What is the appropriate response to a couple's request for preimplantation genetic selection for gender preference, specifically a male baby, in a woman with polycystic ovary syndrome (PCOS) who has had 6 failed inductions of ovulation?

Appropriate Response to Gender Selection Request

You should refuse to perform preimplantation genetic testing for nonmedical sex selection, as this practice is explicitly deemed unethical by international guidelines and professional societies.

Ethical Framework for This Decision

The request for sex selection without medical indication falls squarely into the category of selecting for "nonmedical traits," which multiple international normative documents explicitly argue against 1.

Why This Request Should Be Refused

Several documents explicitly argue against using PGT for nonmedical traits, stating that sex selection can only be used for preventing serious sex-linked diseases or avoiding transgenerational health risks 1. The reasons provided include:

• Sex selection encourages gender discrimination and preference for male offspring 1
• It is linked to eugenics concerns and affects the welfare, expectations, and integrity of offspring 1
• Selecting for nonmedical traits could affect the open future of the child and lead to stigmatization 1
• It impacts our societal perception of gender equality 1

The Medical Context Does Not Change the Ethics

The fact that this patient has PCOS with 6 failed ovulation inductions makes her a candidate for IVF and potentially PGT for medical reasons (such as aneuploidy screening), but this does not justify using the technology for gender selection 1. The medical indication for assisted reproduction does not extend to nonmedical trait selection.

Nuances in International Guidelines

While the overwhelming consensus opposes nonmedical sex selection, there are limited exceptions worth noting:

• Some documents from ASRM, ESHRE, and the European Society of Human Genetics show disagreement on ethical acceptability of nonmedical sex selection 1
• A minority position supports sex selection for "family balancing" (when parents already have children of one sex) 1
• The Nigeria Association for Fertility and Reproductive Health supports it on an individual basis with ethics committee assessment 1

However, this couple is requesting a male baby as their first child, which does not meet even the limited "family balancing" exception 1.

The Correct Clinical Action

Option C (refuse) or Option D (tell them it's unethical/prohibited) are the appropriate responses, depending on how your institution frames ethical refusals. Both communicate the same essential message: this service will not be provided for this indication.

What You Should Do:

• Clearly explain that PGT for gender selection without medical indication is considered unethical by international professional societies 1
• Offer appropriate fertility treatment for her PCOS and recurrent ovulation induction failures, which may include IVF with or without PGT for aneuploidy screening if medically indicated 1
• Do not refer to another provider for this specific purpose (Option B is inappropriate), as this would facilitate an unethical practice 1
• Document the request and your refusal in the medical record 1

Common Pitfall to Avoid

Do not confuse the couple's reproductive autonomy with unlimited choice in embryo selection 1. While reproductive autonomy is important and frequently cited in PGT guidelines, it does not extend to selection for nonmedical traits, particularly gender 1. The autonomy argument has limits when it conflicts with broader ethical principles regarding gender discrimination and the welfare of future children 1.