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Build Your Own Baby

Many Chinese women are turning to overseas or unlicensed clinics to use IVF to select the sex of their child. Is the expensive procedure harming mothers and their babies?

By Du Wei , Wang Yiran Updated Oct.1

Lying on a bed, Su Yue watched a doctor implant two healthy embryos into her. It was two years ago when she was undergoing a third-generation in-vitro fertilization (IVF) procedure in Thailand following two miscarriages. She had already had 14 eggs taken out and fertilized, six of which were found viable, three females and three males. Su chose to have one boy and one girl and gave birth to the twins 35 weeks later.  

The most common form of assisted reproduction technology, first-generation IVF, or conventional IVF, deals with infertility caused by ovulation issues by fertilizing eggs with processed sperm. Second-generation IVF focuses on male infertility issues by selecting the best sperm for an egg. Third-generation IVF includes screening for gene defects, and since the screening includes the sex chromosome, it supports sex selection.  

Although the technology is widely used elsewhere, China, where ultrasound operators are forbidden to reveal the sex of fetuses to prevent sex-selective abortions, severely restricts the use of third-generation IVF. But as demand for IVF is growing due to traditional preference for boys and a rising infertility rate, many Chinese women are turning to overseas clinics, or even underground domestic clinics, despite experts warning of the high risks involved. 

Growing Demand 
Focusing on preimplantation genetic diagnosis technology, third-generation IVF takes out one to two cells from an early stage embryo, known as a blastophere, for genetic screening. Only embryos that pass the screening are implanted. Although this technique was first used in China in 2000, by the end of 2020, fewer than 100 hospitals had approval to use it, according to the 2021 list published by China’s National Health Commission.  

Meanwhile, the government set restrictions on who can undergo third-generation IVF: those who have miscarried three times or more, those who have miscarried twice with one medically proved to be caused by chromosome abnormality, those with gene disorders or carrying diseased genes, and those above 37 years old.  

Along with the restrictions, the small number of licensed hospitals means demand is far greater than provision. According to research on China’s future assisted reproduction market published by Qianzhan Industrial Institute, a leading industrial analyst based in Beijing, China’s infertility rate rose from 2.5-3 percent 20 years ago to about 12.5-15 percent in 2016 and the size of China’s assisted reproduction market grew from 10.3 billion yuan (US$1.6b) in 2012 to 33 billion yuan (US$5.1b) in 2017. The report predicted that by 2025, the market value would increase to 101.2 billion yuan (US$15.6b), and by 2030, 150 billion yuan (US$23.1b).  

The research found that China’s preimplantation genetic diagnosis service market, counted based on a customer’s total expenses for those services, rose from 132 million yuan (US$20.3m) in 2015 to 1.1 billion yuan (US$169.2m) in 2019.  

In 2018, the same institute published another report on China’s cross-border artificial reproduction market, revealing that by the end of 2016, the number of artificial reproduction cycles Chinese people underwent overseas had risen by 18.75 percent to 380,000 cycles. One cycle includes every procedure, from preoperative examinations to implantation. By 2023, the number of people going overseas for assisted reproduction will reach around 3.73 million, according to the report. This figure may change however, as overseas travel into and out of the Chinese mainland is still curtailed by pandemic restrictions.  

During her second pregnancy, Su’s doctor found that the 14th pair of chromosomes of Su’s embryo had three chromosomes instead of two. It meant that Su might miscarry again due to a genetic defect and that she met China’s requirements for third-generation IVF.  

But as it takes longer to do egg retrieval in China, double or triple the time of an overseas hospital, Su went to Thailand, although she had to pay 150,000 yuan (US$23,076) for the procedure, double the price in China.  

Another reason Su chose Thailand was that she wanted to have boy-girl twins through a medical process that is not allowed in China.  

“Licensed hospitals in China will only implant one embryo... since a twin pregnancy increases the risks for the mother, such as gestational hypertension, gestational diabetes and premature delivery, among others,” Ma Xiang, an assisted reproduction physician at the People’s Hospital of Jiangsu Province, told NewsChina. 
Su agreed, revealing that her twins had health issues and in their first three months had to undergo procedures that other infants seldom need, including CT and MRI scans.  

She said another mother on her ward had been pregnant with IVF twins, but one fetus stopped developing in the 18th week.  

“Having experienced all of these things, I wouldn’t recommend any woman who has IVF to have twins, since it will truly bring the mother and the fetuses many risks,” she said. 

A booth for IVF in Thailand at the 2018 International Medical Tourism Exhibition, Beijing, November 16, 2018

Going Underground
Like Su, many Chinese people have a strong preference for a baby’s sex. Influenced by traditional beliefs that persist in some Chinese regions, especially rural areas, many families prefer sons over daughters.  

According to China’s National Bureau of Statistics, the sex ratio at birth, measured by the number of male births to 100 female births, stood at 108.5 in 1982, well above the international standard of 107. It kept rising since then and peaked at 118.6 in 2005. Though it kept declining in the following years, it remained above 110. In 2020, it was 111.3, the lowest since the early 1990s.  

Su said that according to her understanding, the vast majority of those who get third-generation IVF in Thailand want a son, and only around one in 10 want a girl.  
But those who cannot go overseas turn to unlicensed clinics, attracted by advertisements which claim to allow people to “customize your baby.”  

“Just do third-generation IVF, guys. It’s good,” Chen Ting, who had a son through third-generation IVF, posted online. She told NewsChina that she wanted a son. In the clinic where she received the operation, she met a woman who wanted the same.  
“She’d already had three daughters,” Chen said.  

Su claimed one of her friends underwent third-generation IVF in an unlicensed clinic. 

“She was put into a black van with her eyes covered. She couldn’t have any electronic devices. She didn’t know where the van went and since the egg retrieval needs general anesthesia, she didn’t see her doctor’s face throughout the operation, and she didn’t know their name,” Su said. “The entire process was closed up tight... You didn’t know whether the doctor put something in your body or took something out, like a kidney,” Su added.  

On the pretext of wanting the procedure, a NewsChina reporter contacted several unlicensed clinics, most of whom said they have their own labs and contract doctors from public hospitals. One of the clinics told NewsChina it employs a renowned assisted reproductive physician from a top hospital in Beijing at an annual salary of at least 2.6 million yuan (US$386,910). The person boasted their success rate for third-generation IVF was around 80 percent, much higher than public hospitals (50-60 percent) and that their clients include pop stars and online celebrities. But when the reporter proposed visiting their lab, he refused, saying it was too far away.  

“Underground clinics come with enormous risks, because they can’t guarantee standard operations and may even overuse drugs. Besides, egg retrieval may harm the mother or could cause lethal hemorrhaging and infection,” an assisted reproduction physician at a top-level hospital in Beijing who declined to give her name told NewsChina. “From what I understand, these clinics shift around to avoid detection, and some even do the procedures in a dingy shed,” she said.  

Others act as agents to sell coveted appointments for third-generation IVF at licensed hospitals. One told NewsChina on condition of anonymity that he acts on behalf of three Beijing hospitals that have approval to do third-generation IVF, priced at 188,000-238,000 yuan (US$28,923-36,615). A client first pays a deposit of 50,000 yuan (US$7,692) and the second payment comes after they register at a maternity hospital for birth services. The rest is paid two days before the egg retrieval. The agent said it is extremely hard to get a slot at a licensed hospital if one does not meet the requirements. On the black market, an appointment just to register with a licensed hospital costs 88,000 yuan (US$13,539).  

The agent said that public hospitals can help with sex selection “secretly,” but he refused to reveal more details.  

Most of the underground clinics NewsChina contacted said they sign a contract with their clients. “What on earth are you worrying about? We will sign a contract with you,” one of the agents said in response to NewsChina’s questions.  

However, contracts like this do not protect clients. A case published on legal website China Judgments Online in May 2021 showed that a court in Beijing did not support a plaintiff’s claim for compensation after alleging the third-generation IVF she had at an unlicensed clinic failed due to malpractice.  

Ruling that sex selection by technology does not conform to China’s laws and regulations and will lead to a more imbalanced gender ratio, the court voided the contract between the plaintiff and the clinic, saying both sides are responsible. The court ruled the clinic must refund some of the plaintiff’s money but rejected a demand for additional compensation.  

“Chinese laws do not protect the interests of mothers-to-be unless the sued clinic has truly caused them physical harm,” Guo Lei, a lawyer at Beijing Zunping Law Firm told NewsChina, adding that Chinese laws do not yet cover issues related to illegal assisted reproduction, let alone clarify the responsibilities. This gap means that underground clinics pay little for violating the law. 

Track Record 
Chen Ting told NewsChina that she underwent third-generation IVF at an underground clinic because the second-generation IVF she underwent at a public hospital failed. She attributed the latest success to the more advanced technology.  

However, the success of third-generation IVF compared to other techniques is still a subject of research. According to a survey published by Chen Zijiang, a scholar at the Hospital for Reproductive Medicine Affiliated to Shandong University, in The New England Journal of Medicine in 2021, among those aged under 38 with no genetic diseases but suffering frequent miscarriages, the accumulative success rate of first-generation IVF is no less than third-generation IVF. So although the miscarriage rate of third-generation IVF seems lower than that of the first two generations in clinical practice, the accumulative success rate for at most three implantations is almost the same for all IVF techniques.  

In the same issue, a commentary discussing the effects of third-generation IVF technologies said there was not enough evidence to support the clinical use of preimplantation genetic screening for chromosomal abnormalities, known as a PGT-A test.  

“I can’t tell a patient which generation of IVF is most suited for her, if say she has already miscarried twice. We have to make a judgment based on physical tests,” Wang Wenjuan, an assisted reproduction physician at the Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, told NewsChina.  

According to Wang, the three generations of IVF technologies target different groups, and the third is not an update of the other two. Wang said that third-generation IVF might help with a “good birth,” but there is not enough evidence to support this idea. 

“As an invasive operation, third-generation IVF has to take out [one or two] cells to do the genetic screening, which could be harmful to the blastosphere and harm the fetus. There is still no clear idea about the third-generation IVF’s long-term complications and it needs years of follow-up tests,” Qi Jia, an assisted reproduction physician at the Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicines, told NewsChina.  

Ma Xiang argued that the “good birth” effect of third-generation IVF differs among people. For those who third-generation IVF targets, the technology may help them screen for gene defects, but much of the genetic screening related to the technology is still being explored, and it definitely cannot screen genes for IQ or appearance.  

“Test tube technologies should be applied on the premise of respecting lives... third-generation IVF aims to prevent some foreseeable [genetic] risks rather than gender selection,” she said.  

According to interviewed experts, test tube technology has now developed a fourth generation – Germinal Vesicle Transfer (GVT). Targeting older women and those who have suffered repeated failures in embryo implantation, GVT replaces the nucleus of an old egg with that of a young one to synthesize a new egg with the original egg’s genes and the younger egg’s cytoplasm – the gelatinous liquid inside a cell. The technology requires donor eggs – genetic material from one male and two females – a “three parent baby.”  

The first three-parent baby was born in Mexico in April 2016 to a Jordanian couple whose previous two children had died of a genetic disease.  

In China, this technology has not been approved and is not known to what extent or whether it is harmful to a fetus. But experts warned that since it involves a third party, at the very least the new technology brings up more complicated ethical issues.

Chinese families used to put up a poster of a chubby baby during Chinese New Year to wish for a thriving family blessed with many children, especially sons