Words by Aria Babu

21st January 2022 Issue 6

While for most women pregnancy is a miraculous experience that gives them a unique bond with their child, having children can be challenging. Some women face serious risks during pregnancy. For others it is not even an option.

The risks of pregnancy vary widely. Generally, even when pregnancy is possible, it is rarely easy. For many women, it can involve illness and pain, starting with morning sickness and months of carrying extra weight that make walking and sitting difficult. Many pregnant women report that they feel fatigued, can’t sleep properly, and get swollen ankles and "baby brain", which makes them forgetful and scattered.

For women who were taking medical treatments before, it’s often unclear whether those treatments will be safe during pregnancy and which doses should be given. This is especially difficult for women with epilepsy, depression, anxiety, high blood pressure, ADHD, or chronic pain. Pregnant women were initially refused Covid-19 vaccines in some countries, despite being at a higher risk of serious illness and miscarriage from Covid itself.

There are major threats to the mother’s and child’s health from any pregnancy, some so dangerous that some women are unable to have children at all. Pregnant women can develop gestational diabetes, or pre-eclampsia, which causes seizures, high blood pressure, vomiting, and swelling. In severe cases, this can result in the death of the mother and her baby.

Then there is the delivery – one of the most painful things a woman will ever experience. Lots of women experience complications that can lead to long-term problems: 90% experience some vaginal tearing and 6% experience a third- or fourth-degree tear, which leaves 3% of mothers with faecal incontinence. Many women find sex painful for months after giving birth and report incontinence or pelvic floor problems. About 700 women a year die of pregnancy or childbirth-related conditions in the United States alone, while 300,000 die worldwide, mostly from preventable conditions and diseases.

Vaginal birth itself increases the risk of blood clots, haemorrhage, and sepsis, particularly if there were complications with the growth of the baby. To avoid these risks, caesareans are also an option. But, of course, they are also risky. Cutting through the muscle tissue of the abdomen is no small matter, taking time and care to heal. It’s difficult to follow all of this through when a mother is caring for a new infant, which is why the stitches can tear or the wound can become infected.

Immediately after giving birth, hormones fluctuate. The birth causes a release of oxytocin and decrease in progesterone, estradiol, and dopamine, meaning that many new mothers go through a phase after birth where they cry easily and experience a low sex drive – known as the "baby blues". One in ten women experience this so acutely that they suffer from postnatal depression and one in a thousand experience postpartum psychosis. After giving birth, a woman’s body will probably never be the same. In all likelihood she’ll have gained weight, her breasts will sag, and the stretch marks on her belly may never go away. Her bladder control will never be what it was and sex may feel worse than it used to.

Of course, there is a reason why most women are willing to persevere through this difficult process – children are wonderful. Having children and building a family is, for many people, the most important and meaningful thing in their life. But many women and couples do not have this choice, or face risks far too great to try. For them, there may be another way.

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Artificial wombs could make it possible to grow a baby from conception to birth outside the mother’s body – so women who cannot give birth could still have children if they want to.

This would be life-changing for many women and couples. According to the Centers for Disease Control and Prevention (CDC), about 6% of married women aged 15–44 in the United States are classified as being infertile; 12% of women have "impaired fecundity" – that is, difficulty getting pregnant or carrying a baby to term. Many more women reach the end of their fertile years without having as many children as they would have wanted. In vitro fertilisation (IVF) works for some, but three cycles still only gives a 45–53% chance of a successful pregnancy. Artificial wombs could allow many more women to have the children they want.

As healthcare, artificial wombs could save prematurely born infants as well. At the moment, babies born at twenty-four weeks have only a 60% chance of survival. Fifteen million babies worldwide are born prematurely each year, and one million of them die. In the United States, a third of infant deaths are related to premature birth. Those that do survive are kept alive by today’s version of an artificial womb: neonatal incubators. But developing a more genuinely womb-like environment would be a lifeline to the millions born too early. They could also be lifesaving to babies at risk from maternal illnesses, such as diabetes, which can complicate pregnancies and lead to miscarriage. And they could protect babies from rubella and diseases where vaccination is impossible.

If they can be established as a safe, affordable technology for women who cannot have children, some women may want to use artificial wombs for other reasons too. The knowledge that women are at their most fertile in their twenties shapes much of their lives. They know that if they are single, or lack the necessary stability in their twenties and thirties, they may not have a chance at motherhood at all. This affects what career and educational opportunities they pursue and who and how they date.

Artificial wombs, combined with egg freezing and the creation of synthetic eggs through a process called "artificial gametogenesis", could give women more options about how they live their lives. While some will object to broader access to this technology, it would be a mistake to let these disagreements prevent access to artificial wombs for women who have no choice at all.

Where we are now

People rarely conceptualise it this way, but healthcare today already allows some women to spend parts of the gestation period not pregnant. The zygotes created by IVF can be kept outside the body for two to three days before they need to be implanted into a womb, and babies born earlier than twenty-four weeks have been able to survive in incubators. Artificial wombs, in effect, would fill in the gap between three days and twenty-four weeks.

The first patent for a complete artificial womb was filed in 1955. The design included a tank filled with amniotic fluid, a synthetic umbilical cord, blood pumps, an artificial kidney, and a water heater. Although this crude first attempt was not sophisticated enough to function properly, the technology has improved greatly since then.

To start with, scientists have been able to grow embryos in the lab for thirteen days – the ethical limit that is recognised for human embryo experimentation. More research has gone into creating synthetic embryo models, which have revealed that embryos can implant on donor womb lining and grow their own amniotic sac.

A major problem with current incubator technology is that it requires babies to breathe for themselves, despite their lungs not being fully developed. Respiratory failure is one of the most common problems for infants born before twenty-eight weeks who are put into an incubator. Now, though, technology has been developed that can get around this. US researchers have built a synthetic amniotic sac and umbilical cord that can keep lamb foetuses alive at eighteen weeks, roughly the equivalent of twenty-two weeks for a human, without them needing to use their own lungs. Early studies indicate that this more womb-like environment is more effective than current incubator technology.

In Israel, some researchers have managed to grow mice in an artificial womb for twelve days, which is the physiological equivalent of twenty weeks in humans. But for these even younger foetuses, even more breathing support is necessary and they require a pressurised oxygen mixture to be pumped into them.

So we are still some way off artificial wombs that could bring a human foetus to term, and the plausible first stage may be womb-like incubators for premature babies. Despite this, artificial wombs are a polarising idea, even if they are only limited to women who would otherwise be unable to have children.

Lots of people have an instinctive aversion to tampering with motherhood and birth. Many people, especially mothers, are worried about the health risks and ethics of such technologies. Some imagine dystopian factories churning out babies with short, painful lifespans, with little concern for the value of life. But the first question should be whether artificial wombs present any risks over and above technologies that most of us are already comfortable with, particularly for those who lack other paths to parenthood.

People have always been resistant to new reproductive technology. Almost every culture in the world has a history of treating motherhood and fertility as sacred. This is understandable, but has also created barriers to the adoption of reproductive technology.

When the pill was first approved as medical treatment in 1957, lawmakers were hesitant to approve its use as a contraceptive due to fears of promiscuity. It took eight years for married American women in every state to be allowed to use it as a contraceptive, and fifteen years for this right to be extended to unmarried women. Other countries took even longer: the Republic of Ireland did not legalise access to condoms and spermicides without prescription until 1985.

Access to IVF was delayed for similar reasons. The UK’s Medical Research council rejected the initial funding proposal for IVF due to ethical concerns and the applicants had to find the funds elsewhere. Thankfully they managed to, and one of the inventors went on to receive the Nobel Prize in Medicine for his discovery. And although they are still opposed by the Catholic Church and some other religious groups, much of the rest of society now agrees that the pill and IVF have made the world a better place by giving women more power to have or not have children as they choose. In a century’s time, would we look back on artificial wombs any differently than we look back on the pill or IVF?

Beyond potential social resistance, there are other obstacles that hold back the development of this technology. There are widespread taboos that prevent frank discussion about women’s bodies and reproductive health. Scientists, investors, and life science entrepreneurs are all disproportionately male, meaning they are less aware of women’s issues and likely more uncomfortable breaking taboos when they do consider them. Women’s health issues tend to be under-researched and under-funded. There is five times more research into erectile dysfunction than there is into premenstrual syndrome. Less than 2.5% of publicly funded research is dedicated towards reproductive health, despite the fact that one in three women in the UK suffer from some kind of gynaecological or reproductive health issue.

And our knowledge of women’s health has been held back by decisions in the past. In 1977, the United States’s Food and Drug Administration enacted a de facto ban on clinical trials in women of child-bearing age because their fluctuating hormone levels meant that they were considered too complex to be studied – and this decision was only fully reversed in 1992. We’ve lost time to learn about how drugs interact with women’s bodies.

Making it happen

So, what can we do to turn artificial wombs from a concept in science fiction to actual healthcare?

First, we need more resources for research, meaning we need to attract more scientists and investors to the field. "FemTech" is a large and growing market, attracting billions of dollars in investment. Most of this has focussed on cycle and fertility tracking, egg freezing, and IVF. But investment into ambitious, blue-sky projects is patchy. One reason is that there is uncertainty around how quickly people will feel comfortable to use this technology when it comes to market and around the restrictions that governments may enforce in accessing it.

One way to solve this would be for governments to offer help to women in a results-driven, approach-agnostic manner. That is, instead of the current situation where, for example, £10,000 is spent per cycle of IVF by the UK’s National Health Service with a 20–35% success rate, they could commit to spending up to £30,000 for each healthy live birth that was delivered by fertility clinics and pharmaceutical companies. This kind of results-driven funding model would give fertility startups and investors a greater incentive to develop more innovative methods of helping women and couples to have children. Artificial wombs are just one idea from a whole host of possible inventions that could help them conceive.

Second, fertility research suffers from a data gap. More data could make a huge difference to all areas of health research – this is no less true for fertility. Across the world, in different hospitals and research labs, there sits a vast repository of information about people’s reproductive systems. While there are some companies which are gathering data from fertility clinics and monitoring hormone levels it has mostly been left without being standardised or aggregated.

Governments can help by harvesting this data and sharing it with researchers. But the best thing they can do is make it easier for people to share their data between private companies if they want to. Under current data privacy laws it is difficult to gain patient consent to share their data – even if many would be happy to donate it in the name of science. People are keen to donate their blood while they are alive and their organs and bodies once they are dead. They should be given the chance to donate their data, which could save or create even more lives.

Third, we are held back on research by existing laws. For example, embryos cannot be kept in a lab beyond fourteen days due to the "fourteen-day rule", which is an internationally recognised ethical standard. The specific date was chosen arbitrarily but is around the time when cells start to specialise. At this point of embryo development, there is a 70% chance that it would be discarded by the womb. Higher brain structures only start to appear between twelve and sixteen weeks and the foetus has not yet developed the parts of the cortex that experience pain until about twenty-four weeks, which is when abortions are no longer allowed in the UK.

If the rule was pushed to twenty-one or twenty-eight days, scientists would gain much more knowledge about how embryos develop, which could lead us to a better understanding of fertility, helping us keep more babies alive. For clinical trials that involve trying to save the lives of prematurely born infants, we should have a rule that none should be made worse off by these trials, meaning that artificial wombs should only be used on babies that would otherwise have died from being delivered too early, and if they have a reasonable expectation of saving their lives and avoiding suffering compared to other alternatives.

The main problems that the sector faces are a lack of interest from an establishment that is nervous about causing uproar and outdated ethical standards written when we knew less about how embryos developed. We need more compassionate and intelligent people working in biomedical research, life sciences investment, healthcare procurement, and medical ethics – and we need them to change what the current landscape of reproductive technology looks like.

Human beings have the hardest pregnancies in the animal kingdom. Because we walk on two legs, we have unusually narrow hips. Because we have such large brains, we have large heads that are difficult to give birth to. The Book of Genesis was right – the price we pay for the knowledge of good and evil is sorrow when we bring forth children. It is a testament to our capacity for love that most mothers choose to have children despite this, but not all get that choice. In 1978, Louise Joy Brown became the first human being to be created without sex. I hope in my lifetime to see the first human being created without pain.

Aria Babu is a senior researcher at The Entrepreneurs Network. You can follow her on Twitter here.

Illustration by Michael Driver for Works in Progress.