# What are the ethical considerations when supporting single women undergoing medically assisted reproduction (MAR) ?

A. Le Bris, N. Decaux Ferré, Célia Ravel

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A. Le Bris, N. Decaux Ferré, Célia Ravel. What are the ethical considerations when supporting single women undergoing medically assisted reproduction (MAR) ?. Ethics, Medicine and Public Health, 2026, 34, pp.101229. 10.1016/j.jemep.2025.101229. halshs-05414923

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Original Article

# What are the ethical considerations when supporting single women undergoing medically assisted reproduction (MAR)?

A. Le Bris<sup>a</sup>, N. Decaux Ferré<sup>b</sup>, C. Ravel<sup>c,d,*</sup>

ARTICLE INFO

Keywords:

CECOS

Medically Assisted Reproduction (MAR)

Single women

Support

ABSTRACT

**Background:** Since the revision of French bioethics laws in 2021, requests for medically assisted reproduction (MAR) from single women have increased significantly. Specific challenges are faced by CECOS (*Centre d'Étude et de Conservation des Ovocytes et du Sperme humain*).

**Purpose:** This article questions the ethical aspects of current support for single women undergoing MAR and motherhood.

**Methods:** Here, we analyze single motherhood through the lens of the founding principles of medical ethics: respect for beneficence, non-maleficence, autonomy and justice.

**Findings:** The decision of a 'single' woman to start a family through MAR, without a partner (which does not mean that she is isolated or lonely) as being on the margins of dominant social family norms. Concerns may be expressed about the absence of a second parent and may sometimes mask value judgements on the part of relatives and healthcare professionals.

**Conclusions:** It is important to support all types of motherhood by consolidating services dedicated to maternal and child health.

Introduction

Currently, about 3% of children born in France are the result of medically assisted reproduction (MAR). Until 2021, it was restricted for heterosexual couples suffering from infertility or at risk of transmitting a serious disease. The Bioethics Law of 2 August 2021 extended access to all women (single or in same-sex couples) [1]. This opening was aimed in particular at reducing cross-border reproductive care, in line with a logic of equal rights. Since then, requests for MAR from single women have dramatically increased, with 10,600 women awaiting MAR with sperm donation as of 31 December 2024, 45% of whom were single women [2]. However, behind this legislative advance lie pitfalls. The experiences of women who choose to become single mothers raise questions for institutions, healthcare professionals and society as a whole. Although such support is recognized as essential, it often remains insufficient, fragmented or ill-suited to their specific needs. Several levels of care can be identified: at the individual level, support for single mothers is based on listening and offering appropriate solutions by

healthcare professionals trained in these issues. The “Haute Autorité de Santé” (HAS) also emphasizes the importance of personalized follow-up during the ‘first 1,000 days’ of a child’s life, a crucial period for the development but also for the mother [3]. This follow-up involves co-ordination between healthcare professionals and social workers to identify vulnerabilities and offer targeted support. Since September 2022, a total of 580 unmarried women have sought assisted reproductive technology (ART) at the Centre d'Étude et de Conservation des Œufs et du Sperme humains (CECOS) of Rennes University Hospital. In response to this emerging phenomenon, we initiated the interdisciplinary research project FEMINA (*Femmes sEules et Maternités médicalemeNt Assistées: normes, enjeux et représentations* / Single Women and Medically Assisted Motherhood: Norms, Challenges, and Representations), which has been accredited by the Maison des Sciences de l'Homme en Bretagne for the period 2024–2027. Our analysis draws on a combination of field observations conducted at the CECOS in Rennes and the *Institut de la Parentalité*. This article analyses single motherhood through the lens of the founding principles of medical ethics according to Beauchamp and

<footnote><sup>a</sup> Univ Rennes 2, UFR Sciences Humaines et Sociales – ESO UMR 6590/MSHB UAR CNRS 3549, Rennes, France</footnote>

<footnote><sup>b</sup> Institut de la Parentalité, Rennes, France</footnote>

<footnote><sup>c</sup> Univ Rennes, Inserm, EHESP, Irset - UMR_S 1085/MSHB UAR CNRS 3549, Rennes, France</footnote>

<footnote><sup>d</sup> CHU de Rennes, Laboratoire de Biologie de la Reproduction-CECOS, Rennes, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: celia.ravel@chu-rennes.fr (C. Ravel).</footnote>
Childress [4]. These four principles formalize the values that give moral legitimacy to a medical decision: respect for beneficence, non-maleficence, autonomy and justice [5]. This manuscript adopts an ethical framework as its aim is to conduct a normative ethical analysis rather than present empirical results.

## MAR and single mothers by choice: beneficence

Gamete donation is strictly regulated in France by the *Agence de la Biomédecine*, a national agency under the supervision of the Ministry of Health, responsible for processing data relating to gamete donations and embryo reception concerning donors and recipients. Sperm banks are connected in a network constituting the “Federation of CECOS”. Three fundamental principles were defined relating to sperm donation: volunteering, gratuity, and anonymity [6]. The Commission for Access to Third-Party Donor Data for Persons Born through Assisted Reproductive Technology (CAPADD) responds to requests from children conceived through gamete donation in France. It reports to the Minister of Health and is chaired by a magistrate from the judicial system. Since 31 March 2025, gamete donors must agree to be contacted once the child reaches the age of majority. In France, they can give birth to a maximum of 10 children. Indeed, the advent of genetic testing has brought to light many family secrets, some of which are painful. In any case, with the development of genetic testing in society and the 2021 law, it was inevitable that access to origins would be established [7]. The decree of 5 October 2023 allows for the treatment of ‘single, unmarried women’. A guide to best practices has been drawn up and requires a medical assessment prior to MAR, including clinical and biological tests to detect infertility; to assess the most appropriate technique, to assess the risks to the physical and mental health of the mothers and in the interests of the unborn child; to assess the chances of success and the risks of failure and the risk-benefit balance of MAR treatment [8]. Health safety is rigorously ensured, as donors undergo a medical examination. Specific information is then provided, along with the consent form for MAR, an interview with a psychologist or psychiatrist which is systematically offered before MAR with gamete donation and is mandatory before embryo transfer, and, where applicable, a social services assistant. The decision to proceed with MAR and the choice of technique to be used (ovarian stimulation for intrauterine insemination, in vitro fertilization, in vitro fertilization with microinjection, double gamete donation or embryo transfer in cases of ovarian failure) are determined by a clinical and biological decision. The organization of the attempt includes prescribing treatment, any pre-operative anesthesia consultation, the provision and transport of gametes, and MAR procedure. The single woman undertakes to provide the donation center with information on the progress of the pregnancy, its outcome and the identity of each child born as a result of the donation. She is also informed that, despite the medical evaluation, there is still a risk of transmitting genetic disorders and abnormalities in assisted reproduction, as in natural reproduction. She is specifically informed of the obstetric risks of pregnancies achieved through egg donation and embryo transfer. The issues surrounding parenthood through gamete and embryo donation are discussed, in particular questions relating to informing the child about the circumstances of their conception. Consent to MAR with a third-party donor is notarized in accordance with the conditions stipulated in the Civil Code. This notarized consent prior to the conception of the child thus protects the parental project of single mothers. CECOS therefore offer personalized support to single women, including medical consultations, psychological support and information on gamete donation, as well as explanations of the procedures for both sperm and egg donation, including the legal and ethical aspects. These evaluations and counseling sessions are intended to safeguard both the mother and the future child, thereby constituting an application of beneficence in the context of single motherhood by choice. Therefore legal and clinical framework aims to promote the well-being of single women by providing structured medical, psychological and social support throughout the MAR process.

## MAR and single mothers by choice: non-maleficence

### By identifying vulnerabilities

Single mothers often stand out for the intensity and thoughtfulness with which they approach parenthood. This mature, conscious and deliberate desire to have a child can strengthen the quality of their presence in the child's life, the strength of their emotional bond, and the child's sense of security. Unlike unplanned pregnancies or those occurring in chaotic circumstances, this type of parenting is often accompanied by substantial emotional and material preparation. However, during the perinatal period of the first 1,000 days [3], vulnerabilities may appear or be reinforced. This sensitive period is still under-explored: we now know that nearly 23% of women, in all situations, report psychological distress during pregnancy or immediately afterwards. Suicide is one of the leading causes of mortality during the first year of a baby's life [9]. Single mothers bear sole responsibility for raising children, household chores and financial constraints, which can lead to mental overload and chronic stress. Single mothers face unique challenges that can significantly increase their risk of developing maternal depression, despite careful planning and anticipation of logistical and organizational aspects, and despite having a supportive and caring network around them. Women who have previously suffered from depression or anxiety are also at greater risk of developing depression or anxiety. Sleep disturbances and intense fatigue associated with caring for a newborn can play a role in the development of depression and have significant consequences for the woman's well-being and the child's development. This is particularly relevant in a context where structural gender inequalities remain significant. MAR can be paradoxical, offering greater reproductive justice while maintaining or even accentuating socio-economic inequalities: some studies show that women who use MAR alone tend to have greater socio-cultural and economic capital. They are better prepared for what lies ahead and are generally surrounded by support (mothers, sisters, friends) [10]. It is important for these mothers not to be left alone with their choices, so the opportunity to talk to a supportive network is essential. In the case of single mothers, several specific concerns arise: certain vulnerability factors can influence the attachment bond with the child, such as prolonged maternal isolation or intense exhaustion, financial difficulties or a lack of relays, social or moral pressure on the mother, which can affect her emotional availability. Support (family, professional, psychological) is therefore a key factor in maintaining a climate conducive to attachment. The example of sleep difficulties for both mother and child illustrates this problem of daily support. The consequences of sleep deprivation for the mother can be varied: fatigue, risk of burnout, postpartum depression (maternal regret, impulse phobia, maternal hypervigilance...). In response, the child will emit a stress stimulus, activate its attachment system and cry very loudly on purpose to get a human to come and reassure it, reaching up to 80db (the pain threshold), further exhausting the mother.

### Ensuring the well-being of the mother and child

Formulated by John Bowlby and further developed by Mary Ainsworth, attachment theory posits that the quality of the early emotional bond between a child and their primary attachment figure determines their emotional, cognitive and relational development [11]. According to this theory, children need at least four or five attachment figures to stabilize their development. Attachment is a set of innate behavioral or motivational systems that promote relationships and can be modified by the environment. The attachment figure is the person towards whom the child will direct its attachment behavior. This can be any adult who engages in lively, sustained social interaction with the baby and who, by responding readily to its signals and approaches, will act as a caregiver. The primary need in children, which is the need for emotional security, requires the presence of a person who can respond to this safety need
through repetition, which is built up over months. This persistent bond with a specific figure thus enables attachment, which is a vital bond for the immature baby [12]. This relationship fulfils the need for emotional security, providing comfort in stressful situations, which is distinct from the concept of maternal love. Any change, even a minor one, in the surroundings will cause discomfort and stress, and the child needs to understand what is happening. When distressed, human babies seek out human figures in their environment and gravitate towards a few familiar figures who will become attachment figures, with innate behaviors to develop as best they can. This bond is built through the emotional availability, sensitivity, consistency and security provided by the parent. In the context of single motherhood by choice, the child is mainly in contact with a single parental figure. The quality of this relationship, with its emotional availability, sensitivity, and consistency, is crucial for attachment development. This doesn't necessarily mean a secure parent-child bond can't form, as long as the mum is emotionally and physically present, attentive to her kid's needs, and able to provide a stable, consistent, and safe environment. Numerous studies in developmental psychology show that a single parent can be sufficient for the creation of secure attachment, as long as this relational quality is present [13]. Even if the mother is the only direct parent, the child can form secondary attachment bonds with their grandparents, godparents, close friends, stable childcare facilities (childminders, nurseries), or later, with teachers or educators. This meets the child's social and emotional needs beyond the mother-child dyad [14]. However, if the single mother is indeed an attachment figure, who else can provide security for the child when she is exhausted? Pediatricians warn of a possible "role reversal." This phenomenon, which can arise in various family structures, involves the child gradually assuming the role of emotional support for the parent—becoming their confidant, helper, or source of stability. When the attachment figure is fragile or inconsistent, the child may develop feelings of insecurity. This is referred to as "parentification, " when the child takes on an adult role within the relationship. In the specific situation where a woman has chosen to have a child alone, the risk of isolation difficulties without assistance. This can lead to a form of self-censorship: suppressing her anxieties or struggles out of fear of being judged responsible. Healthcare professionals must be careful not to induce guilt, but instead offer support and encourage open dialogue. Minimizing complaints ("You chose to be alone"), avoiding mental health topics, or not addressing parenting challenges for fear of intrusiveness further intensifies isolation and deprives both mother and child of preventive and compassionate support. This sense of isolation is often accompanied by a "double burden" of guilt: self-blame for not fulfilling her role perfectly, combined with societal judgment. Professionals should act with vigilance and empathy, acknowledging difficulties without reducing them to individual responsibility. Role reversal can occur in any family structure, not only among single mothers. Support must be tailored to each situation in order to prevent isolation and foster healthy family balance.

## MAR and single mothers by choice: respecting autonomy

Today, individuals have acquired full control over their “reproduc-
tive destiny” [15]. However, under pressure from their biological clock,
some women see single parenthood through MAR as a way to fulfil their
desire to have children after years of unsuccessful attempts to find a
partner. The choice to become a single parent may also be motivated by
a desire for autonomy and freedom, driven by a desire to break free from
the pressure of traditional family norms [10]. Unlike situations where
solo motherhood occurs as a result of an accident, separation or un-
foreseen circumstances, their desire to have a child is part of a carefully
thought-out, long-term plan. What particularly characterizes their
approach is the separation they make between sexuality and procre-
ation; the idea of (re)forming a couple is not necessarily ruled out. MAR
thus becomes a tool for chosen motherhood, which they see as a solution
that allows for a structured and ethical approach that respects their

autonomy. On blogs or discussion forums and within associations, women who are planning to become single mothers or who are already single mothers share their experiences, including the negative reactions or judgements they have encountered from certain healthcare professionals. The media has sometimes reported on women who have faced judgement or difficulties accessing MAR because of their status as single women: some professionals may be influenced by a traditional view of the family, focused on a heterosexual two-parent model. Single mothers by choice say they sometimes encounter a paternalistic attitude. Although their approach is no longer illegal, single women face cumbersome procedures that are considered intrusive, and they describe facing a medical evaluation system that is perceived as discriminatory. Women without partners must undergo psychological consultations, interviews with social workers according to CECOS guidelines, and have their cases evaluated by a multidisciplinary committee. Psychological counselling in particular can be perceived as a form of moral judgement on their plans for motherhood. This process is often more complex than for couples. This lack of support increases the stress and isolation felt by these women. Some women are rejected because of their age, either too young or too old – even though they were eligible – or because of a disability. They point to the inconsistency in the application of the law, with each center having its own criteria. This creates a feeling of unfair selection. For example, a fertile, single 20-year-old woman may be asked to wait before considering a maternity project. Requests from very young women raise ethical questions regarding decision-making maturity and the potential tension between respect for reproductive autonomy and the risk of unintended paternalism.

## MAR and single mothers by choice: justice

Following the opening of MAR to single women in France, CECOS
centers have observed a huge increase in demand resulting in consid-
erable waiting times for initial appointments. Some women have had to
wait more than two years before receiving care, prompting some to seek
faster treatment abroad. This has created inequalities in access linked to
financial resources. A comparison between single women accepted for
gamete donation and women in couples awaiting conventional IVF
showed that single women were, on average, older and had a higher
socio-economic status [16]. There are growing concerns about length-
ening waiting lists and the limited human and material resources
available to manage this influx. In the face of increasing demand, re-
quests must be evaluated and prioritized according to medical and
psychological criteria. However, how can high-quality support be
ensured with constant or even diminishing resources in university hos-
pitals, CECOS centers, and mother and child protection services (PMI)?
While support is already available at the time of conception, it is also
essential to consider postnatal follow-up to support the mother in her
parenting role and ensure the child's development. This is precisely
where current PMI challenges lie. Recent data confirm that these ser-
vices suffer from a lack of human and financial resources, which affects
their ability to respond effectively to families' needs. The situation is
concerning: PMI services are facing a "major crisis". In a report written
in conjunction with the General Inspectorate of Social Affairs (IGAS),
Michèle Peyron sounds the alarm [17]. She highlights an increasing
disengagement from this structure even though social health in-
equalities continue to widen. In some regions, half of physician positions
are vacant, and two-thirds of these professionals are expected to retire
soon. PMIs do not form a structured national network making exchanges
with public authorities difficult. Added to this, there is a lack of regional
coordination: 35% of PMIs surveyed report having no connection with
other services or any common approach aimed at harmonizing their
practices. Above all, PMIs have undergone a profound change in their
role: whereas they used to provide systematic follow-up for all new-
borns, they now handle only emergency situations and focus more on
social.
## Conclusion

During his speech on 16 January 2024, French President Emmanuel Macron expressed an ambition of a "demographic rearmament". He stated that "France is slowly but surely moving away from a birth rate model that was once our strength, calling for a national mobilization" to reverse the downward trend in births [18]. With this in mind, he outlined a series of measures: improving access to healthcare for pregnant women, upgrading early childhood professions. Parental rights have been expanded with the 2021 bioethics law, which opens up MAR to single women and female couples. This is a major step towards equality, but it has not been accompanied by sufficient resources. CECOS centers are now overwhelmed: waiting times can be as long as two years due to a lack of gamete donations and human resources. In a context of global uncertainty – growing geopolitical tensions, the return of war in Europe, ecological anxiety – this injunction to have children resonates in an ambivalent way. While our society now formally recognizes the right to have a child without a partner, it does not fully provide the means to do so. Worse still, their efforts are often stigmatized in a society that struggles to value forms of parenthood that fall outside the traditional model. Public policies are struggling to keep up. The chronic shortage of childcare places further exacerbates inequalities. All of this points to a profound paradox: while women are being called upon to ‘boost’ the birth rate, their role as mothers continues to be devalued, with little consideration given to the practicalities of raising young children. If France truly wants to regain demographic momentum, it cannot rely on empty rhetoric. It is not merely a matter of encouraging births, but of recognizing the value of parenting, providing meaningful support for all forms of motherhood and investing substantially in public services for young children as well as in the health sector, from training doctors on these issues to reconsidering and consolidating services dedicated to maternal and child health. Without this, demographic rearmament risks remaining a pipe dream, or even an empty slogan, in a society where having children is now more of a challenge than a responsible choice. Several ethical challenges are identified through the principles of beneficence, non-maleficence, autonomy and justice as applied to the support of single women undergoing MAR. Overall, the analysis highlights the need for strengthened and equitable support structures to ensure ethically sound care for single mothers by choice.

## Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Declaration of competing interest

None.

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