks where demography and estimated male infertility did not justify an extended offer. ⁹³ Others were to define a blood transfusion-like list of health safety criteria, or to create an official status for sperm banks, with compulsory state approval (agrément) for anyone wanting to run a facility. In any case, it was necessary to decide whether the CECOS system should be taken as standard, potentially resulting in the elimination of any other model.

In a memo on the “agrément des banques de sperme”, ⁹⁴ David not only perceived state approval as a preliminary health and safety check, he recommended that the banks were “functionally linked” to a CHU-based insemination provider—or, in case of non-hospital insemination, that the conditions of use and indications were strictly controlled. Even better than only placing the banks into a hospital environment was to incorporate them into infertility units connected with reproductive biology and cytogenetics labs, thus ensuring that AID would remain a response to medical infertility. Even though the direction de la Santé was supportive of these recommendations, its legal expert expressed some caveats. ⁹⁵ Be it justified or not, she said, the CECOS operated based on the doctor's ability to choose, accept or dismiss donors and recipients, making CECOS staff medical gatekeepers. Soliciting the involvement of public authorities through approval procedures would involve imposing the CECOS principles on all operators: de facto or de jure, this would likely produce a debatable monopoly and raise complex issues if outsider sperm banks ever broke the rules. In the end of 1977, nothing was decided, except that going through the regulatory route was politically less slippery than to legislate. But this restricted and quiet political process ⁹⁶ was struck by a much more punchy initiative that came from Parliament.

The Politicization of AID

In the winter of 1978, a bill was tabled by two senators, Henri Caillavet and Jean Mézard, with the explicit ambition to “make AI a means of procreation” (“tendant à faire de l’insémination artificielle un moyen de procréation”). ⁹⁷ Caillavet, notoriously a Freemason, had backed Simone Veil's 1974 abortion law and carried reform bills on organ donation, homosexuality decriminalization ⁹⁸ and on a right to die. Mézard, a member of the commission des affaires sociales (standing committee on social affairs), spearheaded the amendment that made “AI” explicit in Veil's 1978 law. Drafted in the last months of 1977, ⁹⁹ their bold proposal did more than just fill the so-called “legal vacuum”. Its authors flew the flag for “progressive liberalism” and “tolerance”. ¹⁰⁰

The draft had been prepared by a committee, the composition of which did not break with controlled openness. It emanated from Caillavet's senatorial “Association des Libertés” and was composed of many doctors, an ecumenical sample of clergymen, and some law and medico-legal experts. Very few feminist activists ¹⁰¹ or members of civil society had attended this committee. The text—which looks quite rushed—was an awkward attempt to reconcile the divergent points of view. It undoubtedly consecrated some of the ideas of Georges David, who co-headed the committee, such as non-payment and a Malthusian approach to frozen sperm supply, with the setting of quotas. On the other hand, the CEFER was explicitly recognized as a respectable experiment and, above all, the bill broke strong taboos in stepping outside the straightjacket of medical infertility: neither the insemination of unwed women nor post-mortem fertilization was banned.

Confirming David and Veil's fears, the bill induced a public debate ¹⁰² and resulted in the outpouring of previously underlying tensions. Whereas the CECOS disapproved the insertion of non-medical indications, Netter, pointing out that every legal provision was accompanied by regulatory measures with heavy penalties, ¹⁰³ blamed a “coercive, repressive, monopolistic, narrow-minded, and dictatorial” text ¹⁰⁴ and Geller declared the bill was paving the way for “state banks” ¹⁰⁵ instead of leaving sperm storage in the hands of private (though non-profit) organizations. ¹⁰⁶ The legislator, Geller added, might have let single women have access to AID, regardless of their sexual orientation. ¹⁰⁷ Thinking that the text attempted to “set traps for CECOS’ competitors” ¹⁰⁸ in requiring a state approval that was tailored to the CECOS, Geller and Netter suspected that David was its instigator. ¹⁰⁹ Given the profiles of Caillavet and Mézard, and knowing that Pierre Simon had been solicited, ¹¹⁰ one can presume that the senators actually had more connections with the network of liberal life-reformers than with the CECOS circle.

After the widely attacked bill was sent back to the Senate, a new round of hearings ¹¹¹ gave voice to Geller, Netter, and Jondet, and to the feminist and pro-choice lawyer Gisèle Halimi. ¹¹² David's influence was weakened in Parliament but after a series of national scientific meetings which addressed and assessed the CECOS experiment, and moreover in organizing the first international symposium on AI and sperm banking, ¹¹³ again with Minister Veil's backing, ¹¹⁴ the CECOS patron was now consecrated as the pope of AI in France. ¹¹⁵ He featured in a subgroup at the Académie de médecine, headed by the obstetrician Robert Merger, which recommended that the monopoly of approved sperm banks (centres agréés) was protected by a statutory law and presented the CECOS as the “best example” and the surest safeguard against “commodification”. ¹¹⁶

Apologizing for their overly “ambitious” and severely “regulatory” (réglementariste) initial text, ¹¹⁷ Caillavet and Mézard issued a revised version, less subversively entitled “proposition de loi relative à l’insemination artificielle des êtres humains” (“bill about human AI”). The new version excluded single women and widows, ¹¹⁸ but Geller's point of view had been substantially reinforced. ¹¹⁹ The new senatorial report pointed out the artificiality of the dichotomy between “public” centers and “private” but non-profit centers, along with the false opposition between “non-paid donor” and “monetary compensation”. To reconcile ethics and efficiency, it was proposed that donation could be compensated (indemnisée) and in its annex, the report featured a 1979 Council of Europe draft recommendation on human artificial insemination which said that “travelling and other expenses (…) may be refunded to the donor”. Lastly, a “monopoly” of any kind had to be banned and the new text stated that approval only concerned doctors, not centers. Whereas the deputies eventually rejected the bill, the Cavaillet-Mézard initiative had propelled AI/D into the media sphere and doubtlessly exacerbated the “ethical war”.

Towards a CECOS-Centric Standardization

Although no “wild dissemination” of sperm banks really occurred, the legal status quo perpetuated a market dualism: in 1985, 10% of donor inseminations did not involve the CECOS network. ¹²⁰ Notwithstanding the fact that some private gynecologists were still using fresh semen, those fertilizations outside the CECOS network were performed either through the CEFER ¹²¹ or the FRH, where a bank and insemination unit had been opened by Dr Jondet after Necker's bank had joined the CECOS network. ¹²² Throughout the 1980s, the gap between the strategies of the CECOS network and the other banks (especially the CEFER) grew continuously. The CECOS banks pursued their quest for officialization and their efforts to obtain an unnamed monopoly. Conversely, the CEFER team waived the quest for consensus, even more so as Geller's repeated attempts at bringing David to a public and direct confrontation were in vain. The latter had more reasons than ever to avoid public arenas and systematically refuse “polemics”. ¹²³ From the early 1980s, Geller was then forced to play a “maverick” role, making more and more iconoclastic statements intended to reveal the retrograde tendencies of the CECOS (and of mainstream ethicists and the public authorities). Not enjoying the same national media exposure, he was often reduced to the demeaning task of defending the CEFER readers’ letters to the editor in the newspapers. ¹²⁴ This asymmetry definitively anchored a “them-against-us” reading of the conflict in the minds of Geller and Dajoux—and Netter and Jondet. The CECOS doctors were irreversibly seen as arrogant hospitalo-universitaires who disdained vulgar private practitioners; an interpretation with obvious “Paris vs Marseille” undertones. ¹²⁵

While the creation of the Comité consultation national d’éthique (of which David was a member) and expanding worries about a growing “marketization” of ART (with the upsurge of the In Vitro Fertilization sector that boosted requests, including unconventional ones) converged with the CECOS’ aspiration for stricter state control, ¹²⁶ Geller and his collaborators seized the opportunity of certain well-publicized requests to attempt to shift moral boundaries and push forward the values of liberal individualism. These public controversies, such as the “Parpalaix case”, ¹²⁷ are not only textbook-cases of ethical dissent: they were battlegrounds and pretexts for the sperm banks’ rivalry, and affected adversaries’ perceptions of each other as well as the supporting networks. The CECOS camp could argue that their fears were being confirmed, while the CEFER team could denounce “ethical” stances as a “shield the society waves to limit medical progress”. ¹²⁸ The surrogate fertilization case led to Geller's last stand. In 1984 the CEFER patron created a third association (Alma Mater) to ease the cooperation of two other charities, Sainte Sarah (infertile couples) and Les Cigognes (biological mothers). ¹²⁹ This flirtation with boundaries caused fresh public scandal, despite Geller's careful preparation of his legal arguments and the support of several prominent figures including Caillavet, Pierre Simon, ¹³⁰ the famous pediatrician Prof. Minkowski, the IVF star Prof. Émile Papiernik and, last but not least, the socialist Minister of Justice Robert Badinter. ¹³¹ The case led the Conseil de l’Ordre des médecins to take the position that a doctor is not “the blind performer of any request” and to add its voice to the choir of those pleading for ethical regulations. ¹³² After Alma Mater was banned in 1988, ¹³³ Geller retired and the CEFER was closed. ¹³⁴ As a result, in many official papers from these years, “sperm banks” and “CECOS” had almost become synonymous. ¹³⁵ Less newsworthy, the standardization of French sperm banks involved the area of administrative negotiations and bureaucratic procedures. It is noticeable that the CECOS no longer benefited from a privileged and exclusive relationship with national health administrators. ¹³⁶ Not only because of Simone Veil's departure from the government, ¹³⁷ but also due to the IVF boom, which had led to a proliferation of new ART operators (about 300 “ART centres” in the mid-1980s), many of which private companies. This dramatic change in the biomedical landscape meant new professional and economic interests and blured the borders between clinical and biological activites, labs and care facilities, private and public structures. Paid-for semen, a black market, the anarchic dissemination of AID centers, loss of centrally coordinated control over indications, insufficient health safety (including HIV/AIDS) and genetic security (consanguinity): two decades after Georges David's first experiments, all the things the CECOS had always stood against seemed to be back on the agenda.

The direction de la Santé thought regulation could not be postponed anymore and, once again, seized administrative tools—through the principle of a license (agrément) —in spite of the absence of a perfectly suitable legal basis. ¹³⁸ Paradoxically, this did not benefit the CECOS. When the Minister Michèle Barzach, in April 1988, signed decrees that governed ART facilities, the requirements proved so draconian that, out of the 300 applicant ART centers, the specially-formed medical and biological committee only deemed 74 of them technically compliant. The CECOS, due to their private status (except for 4 centers over 20), did not feature in the list of approved centers ¹³⁹ and they had no other choice than accepting a full (i.e., not only functional) attachment (intégration) to public hospitals. The Federation had long seen this option as a relevant means for harmonizing the governance of centers, ¹⁴⁰ but the way it was imposed was perceived as blackmailing ¹⁴¹ and led to difficult and long-lasting negotiations. ¹⁴² Before this was achieved, which took years, the CECOS found itself obliged to make an arrangement with the social security authorities to bypass the lack of agrément. ¹⁴³ And ironically, non-CECOS cryobanks enjoyed the benefits of this procedure. The FRH's sperm bank had obtained the license and prospered until the dissolution of the foundation in 1997. Above all, the specter of “wild” operators came back. The Barzach decrees were based on a distinction between clinical (examinations and fertilizations) and biological (gamete collecting, preparation, and storage) activities, nevertheless they did not differentiate AI/D and IVF, nor intraconjugal and donor procedures. ¹⁴⁴ Their wording was pointed out by the Comité d’éthique as too vague to prevent commercial medical testing laboratories from developing a “sperm market”. ¹⁴⁵ In the context of the HIV/AIDS epidemic, the CECOS communicated about their strict quality control, which an unregulated market could weaken, and even traditional AID was now called into question. In September 1991, on a TV show, the head of CECOS Reims denounced a private company created in Marseille by a biologist and a gynecologist, just after the closure of the CEFER. Officially an IVF center, it used the agrément it had obtained for its “ART” (actually IVF) activity to practice semen cryoconservation and develop a dubious business in selling sperm collected among unemployed or students (depending on the newspaper) in only 48 h–with a lack of rigorous biological controls. ¹⁴⁶ This new case appeared to justify the CECOS’ permanent fears and prompted more professionals and observers to demand external rules. In this light, it is even clearer that the lois de bioéthique (which combined health safety license and most of the CECOS principles on gamete donation and reception) were not only the product of metaphysical considerations. The memory of the CEFER experiment, explicitly constructed by the legislator as an “anti-model”, and the new anxieties about “sperm trafficking” were vivid in the parliamentary debate and alluded to in the 1994 laws themselves.