Assisted reproductive technologies, or ART, are more common in the U.S. than they’ve ever been: The Centers for Disease Control and Prevention estimates that around 11.3 percent of women between 15 and 44 have used some sort of infertility service. In 2013, doctors performed a total of 191,000 cycles of ART at nearly 500 clinics across the U.S., resulting in around 68,000 babies.

But even the most run-of-the-mill medical procedures were once novel—and the earliest days of ART were a far cry from the strict ethical standards of today.

The first physician to take a systematic approach to human artificial insemination was the controversial 19th-century surgeon J. Marion Sims. Although he founded the Women’s Hospital in New York, the first establishment devoted solely to women’s health, he’s also known for more troubling activities: Many of his notable medial contributions were a result of research he conducted on slaves without his subjects’ consent.

The Women’s Hospital opened in 1855, and during its first several years in operation, Sims performed 55 artificial-insemination procedures on six different women; only one resulted in a pregnancy, and it ended in a miscarriage.

His techniques likely would have been effective if Sims had taken his patients’ ovulation cycles into account—but because he didn’t, the first artificial insemination to result in a live birth, performed by the Philadelphia physician William Pancoast, didn’t happen until a few decades after Sims’ attempts. In 1884, one of Pancoast’s patients, a 31-year-old woman, came to see him at Sansom Street Hospital about her inability to conceive.

Pancoast initially assumed that the problem was with the woman’s fertility, but numerous exams led him to ultimately conclude that the issue was actually her husband’s low sperm count. When the husband, a 41-year-old wealthy merchant from Philadelphia, came in for an examination of his own, Pancoast deemed him “of sound body,” with the exception of a case of gonorrhea from years earlier. Microscopic examination indicated that his “spermatic fluid” was “absolutely void of spermatozoons,” likely a result of the infection.

Originally, Pancoast told the man that the problem would be easily fixed with a course of treatment—but after two months without any progress, the doctor determined that the merchant’s seminal ducts were permanently obstructed, and that he wouldn’t be able to impregnate his wife.

Instead of disclosing any of this information to the couple, though, Pancoast scheduled another “examination” for his patient. Here’s how the first successful artificial insemination took place: In front of six medical students, Pancoast knocked out his patient using chloroform, inseminated her with a rubber syringe, and then packed her cervix with gauze. The source of the semen was one of the medical students in the room, determined to be the most attractive of the bunch.  

Nine months later, the woman gave birth to a healthy baby boy. Pancoast didn’t reveal the circumstances of the conception until after the birth—and even then, he told only her husband. Together, the two men decided that she would be better off not knowing the truth about her final “examination” or the biological father of her child.

The story remained a secret until 1909, when Addison Davis Hard—one of the six medical students present the day of the insemination—published a letter in Medical World describing the case. (Prior to publishing the letter, Hard contacted the resulting child, by that point a 25-year-old businessman living in New York, and informed him of the details of his conception.)

“At that time,” Hard wrote in Medical World, “the procedure was so novel, so peculiar in its human ethics, that the six young men of the senior class who witnest [sic] the operation were pledged to absolute secrecy.”

Hard went on to argue that “artificial impregnation offers valuable advantages,” chief among them the ability to ensure that semen without the “promise of good and healthy offspring” was disregarded in favor of “carefully selected seed.”

Even with all the advances in ART over the past century and a half, in other words, one thing has been the same since the very beginning: When babies can be created in new ways, they can also, to varying extents, be designed. It’s an old story, but an ethical debate that’s as relevant as ever.