7 September 2020

Researchers working on building an 'artificial womb' in the United States, Australia and Japan continue to publish regular updates about their success testing prototype 'artificial womb' devices on animal subjects.

The prototypes, EXTEND therapy (also known as the 'biobag') and the EVE-platform, are designed with the intention of artificially replicating the function of the placenta to enable a human entity to remain subject to the process of gestation ex utero. The devices function as a sealed system, with a pumpless oxygenator circuit and cannulae acting as an 'umbilical cord'. The purpose behind their development is that, in those instances in which human entities are delivered from a pregnancy prematurely, they can be supported with continued gestation (allowing crucial organ development to continue) rather than in neonatal intensive care where there is still a high risk of mortality and serious morbidity. The process of facilitating gestation ex utero in these devices is known as ectogestation.

When first announcing successful animal testing of their device in 2017, the EXTEND team postulated that their device might be soon ready for human testing, potentially within five-ten years. While an ambitious trajectory, their experiments continue to yield positive results demonstrating that artificial placental support facilitates continued fetal development.

The technology is specifically sought after as an alternative to conventional neonatal intensive care, but there is also speculation that ectogestation might one day be able to 'grow babies from scratch' and present a reproductive choice for those who are unable or unwilling to gestate. Ectogestation could become a further technological alternative to pregnancy and existing forms of assisted gestation: surrogacy and uterus transplantation.

However, the devices are designed to improve preterm outcomes, their current design and function is dependent upon the subject having fetal physiology. Therefore, even if these devices are shown to work with human preterms, significant work would still need to be done to adapt the devices to be capable of replicating the entirety of a human gestation. Moreover, at present, the Human Fertilisation and Embryology Act 1990 (as amended) precludes the development of such technology because it is unlawful to 'keep or use' an embryo in vitro after 14 days.

Despite complete ectogestation being unlikely to materialise anytime soon, it remains a highly anticipated development because of the unique opportunities it presents for people unable to reproduce and specifically to gestate without technological assistance, for biological or social reasons. Ectogestation could grant these people, including single people, infertile or LGBTQ+ people and couples more control over their process of family formation. For many prospective parents ectogestation might be a more appealing option than existing alternatives.

Surrogacy can involve some legal complications in the attribution of legal parenthood at birth (the intended parents have to apply for a parental order or to adopt the child from the surrogate) and it involves navigating a relationship with a third-party during pregnancy. For some prospective parents, a process that does not involve them incurring legal complications and expenses andallows them to have more control over the process of gestation because it does not involve another person's body might be preferable. There might also be other advantages to the gestation being technologically assisted by an 'artificial womb' as its design features might allow them to better experience some of the relational aspects of gestation eg, the use of their voice.

Ectogestation might also be preferable to uterus transplantation given the potential practical and ethical difficulties in sourcing a donor or the risks in undergoing invasive surgery.

Comparing ectogestation (were it available) to other forms of assisted gestation is not to devalue surrogacy or uterus transplantation, or imply that either of these forms of assisted gestation are ethically dubious, but it does highlight that there are some ways in which some putative parents might prefer this technological alternative. There, of course, may be many ways in which surrogacy or uterus transplantation is thought to be preferable for example, by those who value the concept of a 'natural' human gestation.

When considering the possibilities offered by new reproductive technologies it is important that they are contextualised. This means thinking about the realities of how reproduction and reproductive technologies are and have been regulated, and the impact that these technologies can have on the narratives surrounding reproduction and individual choices. With the development of ectogestation there might be a considerable impact on how pregnancy is conceptualised and on equality in accessing assistance with reproduction.

There are likely to be both financial and legal barriers limiting the widespread accessibility of 'artificial womb' devices. As science and technology have evolved to increase the possibilities for different kinds of family formation, the law has been much slower to respond, and has often continued to limit the availability of the technology to minority groups who want or need access to them the most. For example, in some European countries homosexual individuals are still prohibited from accessing assisted reproduction to start a family, and those who seek surrogacy abroad face hostility at home. And in the UK, until 2008, the law still enforced heteronormative values about the nuclear family in the regulation of IVF with legislation citing 'the need for a father'.

There ought to also be real concerns about how this technology would be made available and to whom since it is likely to be expensive. There is, therefore, the real possibility that it further perpetuates existing inequality in reproduction between those who can afford technological assistance and those who cannot.

The availability of ectogestation and its ability to further increase the visibility of the fetus might also have a significant impact on how pregnancies and pregnant people are treated. There might be an increased perception that with an 'alternative' form of gestation available, pregnant people (whether acting as a surrogate or not) ought to be subject to greater control to 'safeguard' fetuses. There might also be greater scrutiny of parental decisions about how to gestate. If ectogestation is thought to be a superior form of gestation, because it can be better controlled to facilitate 'ideal conditions', this could result in the subordination of pregnant people and those who value the relational aspects of gestation. If human gestation remains the gold standard, this could continue to perpetuate the view of those who cannot or do not gestate, and thus need technological assistance, as'different' or 'deficient', potentially with excessive legal regulation.

The purpose of highlighting these implications of the 'artificial womb' is not to deny the wealth of opportunities it could offer to those people unable or unwilling to gestate. It is to highlight that there are potential negative consequences of this technology that must be equally anticipated so that appropriate responses and regulation can be considered to mitigate these effects.

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Artificial womb technology: the implications of ectogestation as a reproductive choice - BioNews