The Conclusions put forward a first catalogue of procreative rights based on the claims successfully asserted in international case law to date. Obstacles to the development of procreative rights are also considered, from jurisdictional issues (such as the recognition of the subsidiary nature of international human rights law and States’ margin of appreciation in sensitive areas) to certain underlying assumptions in the judicial analysis (e.g. the importance of marriage as a foundation for intentional non-genetic parenthood). Finally, this closing chapter examines incipient and potential rights, that is, claims which have not yet been raised in international litigation (some currently pending in Strasbourg) or which were left to the discretion of national legislatures. Although many procreative rights are still aspirational in nature, it is suggested that the continuously evolving interpretation of the ECHR, aligning its requirements with medical advances and social perceptions, will eventually expand the scope of procreative autonomy in international law.

The Introduction provides an overview of the conceptual background and main themes of the book. It briefly considers the advances in assisted reproduction technology (e.g. in vitro fertilisation and pre-implantation genetic diagnosis) and their benefits for aspiring parents. It suggests that these scientific developments not only have led to the emergence of new trends in bioethical politics, but have also inspired claims in the international human rights arena. In fact, an increasing number of legal cases, most notably in the European Convention on Human Rights system, has started to establish a set of rights in connection with access to medically assisted procreation; they are an extension of autonomy rights, the right to respect for family life and non-discrimination rights. The Introduction offers a synopsis of each chapter, outlining the key bioethical and legal controversies examined therein, as well as the central arguments proposed by the book in light of international litigation.

Chapter 1 argues that parenthood aspirations, including those reliant on novel reproductive techniques, have started to evolve into justiciable rights. It challenges the view that human rights law cannot adequately address bioethical issues and examines commonalities and mutual influences between human rights and bioethical discourse. The chapter first analyses international case law establishing (predominantly negative) obligations in relation to natural procreative capacity. As regards medically assisted procreation, it observes that, perhaps counter-intuitively, most of the claims raised in Strasbourg litigation have been assessed by the European Court of Human Rights as involving active interferences as opposed to lacunae. The chapter provides a catalogue of (alleged) negative and positive obligations as they emerge from the case law; it examines the rationale for the Court’s treatment of a claim through the lens of negative or positive obligations while suggesting that that classification does not have a significant practical impact on the outcome of the case.

A long-term trend of delayed childbearing in the highly developed countries has resulted in a rising number of women having children at advanced reproductive ages. We draw on vital statistics, register and survey data for European countries to outline the main trends in late reproduction, focusing on fertility plans and actual fertility rates among women past age 40. We pay special attention to education differences in late fertility. We document a rapid increase in late childbearing across Europe, fuelled especially by rising first and second birth rates. The share of women planning their first or second child in their late 30s or early 40s has increased rapidly as well, signalling that many women aim to become mothers at an age when they are likely to face infertility or pregnancy complications. We discuss the role medically assisted reproduction plays in this trend. In conclusion, we argue that trends in late childbearing will become one of the critical factors determining the future of fertility and reproduction.

Assisted reproduction technology (ART) encompasses fertility treatments which require manipulation of oocyte, sperm or both in vitro. This chapter aims to provide an overview of ART, including indications for treatment as well as the procedures involved. This will also include complications of ART as well as the evidence assessing the perinatal outcomes of children resulting from ART.

Unexplained infertility refers to the inability to conceive within 12 months of unprotected intercourse, not attributable to any known causes of infertility such as ovulatory dysfunction, reduced sperm quality, tubal pathology or other causes. Treatment for unexplained infertility can be done predominantly through intrauterine insemination with or without hyperstimulation or in vitro fertilisation. Given that these treatments are utilised to improve likelihood of conception in relation to the couple’s chances of spontaneous pregnancy, rather than targeting any specific pathology, a comparison should be drawn between these treatments and their natural conception prognosis. Utilisation of prognostic models can allow differentiation between those likely to benefit from immediate treatment from such individuals who have reasonable natural conception prognosis and thereby can delay treatment for 6 months in hopes of spontaneous pregnancy. This comparison is valuable given the aforementioned treatments have implications for both the woman and her future child, and the cost of such procedures also compromises care accessibility.

Successful assisted reproduction treatment is critically dependent on consistent laboratory performance. Each laboratory process, from collection of oocytes and preparation of sperm for use in fertilisation in vitro, through embryo culture, assessment, selection for transfer, biopsy for genetic testing, to the storage (cryopreservation) of gametes and embryos for use in later treatment, carries an inherent risk of damage, whether mechanical or through exposure to suboptimal conditions outside the body, with consequences for the chance of successful clinical outcome. Training, competency in specific, unique technical skills and consistent performance of all laboratory practitioners are vital in the ART laboratory. Procedures must be carried out meticulously, adhering to standard operating procedures, with precise attention to detail. Strict adherence to guidelines issued by regulatory and professional bodies is necessary and essential in order to minimise risk and maximise performance. The implementation of a Quality Management System ensures consistent, optimised performance, and facilitates risk assessment and root cause analyses.

In this chapter, the evidence and use of in vitro fertilisation (IVF) add-ons in the UK is explored. In addition, the stance of professional and regulatory bodies is described. The term ‘add-on’ has been coined to describe the additional ‘extras’ to a routine or intracytoplasmic sperm injection cycle that are commonly offered to those undergoing treatment with the aim of improving livebirth rates. A summary of the highest quality available evidence for the following add-ons is presented: endometrial scratching; time-lapse imaging; assisted hatching; preimplantation genetic testing (PGT-A); endometrial receptivity array; GM-CSF containing culture media; Embryo Glue (hyaluronic acid); artificial egg activation with calcium ionophore; intracytoplasmic morphologically selected sperm injection (IMSI); physiological intracytoplasmic sperm injection (PICSI); sperm DNA test; and reproductive immunology procedures. There remains a paucity of evidence to support the routine use of add-ons based on the available randomised controlled trial and systematic review evidence. This is particularly important given that most patients pay additional fees to utilise add-ons. In order for patients to receive high- quality care in IVF clinics, clinicians must be prepared to discuss the relevant evidence regarding efficacy and safety of the specific add-on being considered.