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[MUSIC PLAYING] SUSAN STAMBERG: I'm Susan Stamberg from National Public Radio and American RadioWorks. This is a special report on infertility and the medical miracles designed to correct it, the Fertility Race.

SPEAKER: Frequently, you've invested a lot of everything, your heart, your soul, your hopes, and your money. And when it doesn't work, it's very devastating.

SUSAN STAMBERG: In this one-hour documentary report, we examine the history, ethics, and politics of the fertility industry.

ANDREW KIMBRELL: It is the attempt to commodify the act of childbearing and to commodify children. It is baby selling really pure and simple.

SUSAN STAMBERG: And we'll hear from the couples struggling to conceive.

CARMEN: I want a family. I want a husband, which I've got, but I also want us to be a family.

SUSAN STAMBERG: This hour, an American RadioWorks Special Report, The Fertility Race. First the news.

[MUSIC PLAYING]

I'm Susan Stamberg. The world's first test-tube baby turned 21 this year. Her name is Louise Brown. And she was conceived in a hospital laboratory dish in Manchester, England.

Louise Brown's birth revolutionized the treatment of infertility. It made it possible for tens of thousands of women around the world to conceive. Infertility affects an estimated 10% of American couples. Modern treatments for infertility, that were so controversial just a few years ago, seem almost commonplace today-- babies conceived in lab dishes, women carrying babies for other women, egg donors, and frozen embryos.

In this special report from National Public Radio and American RadioWorks, we'll spend the next hour exploring the social implications of infertility and the advanced reproductive techniques designed to correct the problem. Our program is called the Fertility Race. To protect privacy, some names have been changed. We begin with correspondent Stephen Smith and the story of what has become a mundane miracle, the procedure called in-vitro fertilization.

STEPHEN SMITH: On July 25, 1978, a blond, blue-eyed squalling baby girl entered the world swaddled in news headlines. The Associated Press declared her a truck driver's miracle child. Good Housekeeping magazine gasped that her in vitro birth was the most extraordinary birth in human history. But historian Elaine Tyler May remembers that Louise Brown's conception also provoked deep social fears of science gone amok.

ELAINE TYLER MAY: If you look back to the way IVF was discussed in 1978, people were talking about human-animal hybrids, and monstrous babies, and eugenics, and all kinds of scary reproductive engineering. And eventually, that whole discussion calmed down.

STEPHEN SMITH: In-vitro fertilization was a medical breakthrough because it helped doctors overcome intractable problems with the woman's fallopian tubes or the man's sperm count. IVF is now commonplace. It's performed in more than 300 American clinics, which do the procedure some 45,000 times annually.

ALEX: What kind of cup? Same kind of cup?

SPEAKER: Yeah.

ALEX: Milk in here? Mm-hmm.

SPEAKER: OK.

STEPHEN SMITH: The children of Patty and Alex, a suburban Philadelphia couple, are among the 45,000 American offspring conceived by IVF. Doctors never figured out why Patty can't get pregnant the old-fashioned way. There's something amiss in her reproductive system. So Patty and Alex tried IVF and got twin boys Matty and Zach.

PATTY: Come on over, Jack.

ALEX: Hey, [? Dell, ?] give me five.

SPEAKER: Watching Hercules.

ALEX: Look who came in a Hercules box.

STEPHEN SMITH: Patty and Alex struggled for three years to get pregnant. They tried a variety of infertility treatments and spent many thousands of dollars on the quest. Finally, Patty says, their options narrowed to two-- an adoption agency or an IVF lab.

PATTY: I was on this mission. There was nothing that was going to stop me from having success. I probably would have tried in vitro a couple of times before pursuing other options like adoption.

SPEAKER: Mom, what is this?

STEPHEN SMITH: Once the twins were born, Patty and Alex assumed they were done having kids. They watched with pleasure and fascination as Zach developed into a dramatic, extroverted child and Matty became his introspective, methodical opposite. Then after a few years, Alex got to thinking.

ALEX: We have twin boys that are total opposite polar ends of the spectrum. And I'm really curious to see, if we have a third child, where that child would fit.

STEPHEN SMITH: You mean in terms of dispositions?

ALEX: Yeah, disposition, demeanor. And also, I would like to have a daughter.

STEPHEN SMITH: Some couples who were infertile the first time around get pregnant the conventional way later on, but not Patty and Alex. To expand their family meant a trip back to in-vitro lab. Preparing a woman for IVF means giving her daily, often painful drug injections to jolt her ovaries into high gear. A woman normally produces just one egg each month. To better the odds for success, IVF doctors prescribe drugs that can stimulate the ovaries to produce a dozen or more eggs.

Husbands or other relatives usually get enlisted to give these daily shots. But because Alex travels so much for work, Patty's neighbor Janet sometimes stepped in. Braced against the dining room table, Patty waited for a jab.

JANET: Take a deep breath. Little stick, sorry.

PATTY: It's all good, Jan.

JANET: It's going to burn just a little bit.

STEPHEN SMITH: The shots worked and so did her ovaries. Early on a Saturday morning, Patty lay sedated in the procedure room of Dr. Martin Freedman.

MARTIN FREEDMAN: All right, we're going to start on the right ovary.

STEPHEN SMITH: Freedman is a specialist at infertility medicine. He helped Patty and Alex have their twins. Using an ultrasound probe, the doctor searched for eggs in Patty's ovaries.

He expected to collect about a dozen. Gentle suction through the hollow needle captured Patty's microscopic eggs one at a time. After less than half an hour, Freedman pulled off his surgical mask and leaned in to give his groggy patient the final triumphant score.

MARTIN FREEDMAN: We got 17 eggs. 17, yes.

STEPHEN SMITH: The eggs were mixed in a lab dish with Alex's sperm. A few days later, Freedman transferred four embryos back to Patty's uterus. Then the couple waited.

[PHONE RINGS]

14 days later, Patty took a pregnancy blood test. She lingered at home for the call from Dr. Freedman.

PATTY: It's positive. What are the numbers?

STEPHEN SMITH: Patty was indeed pregnant and five months later gave birth to a baby boy they named Scott.

PATTY: Oh, my god, it still amazes me that this is how we make children. I mean, we've never made--

ALEX: What?

PATTY: we've never gotten pregnant any other way. We've done this two times and both times it's worked for us. So it's just it's amazing to me.

SUSAN STAMBERG: Infertile couples often spend years trying to conceive children. Most will never try to adopt. Instead, many undergo painful and expensive treatments such as surgery, infertility drugs, and in-vitro fertilization. Why do people work so hard to have genetically-related children? Reporter Catherine Winter looks at whether humans are driven by a biological imperative to bear children who share our genes.

KATHY: I want to change your diapers now. You got those dirty diapers.

CATHERINE WINTER: Houston geologists Kathy and Gary, who asked that their last name not be used, have diapering their twins down to a smooth routine. The baby boy and girl are eight months old with big eyes and tufts of dark hair. They look like alert little birds. Gary smiles every time he looks at them. As she gives her daughter a bottle, Kathy recalls how much she wanted these babies.

KATHY: I was having trouble with seeing pregnant women, seeing children. Going to baby showers, the thought of that, there's just no way things would-- some days you're fine. But other days, you're a wreck.

CATHERINE WINTER: Kathy and Gary struggled with infertility for years. Gary had a low sperm count. But even with sperm from an anonymous donor, Kathy didn't get pregnant.

Gary started suggesting adoption, but Kathy and Gary found that adoption could be just as expensive as a try at in-vitro fertilization. And they feared the birth parents might someday demand the baby back even though they knew that rarely happens. They worried about the prenatal care an adoptive baby might have received. Did the birth mother drink or smoke? And Kathy wanted to experience pregnancy.

KATHY: Well-meaning people who just don't understand, they see what you're going through and they go, well, why don't you just adopt? And my answer is for the same reason you didn't because they're invariably people that have their own biological children. Why didn't you adopt?

GARY: It's something that's inherent in everybody and all species too. You've got to go out and procreate.

CATHERINE WINTER: They decided to try in-vitro fertilization again. This time it worked. The twins were born last March. Whether people are driven by a primordial edict to bear children is the subject of some debate among biologists and psychologists. Psychology Professor Steven Pinker from the Massachusetts Institute of Technology does not believe human beings have an innate biological desire to have children.

STEVEN PINKER: Primarily, we have a drive to have sex. If we really had a drive to just have children that bear copies of our genes, then you'd have men lining up around the block to donate sperm. There are people who decide not to have children. I think there are very few people who decide that they have no interest in sex.

CATHERINE WINTER: Pinker says, from an evolutionary perspective, there was no need for humans to develop a desire for babies. As long as they wanted sex, they got babies. He thinks the reason so many people do want babies is that human brains don't run only on instinct.

People can reason. They can predict that having children might make them happy. But Pinker says, once a baby is born, an instinct does kick in. Parents are driven to care for their children.

STEVEN PINKER: Imagine that in a maternity ward, the nurse comes up to a new mother and says, well, we have about a dozen babies who've appeared in the last day or two. Do you care which one we give you? I think it's obvious that people would care. They want their own child.

CATHERINE WINTER: Biologists point out that in other species too, animals are more likely to care for offspring related to them. Penguins will find and feed their own young in colonies of hundreds of seemingly identical baby penguins. Pinker says, certainly, it's possible to love and bond with an adopted child. But many infertile people say in order to adopt, they first had to grieve for the genetically-related child they never had.

SPEAKER: That means some pushes don't

CATHERINE WINTER: On a summer day in a Minneapolis suburb, Becky and Kevin Peterson watched their son push a toy duck down the driveway as their daughter rides her bike. Kevin's sister, Carmen Eisma and her husband Steve have just brought the kids back from lunch. The Eismas are childless. They dote on their niece and nephew.

CARMEN: It just seems like it's so ingrained in me that I want a family. I want a husband, which I've got, a wonderful one, but I also want us to be a family.

CATHERINE WINTER: The Eismas are infertile because Carmen lost her uterus to cancer a couple of years before they met. They've tried to adopt while also trying new medical treatments that offer them the chance of creating a genetically-related child. Doctors took eggs from Carmen's ovaries, fertilized them with Steve's sperm, and transferred them into Becky, Carmen's sister-in-law. The Eismas say they were powerfully moved when they saw the embryos they created, embryos that, for some reason, did not survive.

CARMEN: We saw them. I mean it was like I actually did it after all this. I actually did it. Those are my babies.

CATHERINE WINTER: The Eismas plan to try another embryo transfer as soon as they can get the money together, even though the odds are against achieving a pregnancy.

CARMEN: I remember watching shows where these people said they spent $100,000 trying to do the in vitro. And I just said, why would they keep trying? Well, I know now. It's very hard to let it go.

ELAINE TYLER MAY: Psychologists say that the cycle of hope and despair infertility patients go through is sort of addictive. It's like playing the slot machines. An occasional small win keeps people dropping quarters in hoping for a jackpot, even though the odds are with the house and they know it. Dr. Cecelia Valdes is an infertility specialist in Houston.

CECELIA VALDES: I'm always amazed. I had a lady the other day. She was 44 years old.

She said, well, what's the chance that I will get pregnant with my own eggs? And I said, well, maybe 1 out of 100, maybe at the most 5 out of 100. And you'll probably miscarry at least half of those pregnancies. And her answer was, so there's hope?

CATHERINE WINTER: Hope is kept alive, Valdes says, by new developments. What was an experiment last year may be standard treatment this year. Researchers keep coming up with new solutions that offer another chance to people who dream of bearing children.

[MUSIC PLAYING]

SUSAN STAMBERG: Coming up after a short break, the history of our culture's often harsh treatment of infertile people.

SPEAKER: The chief of blessings for any nation is that it shall leave its seed to inherit the land. The greatest of all curses is sterility, and the severest of all condemnations should be that visited upon willful sterility.

[MUSIC PLAYING]

SUSAN STAMBERG: I'm Susan Stamberg. You're listening to a special report from American RadioWorks, the Fertility Race, on NPR, National Public Radio.

[MUSIC PLAYING]

This is a special report from NPR and American RadioWorks, the Fertility Race. I'm Susan Stamberg. Many Americans who are infertile think they have an acute medical problem that's largely beyond their control. But for some, there remains a lingering sense of disgrace and failure at being infertile. That stigma has troubled Americans since colonial times. Correspondent Stephen Smith explains that throughout American history, infertile people got blamed for their condition and most of the scorn fell on women.

STEPHEN SMITH: Colonial Americans took seriously the biblical mandate to increase and multiply. The reasons were religious, but also practical. Many children died at birth or infancy, and new hands were always needed to work the house and farm.

[RELIGIOUS HYMN]

Of those who could not bear children, Puritan preachers offered two opinions. Hardliners such as Boston's Cotton Mather darkly warned that being barren meant God had cast a judgment upon you. In one sermon, Mather wrote, "Without your faith in Christ, no good fruit is to be expected from you, nor do I expect any good fruit lest you come to a union with your Lord Redeemer."

ELAINE TYLER MAY: Childlessness brought an air of suspicion on someone in the colonial period.

STEPHEN SMITH: Historian Elaine Tyler May has studied infertility in American culture. May says that the colonists often feared that the actions of one could bring God's wrath upon the many. Barrenness was a sign.

ELAINE TYLER MAY: If a couple was childless, generally, the woman was considered to blame. It's interesting to note that those people who were accused of witchcraft were much more likely to be childless.

STEPHEN SMITH: Other clergymen counseled a less pessimistic view. According to historian Margaret Marsh, they considered infertility a test of faith imposed by God.

MARGARET MARSH: For some of them, they said, the Lord may choose not to give you children because he has a different purpose in mind for you.

STEPHEN SMITH: To pass God's test, infertile couples had to demonstrate their selflessness.

ELAINE TYLER MAY: One way you could do that was by being a parent in the community by fostering other children, caring for other children, doing good works, doing charity work.

STEPHEN SMITH: For hundreds of years, Americans possessed the murkiest notions of what causes infertility. Until well into the 20th century, society considered it almost exclusively a woman's problem. That was certainly true for the father of our country.

SPEAKER: Good afternoon. Welcome to Mount Vernon. You don't have a lot of time for--

STEPHEN SMITH: At George Washington's Virginia plantation, Mount Vernon, the white children who capered about the house and gardens where Martha Washington's children by a previous marriage. General Washington treated his step-kids like blood kin, but he and Martha never produced children of their own.

SPEAKER: Bedroom of General and Mrs. Washington has a private wing off to the south of the house. Think about how this room would have looked if somewhere the Washingtons would have been able to have a crib in here.

STEPHEN SMITH: Historians say that on at least two occasions, George battled illnesses that could have left him infertile. But in a letter to his nephew, the aging president made clear he thought Martha the barren one, even though she had conceived four previous times. Again, historian Elaine Tyler May.

ELAINE TYLER MAY: The assumption was that if a man was not impotent, that he was fertile.

STEPHEN SMITH: In the early 1800s, physicians began treating infertility as a medical condition and called it sterility instead of barrenness. They still did not fully understand how human reproduction works. Doctors believed that infertility was caused by bodily imbalances, prescribing elixirs and dietary schemes to regulate the female constitution.

Where colonial women stood accused of lacking religious conviction, infertile women in the Victorian era were suspected of ignoring their proper domestic roles. At the time, physicians considered the female body a delicate vessel, easily damaged by unchecked social exertion or stress. One Harvard physician wrote a book arguing that education was spreading sterility by manufacturing women with monstrous brains and puny bodies.

SPEAKER: The reproductive machinery, to be well made, must be carefully managed. Force must be allowed to flow thither in an ample stream and not diverted to the brain by the school.

STEPHEN SMITH: Historian Margaret Marsh says the 19th century impulse to shield women in the safety of the home was part of a larger trend in American society away from the big, extended utilitarian families of the colonial era.

MARGARET MARSH: A new idea arose about what the family meant. Children became the purpose of family life, especially middle and upper middle class family life, in a way that they hadn't been before.

STEPHEN SMITH: In 1861, a prominent Southern society lady named Mary Chestnut had been married for two decades, but at age 38 still had no children. Chestnut agonized in her diary over the scorn she felt from her aristocratic and domineering in-laws.

SPEAKER: Women have such a contempt for a childless wife. Mrs. Chestnut was bragging to me one day with exquisite taste, to me, a childless wretch, of her 27 grandchildren. And Colonel Chestnut, a man who rarely wounds me, said to her, you have not been a useless woman in this world.

STEPHEN SMITH: At the turn of the 20th century, white Americans grew increasingly anxious about what they perceived as an infertility crisis in their neighborhoods. The birth rate among middle class whites was at an all time low, in part because couples were choosing to have fewer children. President Theodore Roosevelt warned that immigrants and minorities were too fertile and that Anglo-Saxons were in danger of committing race suicide by not keeping up baby for baby.

SPEAKER: The chief of blessings for any nation is that it shall leave its seed to inherit the land. The greatest of all curses is sterility, and the severest of all condemnations should be that visited upon willful sterility.

[MUSIC PLAYING]

STEPHEN SMITH: As the first half of the century unfolded, medical science made big advances in understanding infertility. Researchers began to discover how hormones and poor sperm quality can cause the condition. But making babies remained a national cause.

[MUSIC PLAYING]

This March of Time newsreel comes from 1946.

SPEAKER: Among the wartime production feats of which the United States is pardonably be proud, not least are those which have led to a spectacular rise on the nation's birth rate.

STEPHEN SMITH: Throughout the 1940s and '50s, magazines and films described reproduction in patriotic terms.

ELAINE TYLER MAY: The baby boom era was a time of extreme pro-natalism or a strong cultural sense that everyone ought to have children and ought to want children. And you'd find headlines in the 1950s, like one that I found, a picture of Elizabeth Taylor with a baby, that said, a woman at last.

STEPHEN SMITH: May says that if giving birth in the '50s signified true womanhood, becoming a father was for a man a badge of social respectability. For couples who could not have children, post-war medical science promised tantalizing new treatments. There were synthetic female hormones to jump-start troubled ovaries and artificial insemination to dodge the problem of low sperm counts. The press also published dramatic stories about experiments at in-vitro fertilization, propagating human eggs in a laboratory dish.

SPEAKER: From Good Housekeeping magazine 1953. Until recently, a barren woman or a woman who had been unable to conceive could only hide her heartache. Today, she has a right to hope for children. In the past few years--

STEPHEN SMITH: Articles like this fueled a surge in demand for infertility services. But 1950s science promised more than it could deliver. Infertility treatments only worked about a third of the time.

[MUSIC PLAYING]

In the 1960s and '70s, the birth control pill, the sexual revolution, legalized abortion, women's lib all gave Americans a new sense of power over their reproductive careers. Historian Sara Evans says that for earlier generations of women, pregnancy was something that happened to them. But she says the twin liberations promised by birth control and infertility medicine begat an illusion of human control over biology.

SARA EVANS: And the notion that you could decide when to have a child and that you could fit that into all sorts of other plans about your life is deeply ingrained in the American middle class. And to plan it and then not have it happen is a bit of an affront.

STEPHEN SMITH: By the 1980s, an increasing number of American women planned to start having children later in life. While some found getting pregnant difficult, that did not mean that infertility had become more prevalent. Some experts argue that American infertility rates have actually decreased since the 1960s with one exception, women under the ages of 20 to 24.

In that group, infertility jumped 7% due mainly to the spread of sexually-transmitted diseases that can cause infertility. In fact, the infertility rate for married, middle-class couples has stayed at 10% to 13% for more than a century. Historian Elaine Tyler May.

ELAINE TYLER MAY: There's a myth out there that infertility is a disease or epidemic among the affluent, the privileged, especially professional women who postpone childbearing and bring it on themselves. Absolutely, not true. Infertility has always been and continues to be much, much more common among the poor.

STEPHEN SMITH: That's because lower-income people typically have poorer health, which can lead to decreased fertility. And less affluent Americans typically cannot afford infertility treatments, which can easily cost $10,000 or more and are usually not covered by insurance. May is disturbed by what she considers the disproportionate level of media concern over infertility among the affluent.

ELAINE TYLER MAY: You see these magazine covers with the prosperous, white, middle class woman looking sadly at the empty cradle. The implication is that society should invest its resources here because these are the people we should be helping to create the nation's future citizens.

STEPHEN SMITH: In at least one way, May says, little has changed over the past hundred years. American's affluent enough to pay for infertility treatments get them and those who can't pay don't.

SUSAN STAMBERG: Fertility drugs and procedures are relatively expensive. And most couples get virtually no coverage under the basic health insurance plans that come with their jobs. A number of states require employers and insurance companies to offer some kind of infertility insurance, but most do not. In New York, advocates for the infertile say excluding infertility from insurance plans amounts to discrimination. Again, here's Stephen Smith.

[SQUEAKING]

PAMELA MADSEN: These are the Guinea pigs. Everyone hear them squeaking? Here's the Guinea pigs.

STEPHEN SMITH: Pamela Madsen, her husband Kai, and their two kids live in a very small one-bedroom apartment in the Bronx. So small, Pamela laughs, that you can stride from the foyer through the den past the aviary across the living room and into the dining area in half a dozen steps. Then you come to a door into what used to be a snug little breakfast nook.

PAMELA MADSEN: Now, I'm a little embarrassed to open that door because you were here a little bit early. So you can't-- you have to tell them that the bed is made.

STEPHEN SMITH: OK, the bed is made and it's wedged into the space of a dinette set.

PAMELA MADSEN: In my more romantic moments, I call it the pleasure cove.

STEPHEN SMITH: The handy thing is you can reach from the bed to the stove to turn on the teapot.

PAMELA MADSEN: Yes, you can. Yes, you can. Though I've never done that. But it brings a whole new meaning on breakfast in bed.

STEPHEN SMITH: The Madsen's two boys, ages 10 and 6, sleep in bunk beds in the real bedroom. And this whole family plus pet cat, and bird, and eight Guinea pigs, plus bikes and books, home office, et cetera are all jammed into such a small space because Kai and Pamela are infertile. The kids were both born by in-vitro fertilization after a long and costly struggle against infertility that included numerous procedures. The Madsens quit laughing when they explain that their quest swallowed up $30,000 or more leaving them deeply in debt. Doctor bills consumed all the money that might have gone to buying a house.

KAI MADSEN: It set us back a lot. We ran up a lot of credit card debts. We paid for what we could and charged everything else.

PAMELA MADSEN: It was expensive. It changed our lives in a way that felt like a betrayal. A betrayal because we were working people, and had health insurance, and had dreams like any other person.

STEPHEN SMITH: Both Pamela and Kai had health insurance. She was a teacher and he had just switched careers. Neither health plan covered the artificial inseminations or in-vitro fertilizations they needed to get pregnant.

It was a slightly different story for Fran and David Ritter in Queens. Fran's Wall Street accounting job had insurance that covered one in-vitro attempt, but Fran needed three IVFs to get pregnant plus other costly procedures to deal with David's low sperm count. The Ritters spent more than $20,000 altogether.

DAVID RITTER: Thank goodness the stock market worked in our favor over the past few years. It's been tremendous. But that's not the kind of insurance policy that everybody has. You can't depend on a strong, robust economy to fund your IVF cycle.

STEPHEN SMITH: Fran says insurance should have helped. And it would have if she had hurt a knee jogging or got emphysema from smoking, but not infertility.

FRAN RITTER: Just because, biologically, we can't produce our own offspring, why should we be treated any differently? We desire to have a biological family. Why do I have to be treated differently?

STEPHEN SMITH: The Ritters and the Madsens are part of the infertility support and advocacy group Resolve, which wants the government to require employer health plans to cover the condition. Some two and a half million Americans seek some form of treatment for infertility each year. Most only require drug therapy or other relatively simple procedures.

Only about 5% go on to the high-tech treatments like in-vitro fertilization. Margaret Hollister of Resolve's national office in Boston says it's not clear how many infertility patients have to pay their medical bills out of pocket. She believes they are the majority and she says that's not right.

MARGARET HOLLISTER: We say it's an issue of fairness. If infertility is defined as a disease, it ought to be covered by insurance.

STEPHEN SMITH: There is much debate as to whether infertility is a disease, a disability, or merely a social condition. Some commentators insist that because it is not a life-threatening or debilitating condition, it's not as important as many other ailments that go untreated.

ARTHUR CAPLAN (ON PHONE): That could only be said by someone who's never talked to an infertile couple who are probably among the most desperate individuals I've ever encountered.

STEPHEN SMITH: Arthur Caplan teaches medical ethics at the University of Pennsylvania.

ARTHUR CAPLAN (ON PHONE): The misery, the suffering that attends being unable to have a biological child when you want to do that is just enormous. And to argue that health plans are only going to pay for things that are truly diseases just flies in the face of what Americans want from their health care plans.

STEPHEN SMITH: Some infertile Americans are asking the courts for fairness. Last year, the city of Chicago agreed to cover infertility treatments for city employees after a female police officer sued, claiming her infertility is a disability and should be covered by insurance. The US Supreme Court ruled that infertility is indeed a disability, as defined by the Americans with Disabilities Act because it impairs a major life activity. David Ritter of Queens argues that even though he appears perfectly healthy, he is also disabled.

DAVID RITTER: I can do mostly everything, run, jump, skip, but physically we are disabled. We are diseased in a way because we can't procreate naturally.

STEPHEN SMITH: At least 13 states have passed laws mandating insurance coverage for infertility, but the levels of coverage vary. Employers and insurers oppose these mandates. They say the laws benefit a few while boosting the cost of health insurance for everyone else.

Recent studies found that the average premium goes up about $3 a year when infertility is covered. The University of Pennsylvania's Arthur Caplan says infertility should be covered but with limits. Some unsolvable cases, he says, may be too expensive.

ARTHUR CAPLAN (ON PHONE): If you're looking at someone who's in their early 50s who's still trying with the drugs and the in-vitro fertilization, we know what the statistics are there, 1 in 1,000 odds. If you want to pursue that, I think it ought to be out of pocket.

STEPHEN SMITH: Boston University health law professor at George Annas says that the argument should not be about who's eligible for infertility services.

GEORGE ANNAS: The real social justice question here is, how do we cover the 40 to 50 million completely uninsured people in the United States and the other 50 million underinsured people. It's a much more higher priority, ethical, social justice issue than how do we increase the private coverage people have to include infertility services.

SUSAN STAMBERG: Even if infertility activists succeed in passing state or federal insurance mandates, it might just be a partial victory. Legal experts say businesses that are self-insured may not have to comply and that represents the majority of US employers.

[MUSIC PLAYING]

After a short break, we meet the women who offer to share their eggs and their wombs to help the infertile have children. I'm Susan Stamberg. You're listening to the Fertility Race, a special report from American RadioWorks on NPR, National Public Radio.

[MUSIC PLAYING]

SPEAKER: Major funding for American RadioWorks is provided by the Corporation for Public Broadcasting with additional support from the Florence and John Schumann Foundation and Henry J. Kaiser Family Foundation. The series was produced by Minnesota Public Radio. For a CD of the Fertility Race series, send $20 to NPR Tapes, 45 East 7th Street, Saint Paul Minnesota 55101 and visit our website at americanradioworks.org. This is NPR, National Public Radio.

BOB EDWARDS: I'm Bob Edwards host of NPR'S Morning Edition. While you sleep, the world makes news. Whether in London, Johannesburg, Jerusalem, or Tokyo, Morning Edition lets you know what happened and what's coming up during the day. Wake up every weekday to NPR's Morning Edition.

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SUSAN STAMBERG: The fertility race is a major preoccupation for baby boomers, especially female boomers. I'm Susan Stamberg with a special report from American RadioWorks and NPR on infertility and its treatments. As the last wave of baby boomers reaches middle age, some women are finding that they may have waited too long to conceive children. Once a woman reaches her late 30s and early 40s, she produces fewer healthy eggs. Conception becomes more difficult.

But now, women can get pregnant using eggs provided for a fee by a younger woman. And in some cities, the going rate for eggs is climbing to $5,000 or more. Catherine Winter reports.

CATHERINE WINTER: Every year, just before Christmas, a New Jersey infertility clinic throws a party. Hundreds of people fill a hotel ballroom decorated with lights and candy canes. Small children in fancy outfits gape at a puppet show or run among the tables where families eat hors d'oeuvres. One couple, in their early 40s, tried for a decade to conceive.

MIKE: We brought our wonderful son who is now just over two years old and we're very happy.

CATHERINE WINTER: Mike and Eileen's son was conceived in a glass dish in a laboratory where Mike's sperm fertilized an egg from a donor. The developing embryo was placed in Eileen's uterus. The child is genetically related to Mike, but not to Eileen, who gave birth to the baby boy. But the mothers here say being pregnant and giving birth to their children is what's important. Rebecca Blankstein is a mom of an egg donor baby, too. She strokes her infant son Marcus.

REBECCA BLANKSTEIN: He's a very good baby. I'm thrilled to have him. He's been mine really since the day of conception. I've never thought of him as anything else.

[BABY CRIES]

Hey!

CATHERINE WINTER: To conceive Marcus, the Blanksteins paid about $18,000 for drugs, medical procedures, and the egg donor's fee. Despite the cost, the number of infertile couples receiving egg donations has grown steadily over the past decade.

Demand for eggs outstrips supply. Some couples advertise for donors. Some turn to a sister or a friend. A California graduate student named Emily donated eggs to a friend.

EMILY: She is more like a sister to me in a lot of ways. I think that they would make really great parents. And I saw how much pain this was causing my friend in her life.

CATHERINE WINTER: To donate eggs Emily had to endure painful hormone injections to stimulate her ovaries. A woman normally produces one egg a month, but the drugs can make her produce a dozen or more. Then a doctor surgically removes those eggs.

EMILY: I was led to believe that this is an incredibly low-risk procedure, that people do it all the time, that sometimes something mildly bad happens to 1 in 10,000 women.

CATHERINE WINTER: But the hormones pushed Emily's ovaries too far. She produced about 50 eggs. And she wound up with ovarian hyperstimulation syndrome, a complication that can lead to fluid buildup in the chest and abdomen, kidney failure, and even death.

Emily had to be hospitalized. When she got out, she was hardly able to walk up the steps to her apartment for weeks. The doctor had an incentive to put Emily at risk. He had made a deal with the infertile couple. If they didn't have a baby, he didn't get paid.

EMILY: These guys aren't in it as a matter of benevolence, they're in it for the money. He wanted to get the recipient couple pregnant and I believe that he went beyond what's really ethical in terms of my health.

CATHERINE WINTER: Emily is healthy now but still doesn't know whether she'll face problems in the future. The long-term effects of hyperstimulation syndrome are unknown. Many medical ethicists are uneasy about the idea of potentially harming one woman to provide eggs for another, especially when money is involved.

A woman can make $2,000 to $5,000 for one donation, and in some cases much more, particularly for hard to find donors such as Asian or Jewish women. The money is said to compensate the donor for her time and trouble, not to buy parts of her body. But Dr. Ruth Macklin, an ethicist at the Albert Einstein College of Medicine in New York, still opposes the high fees.

RUTH MACKLIN: It certainly sounds like they're not donors but vendors to me. When the rate goes up, everybody follows suit. This is precisely an example of market forces that drive this and it has a very unsavory quality to me.

CATHERINE WINTER: The Center for Surrogate Parenting and Egg Donation in Beverly Hills lets clients search a computer database containing hundreds of profiles of women willing to be donors.

SPEAKER: You can run a query or a search for specific criteria, say, Christian, Caucasian, eye color green, and blonde hair and it pulls up 23 applicants. It has a color picture.

CATHERINE WINTER: Some couples search for a brilliant, gorgeous donor, but many simply want a donor who looks like the mother to be in hopes the child will resemble both parents. The center tries to find a variety of healthy women and tries to screen out those who would long for the children made with their genes. People in the egg donation business say they want donors who believe they're giving up eggs they wouldn't be using anyway, not giving up babies.

SPEAKER: Go, Josh, go!

ARTHUR CAPLAN (ON PHONE): Go, Josh.

SPEAKER: Kick it in, bud. Follow that up.

CATHERINE WINTER: On a Saturday afternoon, 29-year-old Quincy watches her little boy run up the soccer field as her husband, the coach, yells encouragement.

- Yes, Joshua!

QUINCY: Way to go!

CATHERINE WINTER: In addition to her son and a daughter, Quincy has helped produce five other children. Her eggs produced a set of triplets who live in Germany. She's never seen the children.

QUINCY: Curious to what they look like and things like that, but not that I'm missing out on anything. Because I think it's just that you made a family. So you don't long for their children because they wouldn't be a family without you.

CATHERINE WINTER: Eventually, technology may make egg donation unnecessary for older women. Researchers are working on ways to freeze human eggs. So someday a woman might be able to freeze her eggs when she's young and use them much later when she's ready to have children.

SUSAN STAMBERG: Many infertile women have perfectly good eggs, but have other physical barriers to pregnancy, such as problems with their fallopian tubes or uterus. Some of these women recruit other women to carry their babies for them. Surrogate motherhood has been a controversial practice in the United States since the 1980s and the Baby M case, when a surrogate fought unsuccessfully in court to keep her child.

Since then, a quiet and fundamental change has swept through the business known as commercial surrogacy. Today, most surrogate mothers are not genetically related to the children they carry. Instead, they provide the womb in which the fertilized egg is carried to term. This fact may increase both the number of babies born through surrogacy and the legal security of the arrangements. Here's correspondent Stephen Smith.

STEPHEN SMITH: In the family room of their cozy, small town Pennsylvania home, Giusti and Mike page through a photo album of the twins she gave birth to in 1996. It's the usual stuff, plump, bewildered babies tucked into colorful outfits, the faces of beaming parents, and flipping back a few pages, the before pictures of Giusti's belly swollen to improbable dimensions.

MIKE: It was big. The amazing Buddha.

[LAUGHS]

STEPHEN SMITH: Well, twins, you know.

SPEAKER: Yeah.

MIKE: Twins, yeah.

STEPHEN SMITH: And what were they?

MIKE: Both girls.

SPEAKER: Two girls.

STEPHEN SMITH: Two girls yeah.

SPEAKER: They were both girls, 6/12 and 5/8.

MIKE: It's amazing that the one looks exactly like the mother and the other exactly like the father.

STEPHEN SMITH: Meaning Giusti and Mike are not the parents. The genetic mother and father live in Beirut, Lebanon. Giusti he carried and delivered their twin babies for a $12,000 fee. The children were conceived in a laboratory dish using the sperm and egg of the genetic parents and then transferred as embryos to Giusti's uterus.

Giusti is a 39-year-old radiology technician. Her husband Mike, an executive at a technology company. They have two school-aged kids.

As she talked, Giusti shifted on the couch to find a more comfortable position. She was pregnant again, this time for an infertile couple who live an hour away in suburban Philadelphia. For Giusti, the distinction between being a surrogate who provides her own egg and being what's called a gestational carrier is crucial.

SPEAKER: In fact, I don't think that I could be a surrogate. I could not have a part of me out there that I'm not taking care of. I don't even think that I could be an egg donor because I still know that there's a part of me out there that I don't know what's happening to. But with this, I just feel like an incubator or a house for the baby to grow. And so it to me it's completely different.

STEPHEN SMITH: Advances in medical science that make it possible for a woman to carry a genetically-unrelated child are having a profound effect on the practice of commercial surrogacy in the United States. Andrea Braverman is chief psychologist at Pennsylvania Reproductive Associates, the infertility program that Giusti works through. Braverman screens candidates to make sure they can handle both the rigors of pregnancy and giving up the child. She, says gestational carriers are fast replacing so-called traditional surrogates.

ANDREA BRAVERMAN: It is a very different psychological hurdle to navigate if you are genetically related to the child you're carrying. And they feel that psychologically, they are safer, if you will, if they are very clear saying, hey, it's her egg and his sperm.

STEPHEN SMITH: No one knows how many babies are born in the US through surrogacy each year. The number is probably in the hundreds. Agencies and brokers have popped up around the country that will match surrogates and clients for a fee even with the genetic relationship between the baby and the carrier removed surrogacy remains one of the most socially controversial solutions to infertility.

Longtime surrogacy opponent Andrew Kimbrell, a Washington lawyer and activist, sees no ethical distinction between a surrogate who bears a child with her own egg and a gestational carrier.

ANDREW KIMBRELL: It is the attempt to commodify the act of childbearing and to commodify children. It is baby selling really pure and simple, which we have forbidden in all 50 states, but under the guise of a surrogate contract tried to legalize.

JOHN ROBERTSON: It's clearly wrong. Baby selling is you have a born child, which is then sold to another person.

STEPHEN SMITH: John Robertson teaches law and medical ethics at the University of Texas.

JOHN ROBERTSON: Here we're talking about agreements made before conception has even occurred, where there is no existing child. Secondly, the genes, in the case of gestational surrogacy, for that child are being provided by the couple that is hiring the surrogate thus in a sense it's their genetic child.

STEPHEN SMITH: Unlike adoption, surrogacy is virtually unregulated. In most states, the contracts are either unrecognized by the courts or can be difficult to enforce. In a few states, such as Michigan and New York, paid surrogacy is illegal.

Back in Pennsylvania, the baby that Giusti was carrying arrived prematurely. And the boy spent 10 days in the hospital before growing strong enough to go home, but this was the only hitch.

CATHERINE: And she wasn't a part of it, I'm sure.

[INTERPOSING VOICES]

STEPHEN SMITH: This is Catherine's house she's the genetic mother of the baby boy Giusti delivered. Catherine and her husband already had a toddler named Emma who was busy cavorting with a friend. Severe medical problems with Emma's birth nearly killed Catherine and left her with functioning ovaries, but unable to carry another child.

As she cradled her new sleeping baby boy in her arms, Catherine explained it was natural to want Sumner to be her genetic child, but that neither DNA nor gestation are what really makes a mother.

CATHERINE: A mother is somebody who takes a child from birth and raises them. Somebody who adopts a baby, they're their mother. I'm the one who's taking care of him since he was a second old.

STEPHEN SMITH: Later that afternoon, Giusti and Mike dropped by Catherine's house to visit as they often do now. Catherine's husband was away on business. It is Mike who cradled the baby, teasing a pacifier into his fussy mouth. Giusti sat across the room next to Catherine content to watch the baby from afar .

SPEAKER: I'm here to see Catherine actually. It's nice to see the baby when I come in, but it's more just out of the friendship that we've developed.

CATHERINE: The first time she came when he was here, I wasn't sure. I was like, do you want to hold him and feed him? No, that's OK. You can feed him.

STEPHEN SMITH: The two couples are so close, they've even vacationed together. Catherine says while Giusti is sure to be a permanent family friend, they probably won't tell Sumner how he was born until he's a teenager. And Catherine's not too worried about how he'll take it.

CATHERINE: When this child-- when he is old enough to understand and to know something like that, I can't even imagine how people are going to be having babies. So I really don't think this is going to be that obscure.

STEPHEN SMITH: The surrogacy, the lawyers, and the medical bills cost Catherine and David more than $40,000. If they can manage it, they might try for a third child. And Giusti says she's ready to carry the baby.

SUSAN STAMBERG: Surrogates and egg donors are just two of the many controversial, astonishing recent developments in the process of human reproduction. Many more are sure to come as scientists, and doctors, and yes, businesspeople push the edges of biology and ethics. Lurking in the background is the issue of cloning, though it's likely to be some time before that's offered as a therapy for infertility if it ever is.

The social and ethical dimensions of modern treatments for infertility also extend to questions about whether insurance companies should cover the procedures about the use of infertility techniques to help gays and lesbians conceive children and more. You can explore these and other issues in the website companion to this program. Point your browser to americanradioworks.org. That's americanradioworks, all one word, dot org.

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You've been listening to a special report called the Fertility Race. It was produced by Stephen Smith of American RadioWorks with Catherine Winter and Stephanie Curtis. The stories were edited by NPR's Anne Gudenkauf, Sharon Green, and Deborah George. The executive producer for American RadioWorks is Bill Buzenberg. I'm Susan Stamberg.

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SPEAKER: Major funding for American RadioWorks is provided by the Corporation for Public Broadcasting with additional support from the Florence and John Schumann foundation and Henry J. Kaiser Family Foundation. The series was produced by Minnesota Public Radio. For a CD of the Fertility Race series, send $20 to MPR Tapes, 45 East 7th Street, Saint Paul, Minnesota 55101 and visit our website at americanradioworks org. This is NPR, National Public Radio.

ROBERT SIEGEL: This is Robert Siegel. All Things Considered is more than a news program. We bring you stories about ideas, about the arts, about interesting people, and developments in our lives that haven't made headlines, at least not yet.

We bring you the stories of commentators, the insights of scholars, and the experiences of all sorts of Americans. And we start with the day's news. Tune in later today to NPR'S All Things Considered.

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