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Couples turn to assisted reproductive technology for a variety of reasons. As noted, some couples at risk for bearing children with genetic or chromosomal abnormalities seek alternative methods of conception. About 15% of couples in the United States experience infertility, the inability to conceive (Thoma et al., 2013). About 35% of the time, factors within the male are identified as contributors to infertility (Centers for Disease Control and Prevention, 2017c). In addition, single men and women, as well as gay and lesbian couples, often opt to conceive with the use of reproductive technology. However, there are racial, ethnic, and socioeconomic disparities in the use of assisted reproductive technologies. Women and couples who are White, college educated, and of high socioeconomic status (SES) are more likely to use infertility services than African American and Hispanic couples (Janitz, Peck, & Craig, 2016). Race and ethnicity are often linked with socioeconomic status and disparities in health care in the United States. Socioeconomic factors play a large role in access to infertility treatment and assisted reproductive technology (Dieke, Zhang, Kissin, Barfield, & Boulet, 2017).

One assisted reproduction technique is artificial insemination, the injection of sperm into a woman. The male partner’s sperm may be used or, if the male experiences reproductive difficulties, a donor’s sperm may be used. Artificial insemination through a donor also enables women without male partners, whether single or lesbian, to conceive. The most expensive assisted reproductive technology, in vitro fertilization, tends to average over $12,000 per trial, not including medication, and often requires multiple cycles, posing a financial burden too great for low SES women and couples (Teoh & Maheshwari, 2014).

In vitro fertilization, introduced in the United States in 1981, permits conception to occur outside of the womb. A woman is prescribed hormones that stimulate the maturation of several ova, which are surgically removed. The ova are placed in a dish and sperm are added. One or more ova are fertilized, and the resulting cell begins to divide. After several cell divisions, the cluster of cells is placed in the woman’s uterus. If they implant into the uterus and begin to divide, a pregnancy has occurred. The success rate of in vitro fertilization is about 50% and varies with the mother’s age. For example, the success rate is 47% in 35-year-old women, 27% in 41- to 42-year-old women, and 16% in 43- to 44-year-old women (Sunderam et al., 2017).

Assisted reproductive technology contributed to 1.6% of all infants born in the United States in 2014 (Sunderam et al., 2017). As shown in Figure 2.6, about 50% of assisted reproduction technology procedures that progress to the embryo-transfer stage result in pregnancy and about 40% result in a live birth. Infants conceived by in vitro fertilization are at higher risk of low birth weight (Fauser et al., 2014), although it has been suggested that it is because of maternal factors, such as advanced age, and not in vitro fertilization per se (Seggers et al., 2016). Infants conceived by in vitro fertilization show no differences in growth, health, development, and cognitive function relative to infants conceived naturally (Fauser et al., 2014). Because in vitro fertilization permits cells to be screened for genetic problems prior to implantation, in vitro infants are not at higher risk of birth defects (Fauser et al., 2014). However, about 40% of births from in vitro fertilization include more than one infant (38% twins and 2% triplets and higher). Multiple gestations increase risk for low birth weight, prematurity, and other poor outcomes (Sullivan-Pyke, Senapati, Mainigi, & Barnhart, 2017).

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Figure 2.6 Number of Outcomes of Assisted Reproductive Technology Procedures, by Type of Outcome—United States and Puerto Rico, 2014

Source: Sunderam et al. (2017).

Surrogacy is an alternative form of reproduction in which a woman (the surrogate) is impregnated and carries a fetus to term and agrees to turn the baby over to a woman, man, or couple who will raise the child. Single parents, same-sex couples, and couples in which one or both members are infertile choose surrogacy. Sometimes the surrogate carries a zygote composed of one or both of the couple’s gametes. Other times, the ova, sperm, or zygote are donated. Despite several highly publicized cases of surrogate mothers deciding not to relinquish the infant, most surrogacies are successful. In 2015, 2,807 babies were born through surrogacy in the United States, up from 738 in 2004, according to the American Society for Reproductive Medicine (Beitsch, 2017). Longitudinal research suggests no psychological differences through age 14 between children born through surrogacy compared with other methods, including children born to gay father and lesbian mother families (Carone, Lingiardi, Chirumbolo, & Baiocco, 2018; Golombok, 2013; Golombok, Ilioi, Blake, Roman, & Jadva, 2017). In addition, mothers of children who were the product of surrogates do not differ from those whose children were conceived using other methods, and surrogate mothers show no negative effects (Jadva, Imrie, & Golombok, 2015; Söderström-Anttila et al., 2015). Like other forms of reproductive technology, surrogacy is expensive, limiting its access to parents with high SES. Finally, some argue that surrogacy may pose ethical issues. For example, women are often paid at least $30,000 to surrogate a fetus (Beitsch, 2017), creating financial incentives that may be difficult for women with low SES to resist.