Many adults do not have biological children. Sometimes this is a matter of choice and sometimes a consequence of infertility.
Infertility is the failure to conceive for at least one year of unprotected sex, or the inability to carry a live pregnancy to birth. Infertile people are described as involuntarily childless. Some will subsequently conceive naturally, while others are not able to without reproductive assistance. Some will never conceive. About 7% of women remain childless because of female and male infertility, while 16–20% of couples are affected by infertility at some point in their lives.
The conditions that cause male and female infertility are biological and social. Biological female infertility is mainly caused by gynaecological problems, such as tubal defects and endometriosis. Biological male infertility has been linked to impaired sperm production. For both sexes other biological factors associated with infertility include hormonal imbalances, exposure to sexually transmitted diseases and environmental pollutants, and long-term use of certain contraceptives. Lifestyle factors that contribute to infertility include smoking, rapid weight loss and obesity.
Gender is not a significant factor in infertility. About 30% of infertility cases are caused by female factors alone and 30% by male factors alone. Another 30% are caused by combined female and male factors, and 10% of infertility cases cannot be explained.
Age is a critical factor in infertility, and is particularly relevant for women. Their peak reproductive age is between 19 and 25, and fertility drops significantly from their mid-30s. In the early 21st century most women start families when their fertility is declining. This is because of social factors and lifestyle choices such as women entering and staying in the workforce, and using the contraceptive pill. In 2015 the median age of women giving birth was 30. The many women who wish to start a family in their mid- to late 30s are likely to have more difficulty conceiving than younger women, and some will remain childless or only have children through assisted reproduction, adoption or foster care.
Individuals and couples who are voluntarily childless or childfree may have children at a later date or decide not to have children at all. In the past voluntary childlessness was criticised as selfish, unfeeling and unpatriotic. It is more socially acceptable in the 21st century.
Some people are childless because of particular circumstances, rather than outright choice. ‘Contingent childlessness’ may result from being busy with other life activities such as career, education, financial commitments, partnership break-up, re-partnering and other family changes, or being in a same-sex relationship. In New Zealand women who live in cities and those with higher degrees are most likely to fall into this category.
New Zealand’s fertility rate is higher than most other OECD (Organisation for Economic Co-operation and Development) countries. In 2012 it was 2.1 per woman, making it the third equal-highest rate with Turkey after Israel and Mexico. The OECD average that year was 1.7.
Voluntary and contingent childlessness is more common than in the past, and accounts for New Zealand’s declining fertility rate, which has generally been at or just below replacement level (2.1 births per woman) since the early 1980s. This form of childlessness has increased from 1% of women born in 1936 to almost 10% of women born in 1965. Researchers estimate that 25% of women born in the mid-1970s may not have children – most through choice.
Historically, infertile couples remained childless unless they adopted children. In Māori communities children were sometimes raised by relatives in a practice called whāngai, which meant that infertile people or other, usually older, family members could raise children. From the 1960s single mothers were increasingly likely to keep their children, due to the introduction of the domestic purposes benefit and changing social attitudes, so fewer babies were available for adoption. However, the introduction of assisted reproductive technologies (ART) in the early 1980s meant that infertile people could potentially have their own children.
Some infertility researchers believe that infertility treatment will lead to a higher rate of natural infertility, because it may cause a genetic predisposition to infertility to be passed on to children born of this process. Fertility treatment has not been happening long enough to confirm this hypothesis.
ART are medical procedures intended to improve the chance of conception. In-vitro fertilisation (IVF) is the most common. It involves fertilising ova or egg cells outside the womb using sperm and then inserting one or two of the fertilised embryos into a woman’s womb. Infertile people can apply for publicly funded treatment or pay for treatments at private clinics. Public clinics run by District Health Boards are located in Auckland (Fertility PLUS) and Dunedin (Otago Fertility Services). Fertility Associates has five fertility clinics in New Zealand where they do assisted reproduction, as well as clinics where doctors consult with patients in Auckland, Hamilton, Palmerston North, Gisborne, Wellington, Nelson, Christchurch and Dunedin. Repromed has clinics in Auckland, Tauranga and Whangarei. Both companies also treat publicly funded clients.
In 2014, 1,343 babies were born in New Zealand following ART (2.25% of all births), compared to 274 in 1997 (0.5% of all births).
Infertile people are entitled to two publicly funded cycles of fertility treatment. Eligibility is determined by criteria including:
Women need to have been non-smokers for at least three months prior to referral.
The average cost of one privately funded IVF cycle ranged from $11,000 to $13,000 in 2017.
In some cases a couple’s own genetic material is used, while in other cases genetic material from other people is required. It is illegal to buy or sell human gametes (eggs and sperm) or embryos in New Zealand, but they can be donated.
Fertility clinics prefer to use eggs from donors of proven fertility, and who have completed their own family. Sperm and egg donors are medically screened and undergo counselling. If donors are known to the intended parents, then both undergo joint counselling. Donors are not legally responsible for any children produced from their donated eggs or sperm.
Donor insemination (DI) is a low-tech fertility procedure. It involves the simple transfer of sperm into a woman’s uterus. This can be done by medical professionals, or may be done by the woman herself using a device like a syringe. DI is only suitable if fertile sperm is all that is required to achieve conception. It is a common way for fertile single women or lesbian couples to have children.
The first in-vitro fertilisation (IVF) treatment in New Zealand took place at National Women’s Hospital, in Auckland, in 1983. IVF is a response to both male and female infertility. It involves the fertilisation of ovarian egg cells by sperm outside the womb by a medical professional. One to two fertilised eggs are then transferred to the woman’s uterus. Conception is not guaranteed.
Related treatments include intracytoplasmic sperm injection (ICSI) which involves the injection of one sperm into an egg. This is used when the sperm is of poor quality and not suitable for IVF.
Pre-implantation genetic diagnosis (PGD) is used to test embryos for inherited diseases and chromosomal abnormalities before transfer into the womb. It can be used to select an embryo in cases where an older sibling suffers from an inherited disease and the only possible treatment is using the cord blood of a healthy sibling. Approval from the Ethics Committee on Assisted Reproductive Technology (ECART) is required in these cases. PGD cannot be used for social reasons such as selecting the sex.
In the 21st century the freezing of embryos (eggs fertilised with sperm) and eggs or ova increased. Embryo freezing has been available in New Zealand since late 2005. Frozen embryos were most likely to be embryos created during IVF processes that were not inserted into the womb. They were frozen to be used if the in-vitro fertilization process did not result in conception. Frozen embryos can be stored for up to 10 years. After that, people must apply to the Advisory Committee on Assisted Reproductive Technology (ACART) if they want to extend storage or decide whether to discard or donate their surplus embryos to another infertile couple or person.
Ovarian egg freezing started in New Zealand in 2003 and in 2009 women could thaw their eggs for use legally. Sometimes women decide to freeze some of their ovarian eggs because they want to be sure that they have eggs to use through in-vitro fertilisation in the future. This may happen because a woman is about to have medical treatment that could damage their eggs. Some women choose to have eggs harvested and frozen because they want to have eggs available when they are older and choose to have children. The quality and number of women’s eggs decline as she gets older and the storage of frozen eggs can increase the chances of women conceiving if they want to delay childbearing.
The harvesting of eggs for freezing requires hyper-stimulation of the ovaries so that more eggs are available for retrieval. Mature eggs retrieved from the ovaries are frozen. They are thawed and injected with sperm when a woman wants to use them to become pregnant.
Hyper-stimulation, egg retrieval and egg freezing for social reasons is not publicly funded. Funding is available for women whose eggs may be damaged by medical treatment, such as some treatment for cancer.
Women become surrogate mothers for personal as well as altruistic reasons. In a 2008 study one woman said she wanted to be a surrogate, ‘Because I saw what my mother went through with her infertility. I always knew that I wanted to help somebody who may be in a similar position … Although nine months is quite a long time I have relatively easy pregnancies and deliveries. I guess the whole idea of nine months out of my life [is] giving somebody else a lifetime of joy and the opportunity to be a parent … Really, what greater gift is there?’1
In traditional surrogacy a woman carries a baby that is her genetic child for a couple where the woman cannot carry a child – for example, she may have had a hysterectomy. The prospective father provides the sperm. Low-tech self-insemination methods are often used. Some people may use a fertility clinic to screen sperm for sexually transmitted diseases and genetic disorders. To guarantee paternity, traditional surrogate mothers may be asked to refrain from sex for two months prior to insemination and for one month afterwards.
In a gestational surrogate pregnancy a birth mother carries the baby, but the eggs and sperm are provided by others (usually the intended parents) through IVF. Ethics approval must be sought for any surrogacy arrangements involving a fertility clinic. Gestational surrogacy was available from 2002.
Commercial surrogacy is illegal in New Zealand. Birth mothers cannot be paid, but can be reimbursed for ovulation and pregnancy testing, vitamins, legal and counselling fees, and transport to and from inseminations. The parents have to adopt the child after birth.
Assisted reproduction is governed by the Human Assisted Reproduction Act 2004. Under this act fertility clinics can provide treatments that are described on a list of established procedures without seeking any form of external approval. If the treatment is prohibited under the act, then it cannot be offered.
A third group of treatments require approval before they can proceed. In these cases clinics make an application to the Ethics Committee on Assisted Reproductive Technology (ECART). If the Advisory Committee on Assisted Reproductive Technology (ACART) has issued guidelines about this treatment then ECART can consider the application. If guidelines have not been issued then the application is referred to ACART, which can make one of three decisions:
The Human Assisted Reproduction Technology Register holds information about donors, donor children, and parents or guardians provided by fertility clinics. Only gamete (sperm or egg) donations made after 20 August 2005 that result in birth are required by law to be recorded. People involved in fertility treatments prior to this can be recorded voluntarily, and can place restrictions on their information.
Generally, only people recorded on the register can access information. Donor children must be aged 18 or over – before this their parents or guardians can obtain information on their behalf. Donor children must give written consent before information about them is given to a donor. Donors who made donations after 20 August 2005 cannot restrict the release of information about them to donor children, but are advised when this information is given.
Secrecy is not encouraged by fertility clinics. One reason for this is the cultural importance in New Zealand, particularly for Māori, of making genealogical information available to children born of this process. Another reason is for the psychological and emotional wellbeing of offspring. While donors are not legally liable for any children produced, they are sometimes known to their children and included in their lives.
A woman describing the grief associated with infertility said, ‘I came to a real recognition at the time my father died, how sad I was. But a lot of the grief was bound up with also being infertile. It is one thing to deal with grief if you have the sense that you knew that person and you still have what they have given you. The difference with infertility is that it’s grief without legacy.’1
Infertility can cause feelings of guilt, sadness and grief. For some people, fertility treatments can be undignified, embarrassing, invasive, time-consuming and stressful. The main support group for people in these situations is Fertility New Zealand (FNZ), which was established in 1990. FNZ provides members with information about infertility and fertility treatments, runs regional support and contact groups, and lobbies central government for improved access to treatment. Fertility clinics also provide clients with counselling services.
Another support group is NZ Surrogacy. This online group is made up of surrogate mothers, intended parents, egg and sperm donors, and couples experiencing in-vitro fertilisation and adoption. It provides members with information and support, and gives them an opportunity to share their experiences about infertility and donation.
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