Kristen and John Magill adore all three of their daughters -- 11-year-old twins and a 5-year-old baby sister. But when they began to plan for their next -- and last -- child, the Magills really wanted a boy.
"My husband is a 'Junior' and has a family business that he wants to continue in the family name," said Kristen, 37, of Grafton, Mass.
So the Magills combined a family trip to Disneyland in August with a stop at a Los Angeles fertility clinic that enables couples to pick the sex of their babies. Kristen is now expecting twin boys.
"I'm excited," she said. "We always wanted a boy. We really wanted just one, but we'll be happy with two."
The Magills are part of a small but growing number of Americans who are selecting the sex of their children, using techniques developed to help couples who are infertile or at risk for having babies with genetic diseases.
In addition to the standard in vitro fertilization procedure that Kristen underwent, a Fairfax clinic is testing another approach that can sort sperm by sex -- an easier and far less expensive method, albeit not quite as reliable.
The doctors offering the services, as well as some medical ethicists who defend them, argue the procedures make it possible for parents to fulfill a natural desire, harm no one, and enhance the joys of parenthood and family life.
'Wrong' sex
"These are grown-up people expressing their reproductive choices. We cherish that in the United States," said Jeffrey Steinberg, director of the Fertility Institutes, which offers the service at clinics in Los Angeles and Las Vegas. "These people are really happy when they get what they want. These are heartwarming stories."
But others say the practice, which is prohibited in many countries, uses expensive medical care for frivolous purposes, destroys some embryos just because they are the "wrong" sex, and promotes gender discrimination. Moreover, the critics say, the trend is a dangerous first step toward transforming childbirth from a natural process full of surprise and wonder into just another commodity in which a baby's features are picked like options on a new car.
"It runs the risk of turning procreation and parenting into an extension of the consumer society," said Michael J. Sandel, a political philosopher at Harvard University. "Sex selection is one step down the road to designer children, in which parents would choose not only the sex of their child but also conceivably the height, hair color, eye color, and ultimately, perhaps, IQ, athletic prowess and musical ability. It's troubling."
For generations, people who wanted to choose their child's sex resorted, fruitlessly, to old wives' tales and folklore, such as the belief that eating more salty food or meat raises the odds of having a boy. But techniques developed to help infertile couples and to weed out genetic diseases have changed that -- the same procedures used to make sure an embryo is healthy can be used to determine its sex.
So far, most of the couples doing this either suffer from infertility or want to avoid passing on devastating genetic diseases, primarily ailments such as muscular dystrophy that afflict boys more often than girls. Only those who oppose creating embryos in the laboratory for any reason object to sex selection in such cases.
But a small number of clinics have begun offering the procedures to couples with no medical reasons -- who simply want to do the kind of "family balancing" the Magills sought or to plan the birth order of their children.
'Most basic rights'
"The overwhelming number of couples who come in for this are couples who have three, four, five children in one gender and come to us and say, 'Will you guarantee us the opposite?' " said Norbert Gleicher, medical director of the Center for Human Reproduction, which has clinics in the New York and Chicago areas. "Why shouldn't patients have the right to choose this? It's one of the most basic rights in our society that we can build our families the way we wish."
The IVF procedure, which costs about $10,000 to $20,000, requires women to get hormone shots so doctors can retrieve eggs for fertilization in the laboratory. The lab harmlessly removes a single cell from 3-day-old, eight-cell embryos to test them. Only embryos of the desired sex are implanted into the womb. The process is almost infallible for picking sex and has the same overall success rate for producing a baby as standard IVF.
This approach, called PGD from its original use for "preimplantation genetic diagnosis," has been largely banned for nonmedical use in a number of countries, including Australia, Britain, Canada, France, Germany, India, Japan and Switzerland. In the United States, most fertility doctors say they refuse to do the procedure except for medical problems.
"My job is to help people make healthy babies, not help people design their babies. Gender is not a disease," said Ralph R. Kazer, a Northwestern University fertility doctor. "We would rather spend our time helping people who want to have babies who can't have babies."
With scientists rapidly identifying genes for various human traits, the potential for tailoring children in many other ways is becoming increasingly possible, critics say.
"It is the first step towards the concept of a designer baby," said George Annas, a Boston University bioethicist. "If you don't draw the line at disease, where do you draw the line? If gender is okay, it's hard to say any other characteristic we might be able to select in the future is off-limits."
But the doctors doing the procedures and independent experts say science is not even close to allowing parents to pick other traits -- and in all likelihood never will be.
"The overall concern that we have one foot over the edge of the slippery slope is overstated because of the limited role that individual genes play in complex human traits," said Kathy Hudson, director of the Genetics and Public Policy Center at Johns Hopkins University. "There are real biological limits to how much control you can have over the characteristics of your offspring."
Nevertheless, research that her center will release next month found 60 percent of Americans are uncomfortable with sex selection for nonmedical reasons. "The use of a technology to fulfill parental desires is viewed as vain, capricious and frivolous," Hudson said.
The sperm-sorting approach being tested by the Genetics & IVF Institute of Fairfax sidesteps some of these concerns because it does not require scientists to create embryos in the lab and the process can select no traits other than sex.
Originally developed for livestock breeding, the MicroSort technique can sort male-producing sperm from female-producing sperm because the latter carries slightly more DNA. A woman can then be artificially inseminated with the sperm for the sex she wants.
The clinic is offering the procedure -- for about $2,800 to $4,000 per attempt -- at its Northern Virginia headquarters and a new center in Laguna Hills, Calif., for a study aimed at winning Food and Drug Administration approval. Several thousand couples have used it and more than 400 babies have been born, producing boys with about 75 percent accuracy and girls with 90 percent, said David Karabinus, scientific director of the MicroSort unit.
"For someone that really has a desire for that little girl or that little boy . . . this is a very, very important and useful technology," he said.
'Targets women'
But critics say both techniques allow parents to discriminate on the basis of sex, and they point to countries such as India and China, where a preference for boys has led to abortion of female fetuses and abandonment of baby girls, creating a shortage of women.
"It is clear that sex selection targets women," said Alfonso Gomez-Lobo, a philosophy professor at Georgetown University. "From an ethical point of view, all of this is quite unacceptable."
Because MicroSort is not 100 percent reliable, critics fear it may lead to the selective abortion of fetuses, particularly females.
"If you ask couples coming in what they will do if they get the wrong sex, these couples say very frankly they will terminate the pregnancy," said Mark V. Sauer, director of the division of reproductive endocrinology at Columbia University. "I don't want to be a party to that."
Proponents counter that there is no bias against girls in the United States. In fact, American couples are just as likely, if not more likely, to want a girl.
"We get roughly the same number of parents coming in who will request a boy as will request a girl," said David L. Hill, scientific director of the ART Reproductive Center in Beverly Hills, Calif. "It's not as if everyone is coming in wanting a female."
At MicroSort, 75 percent of parents have been seeking girls, Karabinus said.
Still, concern remains about the possibility of more subtle, emotional consequences. What happens in cases where, after paying thousands of dollars and suffering months of discomfort and inconvenience, parents are bitterly disappointed by a baby of the "wrong" sex?
"Consider the father who wants a boy in the hope of having as a son the athlete he had never been. Suppose the son isn't really interested in sports," Sandel said. "What sorts of expectations will burden a child who was designed with certain purposes in mind?"
These kinds of questions raise fears that the increasing ability to control and commercialize childbearing will fundamentally transform parenting.
"This is . . . a threat to the core value of parenthood that is usually expressed by the commitment to unconditional love," Gomez-Lobo said. "Our children should not be the result of our desires. We should love them as they are, not as we wanted them to be."
For their part, the Magills are looking forward to introducing their daughters to their little brothers.
"It's a good thing this is out there and available," Kristen said. "I don't think it's for everybody -- it takes money and patience and everything. But we felt like it was worth it. I'm sure having boys will be a different experience."