Infertility and the “Package Deal” of Marriage, Sex, and Procreation

Editor’s Note: The following article appears in the Spring 2025 issue of Eikon.

Imagine you’re cleaning up after your mother’s fiftieth birthday party when she pulls you aside, her expression uneasy. She takes your hands and says, “I need to tell you something. You have two sisters you’ve never known about.”

Shock and confusion flood your mind. Questions spill out: “Where do they live? What are their names? Can I meet them?” After a long pause, she responds, “They haven’t been born yet.”

This sounds like the opening of a gripping drama — but it reflects the experience of a growing number of people today. Nearly fifty years since the first child was born using in vitro fertilization (IVF), this technology has radically changed our understanding of procreation and parenthood.

On the one hand, it’s resulted in the birth of approximately one million children who are no less formed, fashioned, and made in God’s image than naturally conceived children.

But on the other hand, the fertility industry’s reliance on IVF as a one-size-fits-all solution leaves us with pressing questions about (1) the root causes of infertility, (2) moral problems with how doctors practice IVF, and (3) God’s good design for the “package deal” of marriage, sex, and procreation.

This essay will explore these three areas and consider God’s good design for family flourishing amidst developments in reproductive technology.

Infertility in Medical and Biblical Perspective

In the past year, IVF has moved from being a quiet, personal decision to a major national debate. This shift has brought attention to a deeper crisis: rising infertility rates, outdated reproductive health care, and the longing many couples have for personalized treatment options to heal their infertility.

Discussing this issue first requires a proper understanding of infertility. Infertility is not a disease in itself; rather, it’s a symptom of underlying reproductive health conditions. Put another way, infertility isn’t a singular disease one can “catch,” but rather the overflow of deeper health issues that result in a person’s difficulty in conceiving or gestating a child.

For women, these underlying reproductive health conditions include endometriosis, polycystic ovary syndrome (PCOS), blocked fallopian tubes, uterine fibroids, and hormonal imbalances. For men, such conditions include low sperm count, low sperm motility, erectile dysfunction, and lifestyle factors such as diet, exercise, and environmental toxins.

While it’s tempting to think of infertility as “a woman’s problem,” studies show that couples bear the burden of infertility equally.^[1] Moreover, researchers estimate that a couple’s diagnosis of infertility is typically the result of four or more unaddressed reproductive health conditions.^[2] Today, sixteen percent of U.S. couples live with a diagnosis of infertility, but most “treatment” options fail to address their underlying reproductive health conditions.^[3] Instead, these so-called treatments rely on methods that circumvent the man’s and woman’s body.

To see this circumvention, one need only look at “treatment” for endometriosis, which is one of the leading causes of infertility in women (affecting an estimated ten percent of U.S. women of childbearing-age).^[4] It takes an average of six to eleven years for a woman to receive a diagnosis, and the quality of treatment options vary by doctor.^[5] In many cases, couples are referred to a fertility clinic long before doctors give them diagnosis of or treatment for the underlying condition(s).

It’s true that IVF results in the creation of embryos, but if the underlying conditions and overall health are not addressed, then the ability to create a healthy embryo and support it through pregnancy will remain limited.

In recent years, we’ve grown in our ability to understand infertility. But since sin entered the world in Genesis 3, our bodies simply have not functioned as they ought. This reality is reflected in Genesis 3:16 when God tells Eve that he “will surely multiply your pain in childbearing; in pain you shall bring forth children.” Here, the Hebrew word for pain does not merely refer to the physical pain of labor, but to a deeper fear and futility that will accompany each aspect of procreation — from the pain of infertility and miscarriage to a complete lack of desire to have children.

Infertility is a common motif throughout the Old Testament. Each of the “Big Three” patriarchs — Abraham and Sarah, Isaac and Rebekah, and Jacob and Rachel — dealt with infertility, with others like Hannah similarly crying out for a child.

These examples reflect God’s care for those struggling with infertility, but they also reinforce an important point: our desire for a child, however “right,” does not justify using any means necessary to achieve this end. Indeed, this is why Genesis 1:28 and Psalm 127:3 speak of children as a gift and not a right (e.g., Abram’s use of Hagar to conceive a child).

What Is IVF?

Simply put, IVF (which makes up ninety-nine percent of all assisted reproductive technology procedures) involves the fertilization of a woman’s egg with a man’s sperm in a petri dish.^[6] This sounds simple, but the development of third-party reproduction (including purchasing egg and sperm from a donor bank or hiring a surrogate-mother) adds additional pieces to the puzzle.

These technologies have sparked a childbearing revolution, raising serious moral questions. What happens to the embryos created in a lab? Should embryos be frozen, tested, or discarded? And what responsibility do parents have toward the children they create through IVF?

Instead of relying on advancements in reproductive medicine, many doctors refer parents to IVF as the best, or only, course of action. Here, it’s worth noting that whether an embryo is created in a lab by doctors or conceived naturally in a woman’s body, each is a distinct and living human being complete with his or her own genetic makeup. Thus, IVF deals with actual life, not potential life.

Once doctors create an embryo in IVF, parents have five options before them: they can implant, freeze, destroy, donate to research, or place the embryo up for adoption. All but immediate implantation require parents to indefinitely freeze human life or destroy it outright.

In many cases, parents are encouraged to use preimplantation genetic testing (PGT) to help decide what to do with each embryo. PGT allows doctors to discern an embryo’s sex, potential health concerns, and even intellectual aptitude. In the United States, more than seventy-five percent of fertility clinics^[7] offer PGT for genetic issues, and seventy-three percent offer^[8] testing for sex selection or eye color.

These technologies quickly shift the question from “desire to have a child” to “desire to have a certain kind of child.” While it’s natural for parents to have specific hopes and dreams for their child, embryonic screening takes this to a whole new level, allowing parents to determine not just how they nurture their child but also the child’s actual genetic nature.

And IVF raises significant difficulties for both parents and children.

From a parental perspective, IVF is a costly financial, physical, and emotional experience. A single cycle of IVF may range from $12,000 to $30,000, with an overall failure rate of seventy-six percent.^[9] And the process itself requires women to undergo risky hormone injections, egg retrievals, implantation procedures, and higher rates of pregnancy complications. (For more on these specific concerns, read here^[10] and here.^[11])

And parents’ self-sacrificial love should compel them to consider IVF from the perspective of their child’s well-being and biblical teachings.

From this perspective, it’s worth considering that IVF results in additional health risks for children, including preterm birth,^[12] low birth weight,^[13] cancer,^[14] congenital heart defects,^[15] non-chromosol genetic problems,^[16] and autism.^[17]

As Oliver O’Donovan says, “There is a world of difference between accepting the risk of a disabled child (where that risk is imposed upon us by nature) and ourselves imposing that risk in pursuit of our own purposes.”^[18] It’s one thing to receive one’s child regardless of their health or capabilities, but it’s quite another to intentionally create children through a process that places them in harm’s way.

Further, parents bear a moral duty and responsibility toward their children, including to “leftover” embryos created in IVF. For Christians, who mirror their lives after the radical hospitality of Christ, the tension between feeling like one’s family is complete and the presence of leftover embryos should compel Christians to give their embryos a chance at life.

Parents may either seek an adoptive family for their frozen embryos or implant the embryos themselves to give their children a chance at life. To indefinitely freeze one’s embryos creates a snowball effect (as in the opening story of this essay) that ultimately affects one’s entire family.

And while data from the Centers for Disease Control and Prevention show an overall IVF success rate of twenty-four percent, these numbers rely on IVF cycles and liveborn children, not on total number of embryos created. While studies vary, researchers estimate that only 2.3 percent^[19] to ten percent^[20] of embryos created via IVF are ultimately live born. For embryos involved, then, the success rates are very low.

And the use of surrogates or donors doesn’t do anything to mitigate IVF’s risks. Rather, studies show that these third-party procedures cause children to incur additional emotional and mental difficulties (similar to the difficulties suffered by children who are abandoned by a parent).^[21] For example, studies of donor-conceived children suggest high rates of anxiety, depression, uncertainty on their genetic makeup and heritage (This poses additional problems as questions of unknown siblings and romantic relationships arise).^[22]

The “Package Deal” of Marriage, Sex, and Procreation

But beyond misunderstandings of infertility and of the moral issues embedded in “routine” IVF procedures, these reproductive technologies sever the Bible’s “package deal” of marriage, sex, and procreation. While people have long borne children outside of marriage, IVF renders sex unnecessary for procreation. Hypothetically, with IVF, one could be married to one person, romantically involved with another, and having children with still another via IVF and third-party reproduction.

IVF introduces the possibility of severing the unified and exclusive progression of marriage, sex, and procreation between one man and one woman (Gen 2:24), a principle articulated in Malachi 2:15, when the prophet says, “Did he not make them one [marriage], with a portion of the Spirit in their union [sex]? And what was the one God seeking? Godly offspring [procreation].”

As I argued elsewhere,

From Scripture alone, it seems clear that as additional degrees of separation are placed between each aspect of marriage, sex, and procreation, more opportunities for sin arise. What God has brought together in that “package deal,” let no human separate (Matthew 19:6). Infertility, miscarriage, and stillborn births introduced the experience of separation between these realities, and the pain of this unnatural loss is immense. Reproductive technologies such as hormonal contraception, Plan B, chemical abortion pills, and even IVF can similarly sever the natural relationship between marriage, sex, and procreation.^[23]

This doesn’t mean it’s a sin to use one of these technologies, but it’s important to recognize that they impose degrees of separation that either pause or circumvent the natural relationship between sex and procreation.

Conclusion

Believers should be animated to proclaim God’s good design for marriage, sex, and procreation, and the delight of children to a hurting world. And this heart of love and compassion should be displayed all the more when right desires for children are frustrated due to either nature (infertility) or sinful means (genetic selection).

[1] U.S. Department of Health and Human Services, “How Common Is Male Infertility, and What Are Its Causes?” Eunice Kennedy Shriver National Institute of Child Health and Human Development, last modified, November 18, 2023, www.nichd.nih.gov/health/topics/menshealth/conditioninfo/infertility#:~:text=Overall%2C%20one%2Dthird%20of%20infertility,combine%20with%20a%20woman’s%20egg.

[2]  Joseph B Stanford, et al., “International Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST): enrollment and methods.” Reproductive Sciences, no. 29 (January 2022), doi:10.1093/hropen/hoac033, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9373967/.

[3] World Health Organization,  “1 in 6 people globally are affected by infertility,” last modified April 4, 2023, https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility.

[4] S. Rahman, et al., “Eyes, menstruation and endometriosis.” Facts, Views & Vision in ObGyn 15, no. 2 (June 2023): 107-113, doi:10.52054/FVVO.15.2.074, https://pubmed.ncbi.nlm.nih.gov/37436046/.

[5] Rahman, “Eyes, menstruation and endometriosis.”

[6] U.S. Department of Health and Human Services, “Fact Sheet: In Vitro Fertilization (IVF) Use Across the United States,” last modified March 13, 2024, https://www.hhs.gov/about/news/2024/03/13/fact-sheet-in-vitro-fertilization-ivf-use-across-united-states.html.

[7] William D. Winkelman, et al. “Public perspectives on the use of preimplantation genetic diagnosis.” Journal of Assisted Reproduction and Genetics 32, no. 5 (March 2015): 665–75, doi:10.1007/s10815-015-0456-8, https://pmc.ncbi.nlm.nih.gov/articles/PMC4429433/.

[8] Michelle Bayefsky, “Who Should Regulate Preimplantation Genetic Diagnosis in the United States?” AMA Journal of Ethics 20, no. 12 (Dec. 2018), E1160-1167, https://journalofethics.ama-assn.org/article/who-should-regulate-preimplantation-genetic-diagnosis-united-states/2018-12.

[9] Emma Waters, “Why the IVF Industry Must Be Regulated,” The Heritage Foundation, March 19, 2024, https://www.heritage.org/life/report/why-the-ivf-industry-must-be-regulated.

[10] Craig Turczynski, “In Vitro Fertilization (IVF): A Comprehensive Primer” Charlotte Lozier Institute, last modified December 17, 2024, https://lozierinstitute.org/in-vitro-fertilization-ivf-a-comprehensive-primer/.

[11] Emma Waters, “Taming IVF’s Wild West,” The New Atlantis, no. 73 (Spring 2024), https://www.thenewatlantis.com/publications/taming-ivfs-wild-west.

[12] S. Sunderam, et al., “Assisted Reproductive Technology Surveillance — United States, 2018” MMWR Surveillance Summary 71,  no. 4 (February 2022): 1–19, http://dx.doi.org/10.15585/mmwr.ss7104a1.

[13] Sunderam, et al., “Assisted Reproductive Technology Surveillance — United States, 2018.”

[14] Marie Hargreave, “Fertility Treatment and Childhood Cancer Risk.” JAMA Network Open 5. no. 8 (August 2022), doi:10.1001/jamanetworkopen.2022.30162, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795805#google_vignette.

[15] European Society of Cardiology, “Babies born after fertility treatment have higher risk of heart defects,” last modified September 27, 2024, https://www.escardio.org/The-ESC/Press-Office/Press-releases/babies-born-after-fertility-treatment-have-higher-risk-of-heart-defects#:~:text=27%20Sep%202024,babies%20born%20following%20assisted%20reproduction.

[16] Sheree L. Boulet, et al., “Assisted Reproductive Technology and Birth Defects Among Liveborn Infants in Florida, Massachusetts, and Michigan, 2000-2010” JAMA Pediatrics 160, no. 6 (July 2016), doi:10.1001/jamapediatrics.2015.4934, https://jamanetwork.com/journals/jamapediatrics/fullarticle/2506140.

[17] Christine Fountain, et al., “Association between assisted reproductive technology conception and autism in California, 1997–2007.” American Journal of Public Health 105, no. 5, (April 2015): 963–971. doi:10.2105/AJPH.2014.302383.

[18] Oliver O’Donovan, Begotten or Made?, A New Edition for the 21st Century (Landrum, SC: Davenant Press, 2022), 100.

[19] Waters, “Why the IVF Industry Must Be Regulated.”

[20] Nicolás Garrido, et al., “Cumulative Live-Birth Rates per Total Number of Embryos Needed to Reach Newborn in Consecutive In Vitro Fertilization (IVF) Cycles: A New Approach to Measuring the Likelihood of IVF Success,” Fertility and Sterility 96, no. 1 (May 2011): 40–46, https://doi.org/10.1016/j.fertnstert.2011.05.008.

[21]  We are Donor Conceived, “My Daddy’s Name Is Donor,” accessed March 15, 2025,  https://www.wearedonorconceived.com/uncategorized/my-daddys-name-is-donor/.

[22] Rennie Burke, et al., “How Do Individuals Who Were Conceived Through the Use of Donor Technologies Feel About the Nature of Their Conception?” Harvard Medical School Center for Bioethics, (April 2021), https://bioethics.hms.harvard.edu/journal/donor-technology.

[23] Emma Waters, “Opinion: IVF and the Package Deal of Marriage, Sex, and Procreation,” Republic Sentinel, March 11, 2024, https://republicsentinel.com/articles/opinion-ivf-and-the-package-deal-of-marriage-sex-and-procreation.