Carrying the same pregnancy: A bioethical overview on Reciprocal effortless IVF and similar techniques

Introduction

In 2018, news of the first baby “carried” in the bodies of two women made global headlines. Through a special treatment called Reciprocal effortless in vitro fertilization (IVF) ¹ (ReIVF) and performed in the United States, two women indeed had the same embryo in both their bodies: one in her vagina and the other one in her womb. In the words of Gilbert and Polotski, this was the first time that two women “carried” the same pregnancy. ² Then, in 2019, in Europe, two other women carried the same pregnancy as well, but that time they were enabled to carry the same embryo in both their wombs through a treatment that was like ReIVF. Despite the slight differences between the two treatments, it is worth noting that both were performed successfully, and that two healthy babies were born using them.

As can be seen, in the past years there have been at least two documented cases of pregnancy carried by a couple of persons. Even today, these cases are scarcely investigated yet, and techniques such as ReIVF still receive little or no consideration in scientific literature. The first and probably the main reason is that the techniques mentioned above have been rarely used, but this in no way means that they will not be used and even developed in the coming years. Rather, a bioethical analysis may be needed to address not only the uniqueness of those techniques and the potential and effective reasons of their use, but also their compatibility with the four classical principles of medical ethics: autonomy, beneficence, nonmaleficence, and justice.

Methodology

The four classical principles of medical ethics were initially outlined in the U.S. National Commission's Belmont Report, which was developed in the 1970s in response to the abuses of human subjects in some government research studies. ³ The report identified some basic ethical principles—respect for persons, beneficence, and justice—for the protection of human subjects in biomedical and behavior research, and it developed guidelines for conducting research studies in accordance with those principles. First, considering the principle of respect for persons, the Report stated that everyone had the right to choose whether or not to participate in a research study on the basis of a voluntary and informed consent. Everyone could also stop participating in the research at any time without penalty, and their privacy and confidentiality had to be protected. Second, in accordance with the principle of beneficence it was stated that in every research not only was the potential harm to be justified by the potential benefits, but also that the potential risks had to be minimized, while the potential benefits had to be, conversely, maximized. Finally, concerning the principle of justice, the report stated that the potential risks and the potential benefits that can be found in every research had to be equally distributed between all the involved subjects, and that there had to be equal criteria in the selection of research subjects.

Later, the principles described in the Belmont Report were more fully articulated in 1979 in Beauchamp and Childress’ Principles of Biomedical Ethics. ⁴ The principle of respect for persons was understood as principle of (respect for) autonomy, which mainly referred to the ability of individuals to give a rule to themselves, acting both in accordance with their choice and without limitations or the interference of others. As for the principle of beneficence, it was divided in two different principles, namely the principle of beneficence and the principle of nonmaleficence. On the one hand, the principle of beneficence prescribed to act considering the best interest of the other, requiring agents both “to provide benefits” (positive beneficence) and to “balance benefits and drawbacks to produce the best overall results” (utility). On the other hand, the principle of nonmaleficence referred to the duty not to intentionally inflict evil or harm to the other. The principle of justice remained unchanged, and it still concerned fairness in distribution. Overall, these four principles provided the basis for one of the main approaches to biomedical ethics—that is principlism, or the “four principles” approach. Since principlism aims to provide “a moral framework that is universally binding and that allows for a systematic assessment of moral issues in biomedicine,” ⁵ its principles are argued to be general and universally applicable. The source of the principles of autonomy, beneficence, nonmaleficence, and justice is what Beauchamp and Childress called “common morality,” which is a set of standards and moral norms—like “do no kill” or “prevent evil or harm from occurring”—that all persons committed to morality share. The norms of the common morality are not only shared in all places and across cultures, but they also achieve the objectives of morality by lessening human misery and preventing social relationships from being disintegrated. For instance, the norm of doing no kill lessens preventable death, and it is considered essential to the survival of a society. Besides, all the norms of the common morality realize the objectives of morality and what Beauchamp and Childress considered as the primary objective of morality: “to promote human flourishing by counteracting conditions that cause the quality of people's lives to worsen.” ⁶ Considering this, “principles” are “the most general and basic norms of the common morality,” ⁶ and therefore they are universal. This does not mean that they are absolute, however; as Schöne-Seifert maintains, “they are considered to be prima facie binding, as they lack lexical or hierarchical order and are in need of much context-sensitive analysis and balancing.” ⁷ It follows that under certain circumstances principles can be in conflict, and since there is not an absolute principle they need to be balanced and specified depending on the context.

After more than 40 years since being developed, the principles of autonomy, beneficence, nonmaleficence, and justice still provide guidance to those who review and monitor biomedical research involving human subjects, and they are still considered relevant to address many ethical issues. Although principlism cannot exhaust the complexity of the matter, nor is it the only way to approach a bioethical question, it can offer a general moral framework that might be useful for an initial understanding and assessment of ReIVF as well as of other similar techniques. In addressing such a novel set of techniques and the following ethical issues, the research question is intentionally general and there is no presumption to give exhaustive or conclusive answers. For this reason, the four principles of principlism are here used as the starting points of reasoning. The aim of this article is indeed to start considering the ethical legitimacy of ReIVF and of all the other techniques that allow two persons to carry the same pregnancy, and the principles of autonomy, beneficence, nonmaleficence and justice can provide a “basic moral analytic framework” ⁸ that can be useful for the investigation of little-known techniques. This does not exclude that further factors must be considered, however, as further investigations using other approaches are needed.

Some needed clarifications

Gestation, that is pregnancy, is here considered as a physiological state of an individual during which an entity develops inside her body. ⁹ Since this article only aims to provide a starting point for addressing ReIVF and similar techniques, it assumes in a preliminary way that pregnancy begins with conception and not with the implantation of the embryo in the womb. This is a very controversial assumption since there is still no full agreement on when pregnancy begins. Notwithstanding, this article does not aim at finding a definitive answer to the issues related to pregnancy beginning, but it aims only at questioning about ReIVF and similar techniques on a bioethical point of view. The verb “carrying” and the phrase “carrying the (same) pregnancy” are mainly taken by Gilbert and Polotsky, ² who were among the first scholars to have addressed the topic, and by Mucowski, ¹⁰ who is a reproductive endocrinologist at the clinic that performed ReIVF first. Since ReIVF has not been largely discussed in scientific literature, newspapers articles are considered as well, and some of the phrases that they used to describe ReIVF process like “shared pregnancy” or “carrying the same baby” are used. ¹¹ However, this does not exclude that, in the future, the ReIVF process will be described using other and more suitable words. A more accurate linguistic revision in describing ReIVF is highly recommended.

Finally, this article mostly takes into account ReIVF, which is the first technique used by two persons for carrying the same pregnancy. The ethical issues concerning them are here discussed in relation to the United States, especially when the principle of justice and the possibility that ReIVF might be funded by the state are considered. However, many of the broader points/concerns raised may be applicable across jurisdictions, and many considerations concerning ReIVF may be extended to other similar techniques.

Carrying the same pregnancy: What is Reciprocal effortless IVF and how does it work?

At the end of 2017, at an independent fertility clinic in the United States, a couple composed by two women—woman A and woman B—did bodily participate in the “gestation” of the same embryo, which was carried in two different periods in the bodies of both. Firstly, the eggs of woman A were retrieved and placed with the sperm of a donor inside a little, gas permeable, and air-free plastic device known as INVOcell, ¹² which was then inserted inside the vagina of woman A. After 5 days, the INVOcell was removed from the body of woman A and the fertilized embryos were frozen, waiting for woman B to be hormonally treated for embryo implantation. At the end, an embryo was implanted in the womb of woman B, who carried the embryo until she delivered it in 2018.

The used technique, named ReIVF, is the combination of two already existing IVF techniques: Effortless IVF and Reciprocal IVF. As for the Effortless IVF method, it is based on the intravaginal culture of embryos, which is not a new technique. ² Actually, since as early as 1988 Ranoux et al. suggested placing inside the vagina a hermetically closed tube totally filled with culture, in which eggs would have been combined with sperm. ¹³ Now intravaginal culture is a well-known technique, and when it is performed with the use of the INVOcell in Effortless IVF it seems to be as effective as the more traditional IVF procedure. ¹⁴ In particular, in Effortless IVF the eggs of a person are retrieved and placed with the sperm of a donor inside an INVOcell, which is then inserted inside the body of that person; after some days, the INVOcell is extracted, and the obtained healthy embryos are finally transferred to the womb of the same person who has incubated them. ¹⁵ How one may see, Effortless IVF is different from traditional IVF because while in this latter technique embryos are fertilized outside the human body and incubated inside an artificial incubator, in Effortless IVF both the fertilization and the incubation of embryos occur inside the human body. Effortless IVF is like ReIVF in this respect, since also in ReIVF the fertilization and the incubation of embryos occur inside the human body. However, while in Effortless IVF the person who incubates embryos is the same who carries them and gestation occurs only in the body of one person, in the ReIVF process the embryo that is incubated by a person is implanted in the body of another person and, consequently, gestation occurs in the bodies of two persons.

The main difference between ReIVF and Effortless IVF can be explained by the fact that ReIVF includes not only Effortless IVF, but also Reciprocal IVF, that is a technique through which a person provides eggs, while her partner carries the embryo made by those eggs until childbirth. Since its introduction in the field of medical-assisted procreation techniques toward 2010, Reciprocal IVF has been considered a method with many potentials, capable of ensuring good rates of successful pregnancy and increasing the participation of couples such as lesbian couples in the IVF treatment. ¹⁶ In fact, by using Reciprocal IVF both the persons of a couple can have a biological relatedness to the offspring: one genetically, by providing her eggs (genetic parenthood), and the other one gestationally, by carrying the future baby in her body (gestational parenthood). Considering, then, a lesbian couple, thanks to Reciprocal IVF two women can be both the biological mothers of the same child, being one the “genetic mother” and the other one the “gestational mother,” and it could therefore be said that they “share” (biological) motherhood. ¹⁷ For this reason, Reciprocal IVF is also known as Double Motherhood treatment, or simpler, shared motherhood. However, when Reciprocal IVF is taken singularly, it still presupposes that only a member of a couple carries the child, and it is only in its combination with Effortless IVF that things can be different. Indeed, in ReIVF the person who provides eggs also carries the child in her body as well as her partner, so much so that there are two gestational parents instead of one. In other words, while Reciprocal IVF enables two persons to share “only” biological parenthood, ReIVF offers two persons the extraordinary opportunity to gestate the same embryo in both their bodies and not only to share biological parenthood, but also to carry—if not also “share”—the same pregnancy.

Nowadays ReIVF is not the only technique that allows two persons to carry the same pregnancy, though. In 2019, at a private fertility clinic in Europe, two women—woman C and woman D—did use a technique that was like ReIVF and that allowed them to carry the same embryo in both their bodies. However, while in ReIVF one of the two women had carried the embryo in her vagina, that time both the women were enabled to carry the same embryo in both their wombs. During the treatment, which was considered as a special form of shared motherhood/Reciprocal IVF by the clinic that performed it, the eggs of woman C were extracted, fertilized with the sperm of a donor, and placed inside a special device called AneVivo, which was then inserted in the womb of woman C for about 18 hours. ¹⁸ Next, the AneVivo device was removed from the body of woman C and the obtained embryos, cultivated until they were blastocysts, were finally transferred to the womb of woman D until she came to term. Differently from ReIVF, embryos were incubated inside the womb of a woman and not inside her vagina; thus, gestation occurred in both the women's wombs, and newspapers referred to that as the first ever “two-womb pregnancy,” while the newborn was considered as the first ever “two-womb baby.”

Although cases like those illustrated seem to be unique, they are probably less rare than expected. For example, “an increasing number of same sex female couples are choosing to undergo Reciprocal effortless IVF,” ¹ which means that there might have already been other cases of pregnancy carried by two persons. Moreover, the first “two-womb pregnancy” is the clear demonstration that a treatment that allows a pregnancy carried by two persons has been performed not only in America, but also in Europe, which suggests that they might spread around the world, one day. Although these treatments exist, it currently seems that they are permitted in very few clinics yet. As a result, the scientific literature regarding them is poor and almost inexistent, which is why it is particularly challenging to draw any definitive conclusion on their effectiveness, safety, and bioethical legitimacy. Notwithstanding, since at least ReIVF is the combination of two distinct techniques, as already mentioned, it can be preliminarily investigated from a bioethical point of view by assessing the effectiveness and the safety of those techniques. And because the treatment with AneVivo is rather similar to ReIVF in its steps (eggs fertilization and embryo incubation inside a special device placed in the human body + Reciprocal IVF), conclusions on the latter might be extended to it so that there can be a bioethical overview related to these techniques as a whole.

Principle of autonomy: Looking for a double gestation

With initial reference to the principle of autonomy, it can be argued that ReIVF increases the number of options that intended parents choose from and empowers them to exercise their so-called “procreative freedom,” which constitutes—according to Robertson—a moral and legal right that must be respected. ¹⁹ On the one hand, as Cavaliere and Palacios-González point out, ²⁰ people should be respected in their autonomy, that is the capacity to make free choices in matter of procreation without interference or restraint from others. Following this assumption, people have the freedom to make their own procreative choices and, consequently, to shape their own lives in accordance with their values and interests. On the other hand, since reproductive choices usually have a huge impact on an individual's life, they are also relevant for his/her personal wellbeing, allowing him/her to lead a good life. Indeed, as stated by Murphy, the interest of a couple in having a biological relatedness to their offspring can be interpreted not (only) as a mere wish, but also as something profoundly human, which—in a broader context and beyond any biologism—has a deeper meaning and “expresses deeply embedded psycho-moral values” ²¹ which transcend individualistic expectations. Murphy does not indicate which “embedded psycho-moral values” these may be; however, she offers a re-evaluation of the role played by biological kinship in parenthood, based on the conviction that the “cultural force of biologism” cannot be easily removed. In fact, how Hendriks et al. show in their research, biological relatedness is still believed to be important by many people, who mostly seek to “experience a natural process.” ²² Additionally, the interest in (bio)genetic relatedness have been recognized as a “legitimate interest” by the High Court of Singapore, ²³ so that it could not be reduced only to a mere biologism. Maybe there is more behind the desire of a biological relatedness.

For instance, let's consider some techniques—mitochondrial replacement techniques ²⁰ —that allow both the women in a lesbian couple to share genetic parenthood, that is to be genetically linked to their offspring: Cavaliere and Palacios-González argue that these techniques benefit lesbian couples, and this essentially because they increase the number of procreative options that lesbian couples have, giving them the extraordinary opportunity to share genetic parenthood. The desire for (a shared) genetic relatedness is here considered as an “important good” that people should be free to accomplish, and according to this assumption lesbian couples should not be limited in using it. Moreover, according to Cavaliere and Palacios-González, the use of mitochondrial replacement techniques should not be limited only to heterosexual couples because this would sound discriminatory from an equality standpoint, especially if one agrees that lesbian couples have an already limited number of procreative options.

Considering the arguments put by Cavaliere and Palacios-González in favor of a shared genetic parenthood, similar arguments can be put in favor of a shared gestational parenthood. In fact, while mitochondrial replacement techniques allow two persons to share a genetic bond with their offspring, similarly ReIVF and the other similar techniques allow two persons to “share” a gestational bond with the same entity. Thus, also the desire for gestational relatedness can be interpreted as something important for family-making, something that shapes people's lives and influence their wellbeing. Concerning ReIVF and other similar techniques, they are indeed used to respond to a first desire that is the desire to “experience” pregnancy: a desire that not only some persons perceive as positive and innate, ²⁴ but that has been also found in those human beings that could not physically carry a pregnancy. Proof of this might be the fact that who was born without womb expressed, in several cultures and in different times and places, the desire to be pregnant, in accordance with what was called “womb envy” or “pregnancy envy.” ²⁵ Given that a desire for gestation exists, it might concern both the individuals of a couple, especially if both have the capacity to gestate. Maybe, a good strategy to understand the reasons behind the performing of ReIVF and similar techniques might be flipping the question and wondering not why two persons should choose to use those techniques, but why they should not do that. First, through ReIVF or other similar techniques the person who provides eggs can also carry the embryo for a period and fulfill, consequently, her own desire to contribute more to the development of the embryo. Secondly, it is plausible that ReIVF fulfills a very specific desire, which is the desire of two persons to carry the same pregnancy, that is, to have the same living being inside both their bodies. And supposedly, that specific desire might be anything but new; for instance, some lesbian couples had already looked for sharing motherhood even before it could be technically feasible, ²⁶ and it would not be surprising if some couples had already felt a similar desire for pregnancy in the past. Hence, one may suppose that carrying the same pregnancy could be meaningful for the involved couple because it would answer to the desires of both its member to “share” a moment such as the child's gestation, usually within a shared project of parenting. Moreover, if one considers that ReIVF and similar techniques are unique because they allow a “double gestation,” he/she will see that they are not only an additional reproductive option for prospective parents: they, like mitochondrial replacement techniques, are “a qualitatively significant new option.” ²⁰

In this sense, ReIVF could be a viable option for all those couples who, after giving their informed consent, decide to use techniques to carry the same pregnancy. But even supposing that the desire to carry the same pregnancy with the partner is genuinely good, the vulnerability of human embryos remains to be examined. Firstly, considering that ReIVF as well as the treatment with AneVivo are somewhat both practically and economically inconvenient, one could wonder whether the desire of a unique connection with the offspring could ever justify their use. As much as the desires might be strong, and as much as one might admit the existence of “reproductive rights,” ²³ the desires and claims of a couple should be carefully weighed against their responsibilities toward the child, as well as the risks and the chances of success of the used treatments. ²⁷ In this view, the principle of (respect for) individual autonomy is not the only principle that should be considered in the ethical evaluation of ReIVF and the other similar techniques, but it should be appropriately balanced with the other principles of medical ethics such as the principle of beneficence.

Within the larger field of assisted reproductive technology, some commentators have already been skeptical of the moral ground of the desire for biogenetic relatedness—and they still are—and this skepticism could be even profounder toward techniques such as ReIVF.^{27, 28} In fact, critics might fear that these techniques could represent one of the highest peaks of biologism, since they would constitute a further step toward an overreliance on biological relatedness that risks to override the moral and psychological commitment which parents should have to their children, on the one hand, and to marginalize the importance of a shared parental project in favor of the primacy of biological ties, on the other hand. ²⁹ For these reasons, some scholars such as Purdy ²⁸ and Baylis ³⁰ warn about the groundlessness of a “right” to biological parenthood, pointing out that “family-making should be about establishing loving, caring, nurturing relationships and these may or may not include genetic ties.” ³⁰ Moreover, with specific reference to ReIVF and similar techniques, Musio maintains that carrying the same pregnancy might be an emblem of “hyper-carnality,” ³¹ which means an exasperate and very obstinate effort to penetrate the mysteries of flesh and bodies to the point of removing their corporeal resistance to human aspirations and thereby making them the ideal objects of biotechnological manipulation. Yet, in spite of the criticism and the concerns that can be raised in reference to the ethical legitimacy of techniques such as ReIVF, it is likely that those techniques will continue to be used, so a more in-depth analysis of their social consequences in relation to the principle of justice and to a potential coverage by the health insurance system is required.

Principle of beneficence: For the good of whom?

Concerning the principle of beneficence, some of the arguments put forward by those promoting Reciprocal IVF and Effortless IVF can be used. First of all, one could say that ReIVF accomplishes what is good for requesting couples, because their desire to carry the same pregnancy would be fulfilled, and even what is good for the unborn entity. Indeed, with reference to the use of Reciprocal IVF, Marina et al. maintain that existence is better than non-existence, ¹⁷ and that the unborn entity would be therefore benefited in being brought into the world. Overall, two persons who carry the same pregnancy may feel not only physically, but also psychologically more involved in embryogenesis than those who do not carry it together, as they have the opportunity to actively contribute to their offspring's creation and development and establish with it a “unique connection.” ¹ By using ReIVF two persons can carry the same embryo in their bodies indeed, and this cannot occur—at least for the moment—in no type of couple in which members have no vagina or womb, and by any other technique that is not ReIVF or similar to it. For this reason, techniques such as ReIVF constitute a unique way for accessing parenthood, both for lesbian couples where both parties have the capacity to gestate and for couples composed by two Female-to-Male (FtM) transgender individuals with female organs or by an FtM transgender individual with womb and his partner assigned female at birth.

Furthermore, it might be assumed that techniques like ReIVF reduce jealousy between co-parents, resulting in positive mental and social health outcomes for both the members of the couple. In a study conducted by Pelka in 2009, it was observed that lesbian couples who had opted for an IVF using the eggs of one woman and the womb of the other one reported less jealousy than those who, differently, had chosen artificial insemination, by which one woman became both the genetic and the gestational mother, while the other was neither of them. ³² These conclusions endorse the hypothesis that by sharing biological motherhood two women may feel more “equal” as mothers since both of them can claim to be biological mothers. That said, if sharing motherhood reduces the perceptions of inequality in the couple, there is a good chance that carrying the same pregnancy might reduce them more significantly. In fact, while in the only Reciprocal IVF method the person who provides her eggs does not carry the child, now—thanks to ReIVF or similar technique—she can do it as well as her partner, albeit for a very limited time. Accordingly, by carrying the same pregnancy two persons can have a gestational bond with the same entity, and especially the woman who provides eggs can have a stronger psychological bond with the future baby, with the result of a better mental and social health outcome for her. Therefore, although carrying the same pregnancy does not eliminate the fact that there is always a social parent—since only one of the members of a couple gives birth—it could be an additional expedient to strengthen the bond between the social parent and the child. ³³ Finally, ReIVF and analogous techniques might also be pursued by those persons who want to carry an entity without having to give birth to them. ³⁴ For instance, let one consider persons affected by fear of childbirth (FOC, otherwise called “tokophobia”) or that, for any reason, do not want to give birth; by using ReIVF or analogous techniques, they would carry a child in their bodies without having to completely renounce to do it, and especially without having to give birth.

While ReIVF and analogous techniques can be beneficial to one or both the members of a couple on the one hand, some ethical concerns can be raised on the other hand. Firstly, since in ReIVF as well as in Effortless IVF the fertilization of eggs and the incubation of the embryo(s) take place in the human body, less laboratory equipment, and staff are required. ¹⁴ Hence, there is less involvement from medical professionals than traditional IVF, and medical examinations are very limited. According to Todd, the reduced monitoring during the treatments would serve only to save time and money, that is, only for economic reasons. ³⁵ Under this perspective, time and money saving seems to be a priority, and it could be seen as even more important than the good of the individuals involved, especially of embryos. Without adequate examinations, some babies might be born with a disease that could have been prevented, and it is especially in these terms that the statement about the undisputed value of life/existence seems to be questionable. In addition, during the ReIVF treatment a person does not provide her eggs waiting for her partner to carry the pregnancy, but she directly provides her partner an embryo; in other words, while in traditional IVF embryos are produced externally from the human body, in ReIVF embryos are produced inside a human body and then they are moved from the body of a person to the body of another person. But by doing this, the embryo would appear as an object moved from body to body or as a thing that one owns and gives to someone else, as it has been argued. ³⁶ For this reason, according to a critical perspective ReIVF would reify embryos by making them the objects of a process that has little or nothing to do with them, but that concerns only the desire of intended parents to have a double biological/gestational connection with their offspring. In light of these concerns, the desires and, more specifically, the reasons that are or could be behind the decision to carry the same pregnancy must be investigated. The starting question might be: why should two persons choose to carry the same pregnancy?

Principle of nonmaleficence: Is ReIVF harmful?

With reference to the principle of nonmaleficence, both Effortless IVF and Reciprocal IVF have proven to be quite effective since their results are like those of traditional IVF ³⁷ and—in the case of Reciprocal IVF—even potentially better. ¹⁶ Therefore, since ReIVF is the combination of Effortless IVF and Reciprocal IVF, it consequently is the combination of two techniques that have already proven to be effective. What is more, ReIVF does not require any further steps than those implied by the combination of Effortless IVF and Reciprocal IVF used one after the other. Indeed, in ReIVF one person provides her eggs and incubates the embryos obtained with those eggs in her body, exactly as in Effortless IVF; then, another person receives the embryo(s) obtained with the eggs of her partner and carries it in her body, exactly as in Reciprocal IVF.

The main peculiarity of ReIVF is that the person who incubates embryos is not the same who carries them until childbirth, as happens by using Effortless IVF, but another person; however, the implantation of embryos in the womb of a person instead of in the womb of another person is not per se a source of harm nor does it compromise the efficacy of the performed treatment. Hence, since ReIVF is the combination of procedures that are rather effective and are not particularly harmful neither to intended parents nor to future children, one could suppose that even ReIVF might be quite effective and not particularly harmful. And this can be applied not only to ReIVF, but also to the similar procedure performed with AneVivo. This latter technique, differently from ReIVF, implies that embryos are incubated in the human womb and not in the vagina, but it seems that this does no harm to the individuals involved.

Nevertheless, ReIVF raises some ethical concerns, some of which are typically, if not solely, related to it, while others are related to the techniques that it includes, namely Reciprocal IVF and Effortless IVF. Starting with these latter concerns, when Effortless IVF is used medical examinations and monitoring actions are minimized, so that it is not possible to do any sonogram during the transfer of frozen embryos, ¹⁴ nor to detect, prevent, and treat any potential abnormality that could harm the unborn entity. Moreover, the absence of embryo testing from 16 to 20 hours after insemination could prevent polyspermic embryos ⁱ that might develop healthily from being transferred to the womb, thus denying potentially healthy children to be born. ¹⁴ That being so, even the often-presumed cost-effectiveness of intravaginal cultivation with INVOcell may be questioned. About that, since the fertilization and incubation of the embryos take place in the maternal body and not inside a sophisticated artificial incubator, Effortless IVF requires less laboratory manipulation than traditional IVF, with a consequent reduction in technical time, in personnel, in the used material, and in the costs resulting therefrom. Because it does not even involve a state-of-the-art laboratory where it could be carried out, Effortless IVF could be also used in the office of any physician, thus reducing for potential claimers any geographical restrictions and costs due to travel. ¹⁴ However, not only may this cost-effectiveness be considered as insufficient to justify the use of the technique and balance its potential harm, but also “it appears that costs, and specifically consumer costs, are roughly equal to traditional IVF costs, if not greater.” ³⁸ And if Effortless IVF per se is not economically advantageous as believed, in its combination with Reciprocal IVF it would be even more expensive, because it would be combined with Reciprocal IVF and involve two persons instead of one.

As noted, ReIVF does coincide neither with Effortless IVF nor with Reciprocal IVF and poses specific ethical problems as well. On a first instance, the ReIVF process appears as something cumbersome, which paradoxically complicates a technique—Effortless IVF—that has been developed to simplify the traditional IVF procedure. ³⁹ Effortless IVF could be indeed considered as a “simple” procedure because, when it is performed, the incubation of the embryos takes place in the human body. This is a common characteristic of every INVO procedure, that is, every procedure using INVOcell or other similar devices such as AneVivo. However, while in the conventional INVO procedures the embryos are transferred in the human womb immediately after INVOcell/AneVivo removal, in ReIVF other technical steps—such as using embryo cryopreservation—are added. This counters some of the advantages that Frydman and Ranoux ascribe to the INVO procedures, like the fact that embryos are not cryopreserved or the fact that there is a decreased or even no risk of mislabeling or mishandling the embryos during the procedures. ¹⁴ It follows that ReIVF could be even simpler and cost-effective than traditional IVF, but it will continue to be more complex and expensive than Effortless IVF and the other conventional INVO procedures. Finally, in Effortless IVF the potential health risks deriving from a reduced monitoring during pregnancy are somewhat counterbalanced by the greater cost-effectiveness and simplicity of the technique, compared to those of traditional IVF; in ReIVF, instead, the only counterbalancing reason to carry the same pregnancy and, consequently, to add further steps to the conventional INVO procedure seems to be the fulfillment of the desires expressed by requesting couples.

Between justice and ethical justifications

With regard to the principle of justice, by using techniques such as ReIVF a certain condition of equality among prospective parents could be achieved. In fact, prospective parents would have the opportunity to carry a developing entity in their bodies, albeit one parent will carry the entity for a greater amount of time than the other one and experience the uniqueness of childbirth. Anyway, since techniques like ReIVF have hitherto been used in private clinics only, it should be investigated whether they can also be used in public facilities, and whether they can be covered by health insurance just as artificial insemination and traditional IVF are covered in some states.

Dondorp et al., assert that “equal treatment is a matter of formal justice,” ⁴⁰ but whereas a nonheterosexual couple should have the right to be assisted by public healthcare in the field of reproductive medicine exactly as a heterosexual couple, in accordance with the respect of the principles of equality and nondiscrimination, ⁴¹ techniques such as ReIVF could be an exception to this general view. Indeed, even though they are unique in their implications and irreducible to every other treatment of medically assisted procreation because of their uniqueness, one may presume that their intricacy, their still questionable effectiveness and safety, and the lack of research and insights thereon might exclude them, at least for the moment, from any coverage by the health insurance system.

However, this issue may be worth further investigation, and an essential research question may be the following: Could desire for carrying the same pregnancy be enough to force a state to cover the use of ReIVF and analogous techniques?

Final reflections

On the one side, techniques such as ReIVF grant two persons to have a living being inside both their bodies and physically contribute to its gestational process. This may fulfill the deeply rooted desires of co-gestational parents and reduce, among other things, the disparities that are likely to arise from medical-assisted procreation techniques. Therefore, techniques like ReIVF could make the members of a couple more equal, and potentially they could also enhance the reproductive autonomy of prospective parents by extending their reproductive choices.

On the other side, however, these techniques might represent an obstinate way to look for gestation and biological relatedness over anything else. Compared to the only Effortless IVF or Reciprocal IVF, ReIVF is a more complex technique that needs further investigation and whose effects must be better studied. Furthermore, during the ReIVF treatment embryos could be seen as objects, and the desires of the couples could be seen as not sufficient to perform such treatment.

Anyway, techniques such as ReIVF should not be ignored, especially considering their current uses and their foreseeable developments. For instance, thanks to biomedical development two women might carry the pregnancy not only of the same embryo(s), but also of the same fetus(es), who would be transferred from the body of a woman to the body of another woman. ⁴² In view of the steady progress in the field of life sciences, bioethics cannot find itself unprepared, nor exclude any possibility of dialogue by rejecting a priori ReIVF and the other developing techniques. Rather, a greater discussion on the ontological status of the embryo is recommended, as well as an open debate on how (reproductive) autonomy can be balanced with the moral duty of prospective parents to be responsible for their child and, above all, with the principle of beneficence. For the moment, considering that ReIVF—as well as other similar techniques—gives some couples the opportunity to have a unique connection with their offspring, and considering also that it did reported harm neither to the offspring nor to the involved couples, it can be preliminarily suggested that it is legitimate on a bioethical point of view. Thus, it can be said that ReIVF as well as the other similar techniques should be used, unless there is a strong evidence that it should not be performed because it is harmful or for other reasons. More engagement in the literature with this novel development is encouraged, and a more in-depth exploration of its ethical issues is strongly recommended.