2.1. Characterizing infertility and childlessness

While involuntary childlessness may be conceived in terms of medically diagnosed infertility, I employ the term to capture additional cases that are the result of relational and economic factors, such as not having met the right partner, or lacking the financial means to have a child with security. I do so in order to uncover the social factors that comprise infertility and infertility-related distress, forming a holistic picture of reproductive autonomy and well-being. Such an image is required to comprehensively attend to the question as to whether assisted reproductive technologies (ARTs) can be justified by appeals to welfare. ARTs cannot “treat” the aforementioned social factors comprising infertility, after all. It is recognized that even medically diagnosed infertility often has a social component. For example, delaying the decision to procreate due to facing certain career structures, to a time when it is no longer possible to conceive without medical assistance, makes the subsequent loss of fertility at least, in part, socially determined (McTernan Reference McTernan2015). Further, it may be suggested that “social infertility” resulting from a lack of partner involves the inability to achieve one’s vital goals, and so itself qualifies as a state of impaired health (Maung Reference Maung2019). Medical and social aspects of infertility appear to be co-constituted, therefore. This can also be seen in the way in which anthropogenic environmental pollution and poor nutrition resulting from dominant food systems play a significant role in health and infertility (Sørensen et al. Reference Sørensen, Poulsen, Nøhr, Khan, Ketzel, Brandt, Raaschou-Nielsen and Jensen2024; Wieczorek et al. Reference Wieczorek, Szczęsna, Radwan, Radwan, Polańska, Kilanowicz and Jurewicz2024; Maitin-Shepard et al. Reference Maitin-Shepard, Werner, Feig, Chavarro, Mumford, Wylie and Rando2024). Thus, in focusing my analysis on involuntary childlessness more broadly, and in taking seriously the idea that infertility exhibits social determinants, I consider the ways in which reproductive autonomy and well-being are to be promoted outside of the use of ARTs.

2.2. The assisted reproductive technologies in question

I examine IVF and the emerging uterus transplant in conjunction here, as the alleviation of infertility-related suffering has been provided as a legitimation for both procedures (Guntram and Zeiler Reference Guntram and Zeiler2019; Bozzaro et al. Reference Bozzaro, Weismann, Westermann and Alkatout2023; Warnock Reference Warnock2003). These procedures have also been discussed in confluence in the literature due to the developing status of UTx as an assisted reproductive technology aimed at addressing fertility issues (Cavaliere and Cesarano Reference Cavaliere and Cesarano2025). However, UTx, which involves the surgical transplantation of a uterus, often from a living donor, presents novel risks and harms. It is therefore worth returning to the question as to whether IVF really does attend to suffering alleviation now that further controversial procedures are being justified using the same logic. That these procedures are so different is precisely why I undertake their joint examination. While IVF is rarely questioned now, its grounding justifications (e.g., welfare and reproductive autonomy) are being applied in emergent contexts where confounding factors might be obscured. It is therefore worth considering the extent to which such a justification ever held in the first instance. In doing so, I also uncover the particular risks associated with UTx, which demand a novel justificatory analysis. The approach taken in this paper, of identifying wider factors to include in a welfarist calculation of ARTs, is of particular importance and urgency when such a calculation is applied to justify access to increasingly risky procedures like UTx.

2.3. Parameters of the argument

It is important to note from the outset that I do not make pronouncements on any state-funding-based implications of this analysis or on whether ARTs should be available at all. These positions would require much further and distinct argumentation. Rather, the aim of this paper is merely to uncover the role of the broader social context in producing infertility-related distress and therefore trouble the assumption that ARTs can relieve this distress. There may be other relevant reasons for states to continue with ART provision while also promoting welfare through the kind of societal restructuring I propose. In this sense, my claims are orthogonal to other work on ARTs and infertility that seeks to examine justifications for funding such procedures. Mianna Lotz, for example, has critiqued the idea that UTx should be publicly funded, pointing to the way in which arguments for public provision “do not take sufficient account of the complex relationship between state-funded UTx provision and the likely reinforcement of procreative norms that … ultimately serve to reinforce and entrench existing problematic norms and stigma around infertility” (Lotz Reference Lotz2021). While my argument builds upon this idea that ARTs exacerbate certain factors in the wider social context that play a role in infertility-related distress, it does so toward a distinct and more limited end: assessing whether overall welfare is improved by ARTs.

Lotz develops her argument contra Stephen Wilkinson and Nicola Williams, who argue that various concerns raised against UTx raised do not establish a case against it, whether publicly or privately funded (Wilkinson and Williams Reference Wilkinson and Jane Williams2016). To be clear, I do not seek to establish a “case against UTx” but, rather, query whether a case based on its promotion of welfare is sufficiently convincing. Following this, I do not take any position on whether ARTs such as IVF or UTx should be publicly funded. The question I explore is somewhat prior to such debates, centering instead on whether ARTs promote welfare. Giulia Cavaliere makes a case for the expansion of fertility treatment provision, arguing that “(reproductive) preferences ought to be taken more seriously when discussing fertility treatment provision … and that not doing so can be costly, especially for women” (Cavaliere Reference Cavaliere2024). An axiomatic assumption in this argument is that “fertility treatment enables involuntarily childless people to have genetically related children” (Cavaliere Reference Cavaliere2024). This is what I believe grounds the welfare-based justification of such technologies. However, as I will argue, the success of ARTs in meeting this aim is arguably limited, given around three-quarters of IVF is unsuccessful (HFEA n.d.-b). The accompanying distress, however, is tangibly related to welfare reduction (Pasch et al. Reference Pasch, Gregorich, Katz, Millstein, Nachtigall, Bleil and Adler2012).

3.1. Alternative justifications for ARTs

The question as to whether access to fertility procedures could be grounded in rights was taken up by Mary Warnock in her examination of assisted reproductive technologies such as IVF (Warnock Reference Warnock2003). Warnock endorsed a legal positivist position in her exploration of whether there exists a “right” to have children, suggesting that in the absence of a law conferring that right, to claim a right is to employ no more than a rhetorical device (Warnock Reference Warnock2003). On such a view, the law is a matter of what has been posited, and “moral rights” beyond this—such as a right to procreate—are certainly not legally protected and may well be incoherent.

Until a right is enshrined in law, “you can claim no more than that you ought to have the right, not that you have it” (Warnock Reference Warnock2003). Warnock recognized that this position might seem to give undue authority to the formulation of the law as it is. However, she held that the source of human rights, even as they are enshrined in law, is the concept of need, rather than law. Thus, she argued that no such right to children could or ought to exist, because procreation is not a basic need. To say procreation is a rights-generating need for those who desperately want children “would be to erode the distinction between relative and basic needs, and indeed to make it impossible to distinguish between heartfelt wishes on the one hand and entitlements on the other, between wants and needs” (Warnock Reference Warnock2003). Warnock maintained, however, that the infertile who want to conceive remain entitled to expect that they will be given medical assistance to do so (Warnock Reference Warnock2003). She acknowledged that payment might be required and thus was not making a pronouncement on resource allocation decisions. Nevertheless, on her view, access to reproductive procedures, whether or not they are publicly funded, is grounded in welfare considerations, as infertility causes extreme distress, and the medical profession is generally committed to alleviating suffering. Warnock did not substantiate the notion of welfare that she was operating with—this is a task I take up later in this section through a discussion of theories of well-being.

Notable attempts to provide a rights-based approach to justifying policy for reproductive technologies include John Robertson’s account of procreative liberty (Robertson Reference Robertson1995). Robertson is concerned with the “right” in terms of both moral and legal duty (Robertson Reference Robertson1995) and he argues for both a moral and legal right to reproduce under the concept of “procreative liberty.” However, this primarily entails a negative liberty right to engage in activities necessary to achieve the goal of procreation, without interference by the state or others unless the reproduction harms nonconsenting others in specific ways (Robertson Reference Robertson1996). Crucially, procreative liberty does not guarantee positive access to ARTs.

It seems unlikely that a positive conceptualization of rights underscores current state-sanctioned access to ARTs, as such a “right” to these procedures would be too demanding. To claim that A has a negative right to IVF, for example, would be to say that the state may not permissibly interfere in A’s decision to undertake IVF. By contrast, a positive right to IVF entails a corresponding duty of positive assistance from others. Thus, to say that A has a positive right to IVF is to say that A has a valid claim against another person or the state to fulfill access to IVF. Given the patchy and inconsistent distribution of IVF services in the UK, we can ascertain that there is presently no universal socio-economic right underpinning its delivery, as there is with education, for example. Practicalities aside, if we look closely at precisely what a positive right to IVF would entail, we can see that it demands peculiar goods and duties.

An individual with medical issues regarding ovulation and egg production would require access to donor eggs to undergo successful IVF treatment, for example. For this to be granted to all in need—as a matter of right—might be seen as necessitating access to other people’s bodies to be able to satisfy the demands of this claim. That is, the fulfillment of such a claim, through the imposition of a positive duty on the state or others, may take us beyond a system of consensual gamete donation. While a negative right to be free to engage in certain fertility procedures may entail no corresponding public duty of assistance, a claim of positive assistance to IVF may be more complex to fulfill.

Such concerns are heightened when we consider what a positive right to other forms of fertility assistance, such as surrogacy, or the emerging uterus transplant, might look like. Following Judith Jarvis Thompson’s canonical intervention into the debate on foetal value and abortion, we might say that any right to have children can be distinguished from a right to be given access to the means necessary to have children (Thomson Reference Thomson1971). If the means necessary to have children involve invasive access to other people’s bodies through surrogacy arrangements, or living uterine donations, this might cast doubt on the reasonableness of such a claim. A positive right to UTx that involved forcible redistribution of reproductive materials or coerced access to reproductive means would of course be straightforwardly in conflict with the negative rights of others, and therefore unsustainable (Barn Reference Barn2024). A system involving consensual donation would avoid this, but it remains implausible that UTx could be enshrined and guaranteed as a matter of positive right.

Finally, I consider a justification for ARTs centered on the idea that such procedures serve as “treatments” for a “disease.” There is much debate concerning whether infertility is appropriately considered a disease (McTernan Reference McTernan2015; Kukla Reference Kukla2022), and of course on the nature and definition of disease itself (Reznek Reference Reznek1987; Kingma Reference Kingma, Schramme and Edwards2017, Reference Kingma2010). Through a careful examination of the normativist and naturalist positions on classifying infertility as a disease, Hane Maung argues that there exist deep theoretical disagreements in the literature (Maung Reference Maung2019). As a result, one cannot uncontroversially justify or undermine claims to infertility treatment by claiming that it is, or is not, a disease. Therefore, a preferable approach to justifying state-funding centers on explicitly addressing the specific ethical considerations raised by infertility, as opposed to one that seeks to determine its disease status (Maung Reference Maung2019). In making this case, Maung builds upon an approach proposed by Rebecca Brown and colleagues who also move away from debates concerning infertility’s disease status, and instead focus on its harms, in particular the quality and extent of suffering it can cause, and how it affects individuals’ opportunities to pursue valued life projects (Brown et al. Reference Brown, Rogers, Entwistle and Bhattacharya2016).

In the absence of any forthcoming consensus on infertility’s disease status, it seems most productive to take this irresolvable dispute as a starting point, and consider what follows from such an impasse. Implicit in these accounts, however, is the view that infertility treatments are a way to straightforwardly alleviate the suffering in concern. While infertility’s disease status remains an open question, another looms large: whether ARTs do indeed mitigate this suffering, or whether they may be inimical to this welfarist goal.

3.2. Theories of well-being

It is important to clarify what is to be understood by welfare. Warnock’s account seemed to characterize welfare as the alleviation of suffering, and we might want to expand this notion to map onto well-being more generally. Thus, welfare is to be understood as well-being on various plausible accounts, such as hedonistic, desire-fulfillment, and objective list theories. This taxonomy is not without problems: it does not exhaust the possible views, nor does it establish the theories as counterposed (Arneson Reference Arneson1999). Indeed, it may be a false trichotomy: Parfit himself suggests, at the end of his tripartite analysis, that what is best for people may be a composite of their conscious subjective states and certain objective goods (Parfit Reference Parfit1984). It is beyond the scope of my analysis to engage in a thorough meta-ethical investigation of well-being. Rather, I take these three categories as a useful, well-trodden, starting point to answer the overarching question as to whether ARTs can be said to promote well-being according to said dominant conceptions.

Theories of well-being center on exploring the fundamental good for human beings: what does human flourishing consist in? What would be best for someone and make their life happiest? According to Parfit, the first candidate theory of the good life, or well-being, is hedonism. A hedonistic account of well-being suggests that our life goes well to the extent that we experience pleasure and the absence of pain (Parfit Reference Parfit1984). A good life, therefore, is one in which pleasurable mental states are either dominant or outweigh painful mental states. However, our desire also seems relevant to these experiences of pleasure and pain. This is because pain can also be rational or morally significant, and so desired. This opens the door towards preference-hedonism—the idea that one of two experiences is more pleasant if it is preferred.

Next, Parfit considers desire-fulfillment theories, the most plausible of which he terms success theory. Here, desire is restricted to desires about our own lives, as opposed to, say, the fleeting well wishes we might have for strangers. According to desire-fulfillment theories, what matters for well-being is the degree to which our desires are satisfied. A good life is one in which the agent is able to satisfy their desires, plausibly their most important desires, and where desire-satisfaction outweighs desire-frustration. Success theory differs from preference-hedonism in that the external fulfillment of one’s desires is relevant to the former but not to the latter, which is guided by introspectively discernible features of our lives. On preference-hedonism, if we do not have the experience of one of our preferences going unfulfilled, say, through ignorance, then no difference is made to our state of mind and well-being. On desire-fulfillment theories, by contrast, ignorance cannot shield us—if our desires go unfulfilled, this is bad for us, as what makes a good life is having our desires fulfilled, rather than our experience of pleasure and pain. The relevant feature in desire-fulfillment theories is “simply whether or not the states of affairs that are the objects of one’s various desires obtain; it is irrelevant whether or not one realizes it, or whether one gets some psychological feeling of satisfaction” (Kagan Reference Kagan1992).

Finally, according to the objective list theory, certain activities are objectively good or bad for people, independently of how they experience them or whether they desire them. According to Parfit, the good activities might include “rational activity, the development of one’s abilities, having children and being a good parent, knowledge,” while the bad things might include “being betrayed, manipulated, slandered, deceived” (Parfit Reference Parfit1984). Being well off, or happy, therefore, is “simply a matter of one’s having the various objective goods” (Kagan Reference Kagan1992). The precise list of objective goods is a matter of dispute and there may be “no uniquely rational way to determine what putative goods qualify as entries on the List” (Bronsteen et al., Reference Bronsteen, Leiter, Masur and Tobia2022). Nevertheless, Shelly Kagan observes that, whatever these goods are, there is no reason to think they would be restricted to kinds of mental states (Kagan Reference Kagan1992). Objective list theories can therefore be distinguished from subjective theories of the human good, which make welfare dependent upon mental states. An immediate concern, however, is with the prescriptive nature of the list. “Having children” features on Parfit’s list of goods, with the result that childlessness necessarily reduces well-being on the objective list account. However, increasing numbers of people are choosing to go child-free and self-report happiness tied to this decision (Blackstone Reference Blackstone2019). Anticipating problems with neglecting the hedonistic focus on experience of one’s own life, Parfit responds:

A composite view of well-being, combining subjective desires with objective goods, can avoid the problem outlined above. Richard Arneson, defending an objective list account, notes that entries on the list can be ranked in importance. An objective list theory need not “deny that an individual’s attitudes may partly determine what is prudentially valuable for her” (Arneson Reference Arneson1999). Individual attitudes do not determine which items belong on the list, but some items “may include requirements concerning her attitudes and opinions” (Arneson Reference Arneson1999). For example, possible items on the list may be that “important life aims be satisfied” and it could involve the subjective ranking of aims. Therefore, childlessness need not necessarily reduce well-being on objective list accounts. It would only do so if “having children” was highly ranked by the agent in question.

There is a lot more to be said about the plausibility of these accounts of well-being and the ways in which they interrelate. For now, the key point is that a welfare-based justification for ARTs can plausibly be mapped onto any of these accounts of well-being. That is, ARTs may be justified according to welfare considerations if they (i) produce pleasure and avoid pain in a way that is preferred/chosen, (ii) satisfy or fulfill people’s desires, regardless of whether any feeling of satisfaction obtains, or (iii) result in access to certain highly ranked objective goods. If ARTs do any of the above, they might be seen as promoting well-being. The question that the next section will explore is whether ARTs do indeed promote well-being, on these conceptions. In answering this, I engage in further conceptual analysis of well-being and critical examination of the accounts above.

4.1. IVF outcomes

Regarding the question as to whether ARTs promote welfare in individual cases, it is important to observe that the efficacy of fertility treatments is frequently disappointing and far from guaranteed (Pandian et al. Reference Pandian, Gibreel and Bhattacharya2012; Dapuzzo et al. Reference Dapuzzo, Seitz, Dodson, Stetter, Kunselman and Legro2011; Sadeghi Reference Sadeghi2012). ARTs such as IVF plausibly attend to welfare sufficiently if and only if they end in a live birth.Footnote ⁵ This claim will be further substantiated in the analysis of well-being that follows this empirical overview of IVF success rates. Where IVF is not successful, studies suggest the outcome turns out to be decreased welfare (via the incidence of anxiety and depression) (Holley et al. Reference Holley, Passoni, Nachtigall, Bleil, Adler and Pasch2012; Pasch et al. Reference Pasch, Gregorich, Katz, Millstein, Nachtigall, Bleil and Adler2012; Today.Com 2024; BBC News Reference News2013). There are also significant financial costs associated with both failed and successful cycles, which can impact well-being. Even when successful, treatments remain accompanied by anxiety and depression (Awtani et al. Reference Awtani, Kapoor, Kaur, Saha, Crasta and Banker2019; Wu et al. Reference Wu, Sun, Wang, Sun, Zhang, Huang, Lu and Cao2023), although this distress might be traded off against the favorable result in such cases. It is also worth observing that IVF carries certain risks and can lead to serious adverse outcomes in extremely rare cases, such as when the use of fertility drugs to induce egg production causes ovarian hyperstimulation syndrome (Namavar Jahromi et al. Reference Namavar Jahromi, Parsanezhad, Shomali, Bakhshai, Alborzi, Vaziri and Anvar2018). Further, IVF pregnancies are also considered higher risk, requiring more monitoring, and may lead to gestational diabetes, premature delivery, low birth weight, and miscarriage (Kamphuis et al. Reference Kamphuis, Bhattacharya, van der Veen, Mol and Templeton2014).

While it is impossible to provide a global overview of IVF success rates within the scope of this paper, I showcase statistics from the UK and US, by way of example. According to the UK Human Fertilization and Embryology Authority (HEFA), around three quarters of IVF treatment is unsuccessful (HFEA n.d.-b). As a snapshot, their most recent figures reveal that the average pregnancy rate from IVF using fresh embryo transfers and patient’s own eggs was 31 percent. Patients aged 18–34 had the highest pregnancy rate per embryo transferred at 41 percent, compared to 34 percent for patients aged 35–37, and 25 percent for patients aged 38–39. The pregnancy rate differs from the birth rate, the latter being lower and denoting the actual number of live births. The preliminary average UK IVF birth rate using fresh embryo transfers was 25 percent nationally, with 35 percent for patients aged 18–34 and 30 percent for women aged 35 plus. It is just 5 percent for patients aged 43–44. In the US, the live birth rate, per embryo transfer cycle, for women aged 35 is higher at 39 percent. The average age of fertility patients starting treatment for the first time is now over the age of 35 (HFEA n.d.-a). This means that the figures for pregnancy and birth rates for patients aged 35+ are likely to be the most representative in terms of the typical IVF patient.

There also exist disparities between ethnic groups: for Black and Asian patients aged 18–37, the average IVF birth rate per embryo transferred using fresh embryo transfers were 25 and 27 percent respectively, compared to 33 percent for White patients in 2022–23 (HFEA n.d.-c). Possible explanations offered for some ethnic disparities include the fact that Black patients started treatments later than other groups, were more likely to use imported gametes, and were most likely to have faced a decrease in NHS-funded IVF cycles. NHS-funded IVF cycles decreased most among Black patients in recent years, from 60 percent in 2019 to 41 percent in 2021, 49 percent for Asian, and 53 percent for White (HFEA n.d.-c). Internationally, Black, Indigenous, and other people of color, those living on low incomes, and other historically marginalized communities experience disparate access to infertility evaluation, treatment, and care (Weiss and Marsh Reference Weiss and Marsh2023; Merkison et al. Reference Merkison, Chada, Marsidi and Spencer2023; Perritt and Eugene Reference Perritt and Eugene2021). Reproductive justice (Ross and Solinger Reference Ross and Solinger2017), therefore, involves taking seriously pre-existing inequalities and social determinants—an issue I return to in the final section.

In addition to the problem of fertility treatments having varying degrees of success in the first instance, and thus lacking in their contribution to welfare, it is also the case that failed treatments are associated with psychological distress. A robust body of research, including a number of meta-analyses, finds that women whose IVF treatment failed were at greater risk of anxiety or depression in the months afterward (Ross and Solinger Reference Ross and Solinger2017; Pasch et al. Reference Pasch, Gregorich, Katz, Millstein, Nachtigall, Bleil and Adler2012; de Klerk et al. Reference Klerk, Macklon, Heijnen, Eijkemans, Fauser, Passchier and Hunfeld2007; Fertility Network n.d.; Sejbaek et al. Reference Sejbaek, Hageman, Pinborg, Hougaard and Schmidt2013). Male partners are affected too, but incidences of depression and anxiety are notably higher amongst women (Almutawa et al. Reference Almutawa, AlGhareeb, Daraj, Karaidi and Jahramin.d.; Peterson et al. Reference Peterson, Newton, Rosen and Skaggs2006). Even before an IVF treatment fails to result in a birth, an expanding body of literature shows that women experience heightened levels of psychological distress, most commonly manifesting in anxiety and depression, while undergoing the treatment (Wu et al. Reference Wu, Sun, Wang, Sun, Zhang, Huang, Lu and Cao2023; Van den Broeck et al. Reference den Broeck, Uschi, Enzlin and Demyttenaere2010; Gdańska et al. Reference Gdańska, Ewa Drozdowicz-Jastrzębska, Radziwon-Zaleska, Węgrzyn and Wielgoś2017; Bai et al. Reference Bai, Cui, Xu, Mi, Sun, Shao and Li2019). Such anxiety is plausibly tied to the pressure felt by women to ensure the procedure’s success, and the sense of responsibility regarding appropriate diet, exercise, and behavior. All of this should lead us to question whether infertility treatments are indeed responsive to infertility-related suffering. If the very process of undergoing such treatments is associated with anxiety and depression, and most treatments turn out to fail, which is in turn likely to lead to further suffering, where is the purported suffering alleviation to be found? Looking at statistical probability alone, it seems plausible to maintain that individual welfare is not improved through the use of such treatments, on average and in most cases.

Of course, in individual successful cases, the benefits are likely to be seen as countering any psychological harms associated with the procedure. However, it remains to be shown that these individualized benefits can outweigh the failures of other cases. In section 5, I will argue that individual successes may not offset the wider harms associated with these procedures and that a focus on individual successful cases feeds into a technological solutionism that itself has negative societal effects.

4.2. Does IVF promote well-being?

Let us now consider in closer detail whether, based on these findings, IVF is likely to promote well-being.Footnote ⁶ To recall, on the hedonistic, or preference-hedonistic account of well-being, one’s life goes well to the extent that we experience pleasure and the absence of pain, and that such states are preferred or not preferred. It is likely that, before undergoing IVF, patients experience suffering as a result of a frustrated desire to conceive. As aforementioned, IVF treatments themselves are accompanied by suffering, in the form of anxiety and depression, so painful mental states are likely to increase during the treatment. Most IVF treatments will turn out to “fail” in the sense of not resulting in a live birth. This, as aforementioned, leads to further depression and suffering, particularly amongst women undergoing the procedure. This state is clearly not desired and so is experienced as pain. On the preference-hedonistic account of well-being, therefore, IVF is unlikely to increase pleasurable mental states and is far more likely to constitute a reduction in well-being given the dominance of painful mental states. It would seem that the painful mental state of childlessness following a failed procedure outweighs the positive feeling or sense of “trying,” if most IVF failures result in further measurable depression, as the data suggest.

According to desire-fulfillment theories, what matters for well-being is the degree to which our desires are satisfied. Let us suppose that the desire underpinning IVF is the desire to have a child. To recall, the most recent figures show that the average IVF birth rate using fresh embryo transfers was 25 percent. This means 75 percent of patients undergoing IVF did not have a successful live birth and end up with the child they desired. This is the vast majority of patients with desires going unfulfilled. Desire-frustration significantly outweighs desire-satisfaction, therefore. For most, the states of affairs that are the objects of their desires have not obtained. On a desire-fulfillment theory of well-being, therefore, there are no well-being improvements. Indeed, the results for well-being are even worse on desire-fulfillment theories than on hedonistic accounts. This is because the mere fact that their desires have not obtained is sufficient to mean their well-being is reduced, regardless of how they might themselves feel about it. Even if a portion of the 75% unsuccessful IVF patients do not themselves experience suffering as a result of a failed treatment, their subjective experience is not relevant to well-being on desire-fulfillment accounts. All that matters is whether the relevant state of affairs has obtained, and given there is no successful live birth, the overarching desire to have a child remains frustrated.

It may be objected that the desire underpinning IVF is actually something different. It is directed towards “trying” to have a child via IVF rather than towards the outcome of having a child. Therefore, the appropriate way to measure desire-satisfaction here is to see how many patients had access to IVF if and when they desired it. Results and success rates of IVF are not relevant to desire-satisfaction, only the very incidence of desired IVF is. If we accept this as the correct way to cash out well-being, and therefore as comprising the justification for ARTs, it seems like a strange way to think about the merits of IVF. If we take live births out of the equation and do not consider the possibility of IVF delivering on its promise in our appraisal of it, justifying it only in terms of its sheer availability, this doesn’t leave much room for scientific evaluations, and arguably opens the door toward disappointment and reductions in hedonistic well-being. Intuitively, it seems like outcomes matter when appraising medical procedures.

Further, it may be responded that desires on desire-fulfillment theories do seem to be objective-based. This coheres with how we think about desire more broadly. Normally we desire X, where X is an outcome, rather than only desiring to try to achieve X. After all, “to try” to achieve X is indeterminate—how would one know when one has tried enough? Whether we are successful in achieving X after having tried is one clear way. Returning to Parfit’s conceptualization of a desire-fulfillment theory, he supplies the desire for one’s children’s lives to go well as an example of a desire relevant to well-being. This is quite different from the desire to try to make one’s children’s lives go well. It is hard to see how mere desires to try could be clearly fulfilled, if this formula for constructing desires was generalized. Constructing desire in terms of trying to X may make sense in the case of IVF where there is a very specific route involved in this “trying,” but it makes less sense with other desires relevant to our lives, such as desiring a promotion, a loving partner, or a stable living environment.

One might take a kind of satisfaction in having tried to have a child via IVF, even if unsuccessful. Whether this satisfaction is accurately considered a welfare improvement is unclear. Strictly speaking, on a desire-fulfillment theory, one’s desire remains unfulfilled in such a case, and so well-being is not improved. And, as aforementioned, research suggests that hedonistic welfare seems to be reduced in tangible ways after failed IVF cycles, due to the further measurable incidence of depression. Some research on IVF decision regret indicates that having no live births was associated with increased regret, and among those who had unsuccessful IVF cycles, 40 percent had moderate-to-severe regret (Huang et al. Reference Huang, Jaswa, Ransohoff, John Boscardin, Pasch, Cedars and Huddleston2022). Successful IVF can also be regretted due to its costs, which have a long-term impact, as well as due to associated health risks and impact on the body. Another study found a significantly higher level of regret in those who did not have a live birth (41.74 percent) following IVF compared to those who did (16.78 percent) (Sundaram et al. Reference Sundaram, Morris, Anderson and Noel2020). Various personal news pieces about IVF includes stories of women who regret trying IVF after it failed (BBC News Reference News2013; Today.Com 2024; Connell Reference Connell2013). They cite high costs and the psychological and health toll as reasons to regret the decision to try. It is hard to draw too much from these limited sources and studies, and as the analysis in the next sections suggests, it is also hard to disentangle decision-making and feelings of regret from pronatalist and gendered norms surrounding femininity and childbearing. Regret at putting oneself through such a gruelling procedure may be even more present were it not for the norm towards having children.

An additional problem arises if we conceive of the desire underpinning IVF treatments as the desire to try to have a child. There is debate in the literature as to which desires should be taken as fundamental to well-being. Some desires might plausibly be considered inimical to well-being when fulfilled, such as desires related to harmful addictions. As a result, some desire theorists restrict well-being to the satisfaction of the desires one would have if fully informed or rational. If “many desires are hostage to an agent’s ignorance or irrationality,” then it would seem that their satisfaction “would seem clearly not to make the agent better off” (Bronsteen et al., Reference Bronsteen, Leiter, Masur and Tobia2022). John Bronsteen and colleagues call this the idealisation condition: for a desire to be constitutive of well-being, it must be the desire an agent would have when fully informed about “all relevant empirical facts.” Similarly, Richard Arneson suggests such desires must “survive reflective critical scrutiny” (Arneson Reference Arneson1999) and must not arise from cognitive error or ignorance. A pregnant person’s desire for a steak tartare, for example, may not survive critical scrutiny once they are informed about the toxoplasmosis risk in raw meat, and the harm this poses to the foetus.

On such a reformulation of desire-fulfillment theory, it might be suggested that desires to “try” IVF, with full information about low success rates and risks of further suffering, may not withstand critical scrutiny. One might not have such a desire to try if fully informed about sunk costs and likely failure. Therefore, the desire to “try” having a child via IVF may be excluded from the realm of well-being altogether for not satisfying this idealisation condition.Footnote ⁷ This gives further reason to hold that the desire underpinning IVF treatments is the outcome-based desire to have a child, in which case it remains frustrated in the vast majority of cases. IVF cannot be understood as a welfare improvement on desire-fulfillment accounts either, therefore.

Finally, objective list accounts hold that an agent’s well-being is diminished if the good of having and raising children is highly ranked and has not obtained. Well-being can be promoted by IVF if it realises this good. As the data suggest, objectivist well-being is not promoted in the vast majority of cases where there are no live births, as the relevant good has not obtained. It is worth noting that we might consider other interpretations of the goods on the list. Having and raising children may be seen as speaking to an overarching good of having deep, intimate, relationships, characterised by mentoring and care. It may also pertain to the good of being enmeshed in close and morally significant kinship networks. These other interpretations of the good of having children can be achieved without IVF and, as I will suggest in the next section, may in fact be held back by an approach to reproduction and care that focuses on genetic connectedness and the nuclear family.

4.3. Uterus transplants and the welfarist calculation

I now consider the benefits to an individual in the case of the novel uterus transplant, to establish a rich picture of the kinds of welfarist calculation in operation. There have been significant recent advances in the development of UTx as a procedure to alleviate absolute uterine factor infertility (AUFI). UTx is currently in its experimental phase and both living and deceased donors are used for uterine procurement. The primary aim of UTx is to enable uterus recipients to, following a successful transplant and IVF procedure, experience pregnancy and gestate a fetus to term. The donated uterus is removed after the desired number of successful births in order to suspend the use of immunosuppressants and minimize their long-term side effects (Castellón et al. Reference Castellón, Amador, González, Eduardo, Díaz-García, Kvarnström and Bränström2017). UTx is often viewed as a “treatment” for “infertility” (Brännström et al. Reference Brännström, Belfort and Marc Ayoubi2021). As well as this, it has been suggested that UTx can assist in “gender alignment.” A qualitative study from 2021, interviewing 21 women undergoing uterus transplants, sought to explore women’s experiences of their uterine-related infertility, and the impact of the transplant on their reproductive autonomy (Wall et al. Reference Wall, Johannesson, Sok, Warren, Gordon and Testa2022). It was found that UTx made a positive impact on healing the emotional scars of living without a uterus and “enhanced female identity” through allowing these women to participate in previously unobtainable “common female experiences” such as menstruation, pregnancy, and motherhood.

There exist a number of harms associated with this procedure. Indeed, in order to correctly capture the harm at stake, UTx may more appropriately be viewed as a major transplant surgery, rather than, merely an assisted reproductive technology. Naturally, all established living donor transplant surgery necessitates inflicting some harm upon both the donor of an organ, and the recipient. Donors and recipients undergo a major surgical procedure that invariably requires time to heal, even if additional associated risks of harm do not transpire. This harm, and risk of harm, are typically viewed as justifiable if all parties have provided valid consent to undergoing the procedure. A further condition is taken to be jointly sufficient with the consent condition: the level of harm and risk of harm should not exceed the overall benefit that is to be produced by the surgery.Footnote ⁸ Donation should not, for example, cause significant and long-term morbidity to, or indeed the death of, the donor.

In order to make this calculation in the case of UTx, it bears observing that UTx is an ephemeral transplant, serving short-term aims only. As aforementioned, the uterus is removed once it has served its gestational purpose: this enables the recipient to stop taking immunosuppressants. Immunosuppressants are required to prevent rejection of the graft, but their use is associated with a number of risks, including infection and cancer (Fishman Reference Fishman2007; Kasiske et al. Reference Kasiske, Snyder, Gilbertson and Wang2004). An additional peculiarity of UTx as a transplant is that it is life enhancing, as opposed to life saving, or life prolonging. UTx provides no direct health benefits to the recipient, and indeed damages health to some degree, causing short-term harm through surgery and the required immunosuppression, as well as enabling a high-risk pregnancy that requires close monitoring and additional support (Jones et al. Reference Jones, Ranaei-Zamani, Vali, Williams, Saso, Thum and Al-Memar2021), as well as posing long-term risks of further harm. Such features appear crucial to the ethical assessment of UTx, raising questions surrounding the acceptability of the risk to donors and recipients.

So, even if there are individual benefits associated with the fulfillment of gender-identity and a desire to gestate a genetically related child, these need to be balanced against patient harms.Footnote ⁹ In considering the extent to which UTx might be considered a “medical treatment,” Emily McTernan notes that this would be unusual given that UTx reduces overall functioning:

One study found that six out of 16 (37.5 percent) UTx pregnancies faced major complications during gestation. Preterm births occurred in 10/16 (62.5 percent) UTx deliveries. Pre-eclampsia was the most faced gestational complication, as it was reported in 3/16 (19 percent) of UTx-IVF pregnancies (Daolio et al. Reference Daolio, Palomba, Paganelli, Falbo and Aguzzoli2020). All deliveries were carried out by elective caesarean sections between gestational weeks 31 and 37—a procedure that also carries distinct risks and harms. The individual benefit of such a procedure seems worth questioning, therefore, when the net overall consequence of some treatment is a diminishment of functioning or health.

UTx is clearly riskier than IVF, and any conclusive welfarist assessment should consider these procedures separately. The point here was to show the analogous underpinning logic of welfare improvement. UTx seems to have higher success rates in terms of live births (which involve IVF) (Brännström et al. Reference Brännström, Belfort and Marc Ayoubi2021). However, the total data pool is much smaller given it is still in the clinical trials stage. Further, as aforementioned, UTx is associated with heightened and peculiar risk, to both the individuals undergoing the procedure and to living uterine donors. These additional risks and harms ought to be factored into a welfarist calculation. That is, for UTx to be considered a welfare improvement, the harms of living donor surgery and patient risk need to be given due weight.

Taking stock so far, on the three conceptions of well-being outlined earlier, it would seem that IVF, where it is not successful—that is, in the vast majority of cases—does not serve to promote well-being. Pain rather than pleasure is the outcome, desires are left unsatisfied, and a crucial object on objective list accounts of well-being is not accessed. Unsuccessful IVF attempts in fact lead to a decline in welfare and well-being. UTx trials might have relatively high success rates, but the procedure exhibits additional harms that ought to feature in the welfarist calculation. A secondary aim of this discussion has been to show that, in relation to individual welfare, a welfarist calculation must consider wider risks and harms. Typically, cost-benefit assessments of medical treatments and other established transplants centre on finding this balance of harm and benefit between donors and recipients, as well as by appeals to the value of respect for individual autonomy (Williams Reference Williams2016), which I consider next. It might be suggested that, in the case of fertility treatments, respect for individual autonomy in the face of such risk of harm and uncertain benefit is playing an excessive, and indeed decisive, role in the calculation.