Working in a public fertility clinic for the last year has been an extraordinary experience. We make decisions that have the potential to affect the course of people's lives. Unlike a private fertility clinic, budgets force us to make decisions about who should receive costly fertility treatments and who should not.

Obviously if a couple has a low probability of achieving a pregnancy because of factors that can't be altered (advanced age or extremely poor health) then they will not be offered futile or dangerous therapies. But what about people who have conditions that are related to lifestyle, such as smoking and obesity? What about people who are about to undergo cancer treatments that may affect their future fertility? Should I consider people who aren't in relationships with someone of the opposite sex or those who are single? Should we provide treatment to those who cannot conceive simply because they don't have the time or opportunity to conceive the traditional way because their work schedules clash with their ovulation opportunities? And the most heinous history of all - a woman who has had chosen to terminate a pregnancy in the past or the person who has previously undergone a sterilization procedure and then found themselves in new circumstances with a renewed desire to have more children.

There appears to be an epidemic of the common factors that lead to reduced fertility including tubal disease which is commonly caused by sexually transmitted infections such as chlamydia, obesity and advanced maternal age. It may be argued that these are self-inflicted. Some doctors refuse to perform elective surgery on people who refuse to quit smoking. Should we then contemplate withholding treatment from someone who has never exercised and develops heart disease? Certainly the fractures sustained whilst skiing, hang-gliding or rock-climbing could be described as self-inflicted.

When I was an undergraduate, we were asked to rate 10 illnesses in order of importance. They included conditions such as heart disease, malaria, cancer as well as infertility. Everyone except me rated infertility as the least important. My argument was that whilst being unable to have one's own children may not be life-threatening or have a direct impact on one's earning potential, it certainly has the potential to affect someone's relationships, quality of life and self-esteem. A couple would be highly unlikely to be aware that they may have difficulty conceiving until they make the decision to do so. The realization that they may not be able to do so naturally, can be devastating. I'm sure that a large proportion of those people do not choose to seek traditional fertility treatments for many reasons including a fear of confirmation of infertility, a wariness of doctors and the procedures and treatments required or a belief that there is a divine reason that they shouldn't procreate.

Many people who would be judged as unfit to be parents, have no difficulties at all in conceiving. Most people in society would agree that someone who abuses their children should be punished but fewer people would consider it appropriate for a government agency to demand that they be sterilized to prevent harm to future children. I have had very few clinical interactions where I have felt that the couple thought that the government owed them the right to reproduce but what they do seek is the right to equity and for their case to be heard. As long as the couple is realistic and aware of the potential harms associated with the investigations and treatments, the most important factor is our ability to judge the welfare of the child. But who dares to be able to judge who will make a good parent?

Learn more about this author, Maria Gare.
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