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Elective gender selection of human embryos during IVF
Chapter 4
Elective gender selection of human embryos during IVF: Ethical and public policy considerations Gab Kovacs1, 2 1 O & G Institute, Epworth Healthcare, Richmond, VIC, Australia; 2Monash University, Melbourne, VIC, Australia
The desire to select the gender of one’s offspring has been present for many decades. The topic was thoroughly reviewed in 1987 by Kovacs and Waldron [1], and no preconception method was found to be able to achieve anywhere near 100% success repeatedly and reliably. Techniques considered included diet, timing of intercourse, acid or alkaline douches, coital positions, dietary factors, and sperm separation methods with subsequent artificial insemination or in vitro fertilization (IVF). With the availability of antenatal diagnosis, fetal sex could be detected early in the second trimester, after amniocentesis at 12e14 weeks, or even earlier by chorionic villus biopsy at 8e10 weeks. It was possible to determine the gender of the developing fetus and, if he or she was the undesired gender, to terminate the pregnancy. However, few practitioners would approve of this or provide such a service. Consequently, in 1994, it was declared illegal in India to tell the patient the gender of the fetus during pregnancy, when the Pre-Conception and Pre-Natal Diagnostic Techniques Act banned prenatal sex determination, and was strengthened by an amendment in 2003. Modification of the technique of antenatal diagnosis allowing very early termination if the fetus was of the undesired gender might have been possible if the technique described by Mantzaris and colleagues had been developed commercially [2]. The Monash IVF team published a proof of concept article showing that fetal cells could be recovered from the cervical mucus of pregnant women at 7e10 weeks of pregnancy. These cells were isolated and then tested by genetic fingerprinting for chromosomal complement or for single gene components. Human Embryos and Preimplantation Genetic Technologies. https://doi.org/10.1016/B978-0-12-816468-6.00004-7 Copyright © 2019 Elsevier Inc. All rights reserved.
29
30 Human Embryos and Preimplantation Genetic Technologies
In that pilot study, women undergoing termination of pregnancy were asked to volunteer to have a cervical mucus sample taken just before the surgery. Samples of placenta were also taken after suction evacuation and analyzed for the presence of X and Y chromosomes, so the gender of the products of conception were known. The cervical mucus samples underwent a special preparation and isolation process so that fetal cells could be identified. These cells were then analyzed for X and Y chromosomes. The article reported 100% correlation between the fetal cell and placental samples in 20 samples, and confirmed that the test was able to isolate and identify fetal cells and that genetic fingerprinting worked. Although the technique appeared promising, it was not thought to be robust enough to commercialize. With the development of embryo biopsy within IVF, it became possible to identify the gender of the embryo with certainty. The first cases were gender selection using fluorescent in situ hybridization for X and Y chromosomes to identify female embryos from couples who carried serious X-linked diseases such as muscular dystrophy and hemophilia. The first birth using this technology was at Hammersmith Hospital in London [3]. This technique is now used in many countries to prevent passing on genetic disease to offspring. Gender selection can be used to avoid almost 300 X-linked recessive diseases. The same technique can also be used for social gender selection, in which embryos only of the desired gender are transferred.
SOCIAL GENDER SELECTION Social gender selection can be considered at three levels. First, primary gender selection is the desire and ability to select the gender of the child that the couple would like to conceive, even for the first pregnancy. In countries such as India, China, Indonesia, and Nepal, sons have been favored over daughters, to carry on the family name, for inheritance reasons, and to support their parents in old age. The next level of gender selection is family balancing. This describes couples who already have a child or children of one sex, and who desire to have the next child be of the opposite gender. The third group is composed of couples who already undergoing IVF, maybe even preimplantation genetic diagnosis (PGD), for medical reasons, who may prefer a boy or girl, and wish to add analysis of X and Y chromosomes to the procedure. Although the technology is readily available, it is banned in most countries except for the United States and some European countries that are not members of the European Union. Gender selection is an ethically controversial issue. The Australian Health Ethics Committee (AHEC) of the National Health and Medical Research Council stated in 2007 that “admission to life should not be conditional upon a child being a particular sex. Therefore, pending further community discussion, sex selection (by whatever means) must not be undertaken except to reduce the risk of transmission of a serious genetic condition” [4].
Elective gender selection of human embryos during IVF Chapter | 4
31
ARGUMENTS FOR SOCIAL GENDER SELECTION The technology is readily available, does not carry extreme risk, and should be permitted for patient autonomy and reproductive rights. Deciding which couples may or may not undertake PGD for gender selection and policing individuals with preferences for the sex of a child is beyond the scope of fertility care and may violate patient autonomy and privacy when applied to evaluating individual circumstances.
ARGUMENTS AGAINST SOCIAL GENDER SELECTION The AHEC eloquently describes reasons against social gender selection, but I believe their reasoning is erroneous. Let us consider each of their arguments. Their first is that “Sex selection is incompatible with the parentechild relationship being one that involves unconditional acceptance,” and that the wish for a child should be unconditional. Although no one would disagree with this statement, if a couple strongly desires a child of a particular gender, the child of opposite gender may not be as loved or appreciated. Therefore, using the “best interest of the child” argument, helping a couple achieve the child of preferred gender may actually enhance that child’s quality of life. Argument 2 is that “sex selection may be an expression of sexual prejudice, in particular against girls. As practiced today around the world, it generally reflects and contributes to bias and discrimination against women.” Although this may be true in some countries where boys are preferred, certainly in Australia, the request for family balancing is overwhelmingly for the selection of a female after a number of boys. The third argument against social gender selection is that “sex selection harms men in some cultural groups (by contributing to the shortage of women for men to marry).” Because gender selection by IVF and PGD is expensive and complicated, there would never be enough couples participating to unbalance the gender ratio. It is also probable that in Australia and Europe, requests for either gender would reach a balance. Consequently, I do not believe that any of the arguments for banning social gender selection are logical. The most negative aspect of selecting gender-preferred embryos is that some normal embryos that are of the undesired gender may be discarded. In communities such as Australia and most of Europe, where abortion of a pregnancy in the first trimester is available upon request, discarding un-implanted, 5-dayold embryos does not seem to be a significant crime. A possible solution to discarding embryos of the undesired gender is to make them available for donation, because there is a chronic shortage of embryos for adoption [5]. Another argument against social gender selection by IVF is the possible long-term risk to offspring who are conceived by IVF used for a nonmedical reason. However, no long-term risks of IVF or PGD to the offspring have been identified to date.
32 Human Embryos and Preimplantation Genetic Technologies
A further argument is one that says that we cannot afford to use medical resources that are expensive, when there is no clinical indication. First, this argument could be used against all conditions for which there is no disease to be treated (e.g., cosmetic surgery); second, it implies that couples with gender selection would prevent other patients from being treated. This is not true, because couples with social IVF would be self-funded, and would not be competing for resources with patients with subfertility.
THE COMMUNITIES’ ATTITUDES An American survey of public attitudes found a 68% disapproval rate for the use of social gender selection by IVF [6]. Similarly, a German study found only 8% support for PGS for nonmedical reasons [7]. To determine the Australian community’s attitudes toward social gender selection, we carried out a community survey [8]. This was a cross-sectional telephone survey, by Morgan Gallup Polls, of a random sample of 650 Australians, stratified by geographical area, with quotas controlled by gender and age. This technique is used to assess voting intentions and is well-validated. Both primary gender selection and family balancing were surveyed. The responses were recorded as “yes, allowed,” “no, not allowed” or “undecided.” Whereas 91% of respondents supported the use of IVF to help infertile couples, only 17% supported primary gender selection, and 20%, its use for family balancing. Table 4.1 lists the findings of this survey. In the United States, gender selection is not prohibited by law, but the American Society of Reproductive Medicine (ASRM) does not support or condemn it through the statement of its ethics committee: ASRM Ethics Committee recognizes that there are reasoned differences of opinion about the permissibility of these practices and does not have a consensus on the permissibility of these practices” [9]. Religious attitudes. The attitudes of the major religions were eloquently discussed by Schenker in 2002. (These attitudes have not changed in the years since.)
TABLE 4.1 Attitudes of respondents.
Should gender selection be allowed?
Allowed (%)
Not allowed (%)
Undecided (%)
Couples already having in vitro fertilization
20.7
73.4
5.9
Couples wanting to choose their child’s gender
17.6
76.5
6.0
Couples wanting family balancing
20.2
74.2
5.6
Elective gender selection of human embryos during IVF Chapter | 4
33
In the Jewish religion, the law has evolved from both written religion and oral laws, as per the Talmud and Mishnah, resulting in the Talmudic Halacha. The Jewish attitude toward new technologies is that in the absence of halachic prohibition, the procedure is permitted. In the Jewish religion, there is the requirement for a man to procreate by having a minimum of two children: a boy and a girl. To fulfill this obligation, at least one son is required so that the application of gender selection may be of practical importance. The Roman Catholic religion opposes all methods of artificial reproduction and maintains that fertilization is licit when it is the result of a conjugal act: that is, sexual intercourse between husband and wife. This was confirmed by the Congregation for the Doctrine of the Faith issued by the Vatican in February 1987, signed by Cardinal Joseph Ratzniger and approved by Pope John Paul II [10]. In Islam, Sharia is the basis of religious principles and is not rigid, but is pragmatic. According to a workshop organized by the International Islamic Center for Population Studies and Research at Al-Azhar University in Cairo, Egypt, in November, 2000 [11], Islam supported the practice of IVF. Even PGD for gender selection is accepted, with some reservations, such as for family balancing if the woman has a number of daughters and her next pregnancy should be her last for health reasons. Although Anglicans, Baptists, Methodists, Lutherans, Mormons, Presbyterians, Episcopalians, members of the United Church of Christ, Christian Scientists, and Jehovah’s Witnesses all have liberal attitudes toward infertility treatments, none support gender selection [12].
WHY SHOULD SOCIAL GENDER SELECTION BE ILLEGAL? To make the process illegal is illogical because it does not harm anyone. Acts that are antisocial, such as taking another person’s property or causing a person physical damage by assaulting him or her need to be illegal and punishable, but surely choosing the gender of one’s offspring cannot be placed in the same category as theft or assault.
CONCLUSION The use of assisted reproductive technologies for gender selection for nonmedical purposes remains controversial and is illegal in most countries. Arguments allowing the procedure are patient autonomy and reproductive liberty. Arguments against it include the risks and burdens of the procedure for the woman and possibly for the offspring (although none have yet been identified). Philosophical objections include unconditional love of one’s offspring, not depending on gender; gender bias (presumably against females); and upsetting the gender balance in the community. Furthermore, the ethics of using a complicated medical technique when there is no clinical problem is questioned (although this applies to all cosmetic surgery).
34 Human Embryos and Preimplantation Genetic Technologies
The ASRM Ethics Committee also states that “when nonmedical sex selection is offered in clinical practice, clinic employees with objection to the technique must be permitted to absent themselves from its provision.”
REFERENCES [1] Kovacs GT, Waldron KW. Sex preselection - a review. Aust Fam Physician 1987;16:608e13. [2] Mantzaris D, Cram D, Healy C, Howlett D, Kovacs G. Preliminary report: correct diagnosis of sex in fetal cells isolated from cervical mucus during early pregnancy. Aust NZ J Obstet Gynaecol 2005;45:529e32. [3] Handyside AH, Kontogianni EH, Hardy K, Winston RM. Pregnancies from biopsied human preimplantation embryos sexed by Y-specific DNA amplification. Nature 1990;344:768e70. [4] NHMRC. Ethical guidelines on the use of assisted reproductive technology in clinical practice and research 2004 (as revised in 2007 to take into account the changes in legislation). June 2007. [5] Kovacs GT, Breheny S, Dear M. An audit of embryo donation at an Australian university invitro fertilization clinic: donation and outcomes. Med J Aust 2003;178:127e9. [6] Genetics and Public Policy Center. Public awareness and attitudes about reproductive genetic technology. Available at: https://jscholarship.library.jhu.edu/handle/1774.2/979; December 9, 2002. [7] Hershberger PE, Pierce PF. Conceptualizing couples’ decision making in PGD: emerging cognitive, emotional, and moral dimensions. Patient Educ Couns 2010;81:53e62. [8] Kovacs G. Should couples be able to choose the gender of their offspring? JOGC 2013;35:1105e7. [9] American Society of Reproductive Medicine. Use of reproductive technology for sex selection for nonmedical reasons: an ethics committee opinion (2015). February 1, 2017. [10] Catholic Church. Congregation for the doctrine of the Faith. Instruction on respect for human life in its origin and on the dignity of human procreation, congregation for the doctrine of the faith. 1987. Vatican City. [11] Serour GI, Dickens BM. Assisted reproduction developments in the Islamic world. Int J Gynaecol Obstet 2001;74:187e93. [12] Schenker JG. Gender selection: cultural and religious perspectives. J Assist Reprod Genet 2002;19:400e10.
Elective gender selection of human embryos during IVF: Ethical and public policy considerations Gab Kovacs1, 2 1 O & G Institute, Epworth Healthcare, Richmond, VIC, Australia; 2Monash University, Melbourne, VIC, Australia
The desire to select the gender of one’s offspring has been present for many decades. The topic was thoroughly reviewed in 1987 by Kovacs and Waldron [1], and no preconception method was found to be able to achieve anywhere near 100% success repeatedly and reliably. Techniques considered included diet, timing of intercourse, acid or alkaline douches, coital positions, dietary factors, and sperm separation methods with subsequent artificial insemination or in vitro fertilization (IVF). With the availability of antenatal diagnosis, fetal sex could be detected early in the second trimester, after amniocentesis at 12e14 weeks, or even earlier by chorionic villus biopsy at 8e10 weeks. It was possible to determine the gender of the developing fetus and, if he or she was the undesired gender, to terminate the pregnancy. However, few practitioners would approve of this or provide such a service. Consequently, in 1994, it was declared illegal in India to tell the patient the gender of the fetus during pregnancy, when the Pre-Conception and Pre-Natal Diagnostic Techniques Act banned prenatal sex determination, and was strengthened by an amendment in 2003. Modification of the technique of antenatal diagnosis allowing very early termination if the fetus was of the undesired gender might have been possible if the technique described by Mantzaris and colleagues had been developed commercially [2]. The Monash IVF team published a proof of concept article showing that fetal cells could be recovered from the cervical mucus of pregnant women at 7e10 weeks of pregnancy. These cells were isolated and then tested by genetic fingerprinting for chromosomal complement or for single gene components. Human Embryos and Preimplantation Genetic Technologies. https://doi.org/10.1016/B978-0-12-816468-6.00004-7 Copyright © 2019 Elsevier Inc. All rights reserved.
29
30 Human Embryos and Preimplantation Genetic Technologies
In that pilot study, women undergoing termination of pregnancy were asked to volunteer to have a cervical mucus sample taken just before the surgery. Samples of placenta were also taken after suction evacuation and analyzed for the presence of X and Y chromosomes, so the gender of the products of conception were known. The cervical mucus samples underwent a special preparation and isolation process so that fetal cells could be identified. These cells were then analyzed for X and Y chromosomes. The article reported 100% correlation between the fetal cell and placental samples in 20 samples, and confirmed that the test was able to isolate and identify fetal cells and that genetic fingerprinting worked. Although the technique appeared promising, it was not thought to be robust enough to commercialize. With the development of embryo biopsy within IVF, it became possible to identify the gender of the embryo with certainty. The first cases were gender selection using fluorescent in situ hybridization for X and Y chromosomes to identify female embryos from couples who carried serious X-linked diseases such as muscular dystrophy and hemophilia. The first birth using this technology was at Hammersmith Hospital in London [3]. This technique is now used in many countries to prevent passing on genetic disease to offspring. Gender selection can be used to avoid almost 300 X-linked recessive diseases. The same technique can also be used for social gender selection, in which embryos only of the desired gender are transferred.
SOCIAL GENDER SELECTION Social gender selection can be considered at three levels. First, primary gender selection is the desire and ability to select the gender of the child that the couple would like to conceive, even for the first pregnancy. In countries such as India, China, Indonesia, and Nepal, sons have been favored over daughters, to carry on the family name, for inheritance reasons, and to support their parents in old age. The next level of gender selection is family balancing. This describes couples who already have a child or children of one sex, and who desire to have the next child be of the opposite gender. The third group is composed of couples who already undergoing IVF, maybe even preimplantation genetic diagnosis (PGD), for medical reasons, who may prefer a boy or girl, and wish to add analysis of X and Y chromosomes to the procedure. Although the technology is readily available, it is banned in most countries except for the United States and some European countries that are not members of the European Union. Gender selection is an ethically controversial issue. The Australian Health Ethics Committee (AHEC) of the National Health and Medical Research Council stated in 2007 that “admission to life should not be conditional upon a child being a particular sex. Therefore, pending further community discussion, sex selection (by whatever means) must not be undertaken except to reduce the risk of transmission of a serious genetic condition” [4].
Elective gender selection of human embryos during IVF Chapter | 4
31
ARGUMENTS FOR SOCIAL GENDER SELECTION The technology is readily available, does not carry extreme risk, and should be permitted for patient autonomy and reproductive rights. Deciding which couples may or may not undertake PGD for gender selection and policing individuals with preferences for the sex of a child is beyond the scope of fertility care and may violate patient autonomy and privacy when applied to evaluating individual circumstances.
ARGUMENTS AGAINST SOCIAL GENDER SELECTION The AHEC eloquently describes reasons against social gender selection, but I believe their reasoning is erroneous. Let us consider each of their arguments. Their first is that “Sex selection is incompatible with the parentechild relationship being one that involves unconditional acceptance,” and that the wish for a child should be unconditional. Although no one would disagree with this statement, if a couple strongly desires a child of a particular gender, the child of opposite gender may not be as loved or appreciated. Therefore, using the “best interest of the child” argument, helping a couple achieve the child of preferred gender may actually enhance that child’s quality of life. Argument 2 is that “sex selection may be an expression of sexual prejudice, in particular against girls. As practiced today around the world, it generally reflects and contributes to bias and discrimination against women.” Although this may be true in some countries where boys are preferred, certainly in Australia, the request for family balancing is overwhelmingly for the selection of a female after a number of boys. The third argument against social gender selection is that “sex selection harms men in some cultural groups (by contributing to the shortage of women for men to marry).” Because gender selection by IVF and PGD is expensive and complicated, there would never be enough couples participating to unbalance the gender ratio. It is also probable that in Australia and Europe, requests for either gender would reach a balance. Consequently, I do not believe that any of the arguments for banning social gender selection are logical. The most negative aspect of selecting gender-preferred embryos is that some normal embryos that are of the undesired gender may be discarded. In communities such as Australia and most of Europe, where abortion of a pregnancy in the first trimester is available upon request, discarding un-implanted, 5-dayold embryos does not seem to be a significant crime. A possible solution to discarding embryos of the undesired gender is to make them available for donation, because there is a chronic shortage of embryos for adoption [5]. Another argument against social gender selection by IVF is the possible long-term risk to offspring who are conceived by IVF used for a nonmedical reason. However, no long-term risks of IVF or PGD to the offspring have been identified to date.
32 Human Embryos and Preimplantation Genetic Technologies
A further argument is one that says that we cannot afford to use medical resources that are expensive, when there is no clinical indication. First, this argument could be used against all conditions for which there is no disease to be treated (e.g., cosmetic surgery); second, it implies that couples with gender selection would prevent other patients from being treated. This is not true, because couples with social IVF would be self-funded, and would not be competing for resources with patients with subfertility.
THE COMMUNITIES’ ATTITUDES An American survey of public attitudes found a 68% disapproval rate for the use of social gender selection by IVF [6]. Similarly, a German study found only 8% support for PGS for nonmedical reasons [7]. To determine the Australian community’s attitudes toward social gender selection, we carried out a community survey [8]. This was a cross-sectional telephone survey, by Morgan Gallup Polls, of a random sample of 650 Australians, stratified by geographical area, with quotas controlled by gender and age. This technique is used to assess voting intentions and is well-validated. Both primary gender selection and family balancing were surveyed. The responses were recorded as “yes, allowed,” “no, not allowed” or “undecided.” Whereas 91% of respondents supported the use of IVF to help infertile couples, only 17% supported primary gender selection, and 20%, its use for family balancing. Table 4.1 lists the findings of this survey. In the United States, gender selection is not prohibited by law, but the American Society of Reproductive Medicine (ASRM) does not support or condemn it through the statement of its ethics committee: ASRM Ethics Committee recognizes that there are reasoned differences of opinion about the permissibility of these practices and does not have a consensus on the permissibility of these practices” [9]. Religious attitudes. The attitudes of the major religions were eloquently discussed by Schenker in 2002. (These attitudes have not changed in the years since.)
TABLE 4.1 Attitudes of respondents.
Should gender selection be allowed?
Allowed (%)
Not allowed (%)
Undecided (%)
Couples already having in vitro fertilization
20.7
73.4
5.9
Couples wanting to choose their child’s gender
17.6
76.5
6.0
Couples wanting family balancing
20.2
74.2
5.6
Elective gender selection of human embryos during IVF Chapter | 4
33
In the Jewish religion, the law has evolved from both written religion and oral laws, as per the Talmud and Mishnah, resulting in the Talmudic Halacha. The Jewish attitude toward new technologies is that in the absence of halachic prohibition, the procedure is permitted. In the Jewish religion, there is the requirement for a man to procreate by having a minimum of two children: a boy and a girl. To fulfill this obligation, at least one son is required so that the application of gender selection may be of practical importance. The Roman Catholic religion opposes all methods of artificial reproduction and maintains that fertilization is licit when it is the result of a conjugal act: that is, sexual intercourse between husband and wife. This was confirmed by the Congregation for the Doctrine of the Faith issued by the Vatican in February 1987, signed by Cardinal Joseph Ratzniger and approved by Pope John Paul II [10]. In Islam, Sharia is the basis of religious principles and is not rigid, but is pragmatic. According to a workshop organized by the International Islamic Center for Population Studies and Research at Al-Azhar University in Cairo, Egypt, in November, 2000 [11], Islam supported the practice of IVF. Even PGD for gender selection is accepted, with some reservations, such as for family balancing if the woman has a number of daughters and her next pregnancy should be her last for health reasons. Although Anglicans, Baptists, Methodists, Lutherans, Mormons, Presbyterians, Episcopalians, members of the United Church of Christ, Christian Scientists, and Jehovah’s Witnesses all have liberal attitudes toward infertility treatments, none support gender selection [12].
WHY SHOULD SOCIAL GENDER SELECTION BE ILLEGAL? To make the process illegal is illogical because it does not harm anyone. Acts that are antisocial, such as taking another person’s property or causing a person physical damage by assaulting him or her need to be illegal and punishable, but surely choosing the gender of one’s offspring cannot be placed in the same category as theft or assault.
CONCLUSION The use of assisted reproductive technologies for gender selection for nonmedical purposes remains controversial and is illegal in most countries. Arguments allowing the procedure are patient autonomy and reproductive liberty. Arguments against it include the risks and burdens of the procedure for the woman and possibly for the offspring (although none have yet been identified). Philosophical objections include unconditional love of one’s offspring, not depending on gender; gender bias (presumably against females); and upsetting the gender balance in the community. Furthermore, the ethics of using a complicated medical technique when there is no clinical problem is questioned (although this applies to all cosmetic surgery).
34 Human Embryos and Preimplantation Genetic Technologies
The ASRM Ethics Committee also states that “when nonmedical sex selection is offered in clinical practice, clinic employees with objection to the technique must be permitted to absent themselves from its provision.”
REFERENCES [1] Kovacs GT, Waldron KW. Sex preselection - a review. Aust Fam Physician 1987;16:608e13. [2] Mantzaris D, Cram D, Healy C, Howlett D, Kovacs G. Preliminary report: correct diagnosis of sex in fetal cells isolated from cervical mucus during early pregnancy. Aust NZ J Obstet Gynaecol 2005;45:529e32. [3] Handyside AH, Kontogianni EH, Hardy K, Winston RM. Pregnancies from biopsied human preimplantation embryos sexed by Y-specific DNA amplification. Nature 1990;344:768e70. [4] NHMRC. Ethical guidelines on the use of assisted reproductive technology in clinical practice and research 2004 (as revised in 2007 to take into account the changes in legislation). June 2007. [5] Kovacs GT, Breheny S, Dear M. An audit of embryo donation at an Australian university invitro fertilization clinic: donation and outcomes. Med J Aust 2003;178:127e9. [6] Genetics and Public Policy Center. Public awareness and attitudes about reproductive genetic technology. Available at: https://jscholarship.library.jhu.edu/handle/1774.2/979; December 9, 2002. [7] Hershberger PE, Pierce PF. Conceptualizing couples’ decision making in PGD: emerging cognitive, emotional, and moral dimensions. Patient Educ Couns 2010;81:53e62. [8] Kovacs G. Should couples be able to choose the gender of their offspring? JOGC 2013;35:1105e7. [9] American Society of Reproductive Medicine. Use of reproductive technology for sex selection for nonmedical reasons: an ethics committee opinion (2015). February 1, 2017. [10] Catholic Church. Congregation for the doctrine of the Faith. Instruction on respect for human life in its origin and on the dignity of human procreation, congregation for the doctrine of the faith. 1987. Vatican City. [11] Serour GI, Dickens BM. Assisted reproduction developments in the Islamic world. Int J Gynaecol Obstet 2001;74:187e93. [12] Schenker JG. Gender selection: cultural and religious perspectives. J Assist Reprod Genet 2002;19:400e10.