Local Babies, Global Science

Gender, Religion and In Vitro Fertilization in Egypt

Marcia C. Inhorn

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136073304
• Edition: 1
• Topic: Social Sciences
• Subtopic: Cultural & Social Anthropology
• Index: Social Sciences

In the late 1990s, Egypt experienced a boom period in in vitro fertilization (IVF) technology and now boasts more IVF clinics than neighboring Israel. In this book, Marcia Inhorn writes of her fieldwork among affluent, elite couples who sought in vitro fertilization in Egypt, a country which is not only at the forefront of IVF technology in the Middle East, but also a center of Islamic education in the region. Inhorn examines the gender, scientific, religious and cultural ramifications of the transfer of IVF technology from Euro-American points of origin to Egypt - showing how cultural ideas reshape the use of this technology and in turn, how the technology is reshaping cultural ideas in Egypt.

CHAPTER 1

Introduction

Amira, the “philosopher” whose poignant story forms the prologue of this book, hoped—but failed—to become an Egyptian mother of a test-tube baby. This book is dedicated to Amira and the other childless Egyptians whose attempts at test-tube baby making will be described in the chapters that follow. My anthropological understanding of the constraints these Egyptians face in their quest to succeed at IVF and the even newer ICSI was only made possible because of the hundreds of hours I spent with them in Egyptian IVF centers in 1996. To all of those brave IVF patients who agreed to come forward—but whose names have been assiduously changed in the pages that follow—I can never truly express my thanks and admiration for making visible to me a world marked by stigma, silence, and suffering.

The often secretive practice of IVF and other new reproductive technologies by infertile women and men in non-Western, “developing” societies such as Egypt is a story that has been little told. It is one that Westerners, often reflecting on the “overpopulation” of the developing world, find difficult to believe. Yet, since the birth in 1978 of Louise Brown, the world's first test-tube baby, new reproductive technologies have spread around the globe, reaching countries far from the producing nations of the West. Perhaps nowhere is this globalization process more evident than in the nearly twenty nations of the Muslim Middle East, where IVF centers have opened in small, petro-rich Arab Gulf countries such as Bahrain and Qatar and in much larger but less prosperous North African nations such as Morocco and Egypt.

This book documents the spread of these technologies to this region of the world, asking what happens to the infertile Middle Eastern women and men who attempt to access IVF and ICSI in their pursuit of conception. In so doing, it sheds light on the nature of globalization and transnationalism, and especially the unevenness of globalizing processes. Although IVF centers now flourish in most of the urban capitals of the Middle East, the reproductive technologies themselves—representing, for the infertile, the potential bounty of globalization—are often either inaccessible or unhelpful in overcoming intractable infertility. Thus, globalizing reproductive technologies bring with them both pregnant rewards and false promises, the latter of which are exacerbated by real-world constraints on the use of these technologies in cultural sites located on the receiving end of global reproductive technology transfer.

This book is intended to provide the first extended ethnographic analysis of these constraints on new reproductive technology practice in a resource-poor, non-Western setting. In so doing, it demonstrates the culturally specific responses and complex, local social arrangements surrounding the importation and use of IVF and ICSI in the predominantly Muslim nation of Egypt. The book diverges considerably from earlier Western accounts of these technologies¹ in that it highlights how local cultural ideologies, practices, and structural forces not found in most Western countries literally reshape the use of these technologies in Egypt and, in turn, how the use of these technologies in Egyptian IVF clinics serves to reshape local culture in various ways. For example, specific Egyptian cultural responses to the use of these Western-generated technologies include indigenous theories of procreation that reject the notion of women producing “eggs” for in vitro fertilization; Sunni Islamic prohibitions on the use of third-party donation (of sperm, eggs, embryos, or uteruses); local shortages of hormonal medications that lead to “suitcase trading” of IVF pharmaceuticals across national borders; and severe moral stigma associated with IVF, which militates against the formation of local support groups for IVF patients or patients’ disclosure of their IVF-seeking status to others in their social worlds. This theme of the “local in the global” pervades this ethnography, with Egyptian sensibilities about what constrains them, as Egyptians, from successfully using these technologies foregrounded in the analysis. Indeed, the Egyptian IVF patients in this book ponder the many profound constraints facing them as test-tube baby makers, often wondering out loud whether these local constraints are shared by infertile people in the First World nations where these technologies are produced, as well as in other Third World settings where these technologies are being rapidly deployed.

These cross-cultural ruminations are, in part, a product of Egyptian transnationalism. Today, as in the past,² many Egyptians are “on the move”—be it as labor migrants or pilgrims to the Arab Gulf, as students and professionals in Western countries, or as peripatetic “medical migrants” engaged in a kind of international reproductive tourism.³ This book reflects these global movements, taking us from the IVF wards of private maternity hospitals in Cairo, Egypt, to the Arab Gulf, Europe, and the United States, where both infertile patients and physicians migrate, and then return, carrying with them new expertise and cross-cultural experiences. The stories of Amira and others like her reveal the global enmeshment of Middle Eastern Muslim (and Christian) elites in what is now a very transnational world of infertility treatment-seeking and technological progress. By virtue of their global movement and access to global technologies such as the Internet, reproductive physicians and the highly educated patients they serve in Middle Eastern IVF centers are in continuous conversation with—and thus are able to reflect upon—medical, social, and bioethical developments in the West. As they move between these Middle Eastern and Western worlds, their understandings of IVF and its appropriate use in the conception of test-tube babies are continuously shaped by local social, cultural, religious, and scientific traditions “back home” in their Middle Eastern countries of origin. Thus, the practice of IVF in a place like Cairo, a beacon of education, erudition, and religious authority in the Muslim world, is characterized by a particular Egyptian ethos not to be found in the Western IVF laboratories and clinics where these technologies are perpetually being refined, refashioned, and re-envisioned to treat every conceivable type of infertility. The bioethically questionable direction of some of these Western technological developments is often troubling to Egyptians, who bring their own moral worlds to bear on questions of scientific progress. Thus, the examination of ways in which new reproductive technologies are—and are not—accepted and domesticated in places like Egypt can inform much wider debates about the tensions between locality and globalism in the realm of science, technology, and medicine.

Egypt provides a particularly fascinating locus for investigation of the global transfer of new reproductive technologies because of its ironic position as one of the resource-poor, overpopulated Middle Eastern nations. As the fifteenth largest country in the world,⁴ Egypt has pursued population reduction goals through family planning and other economic development efforts since the early 1960s, the first Muslim Middle Eastern nation to do so.⁵ In a nation of nearly 70 million people, it is perhaps not surprising that infertility has never been included in Egypt's population program as a population problem, a more general public health concern, or an issue of human suffering for Egyptian citizens, especially women. Yet, when Egypt hosted the International Conference on Population and Development in 1994, infertility was officially placed on the global reproductive health agenda.⁶ One year later, the Egyptian Fertility Care Society published the results of its World Health Organization (WHO)–sponsored study, placing the total infertility prevalence rate among married Egyptian couples at 12 percent.⁷

Given the substantial size of this infertile population, as well as the strong culturally embedded desire for at least two children expressed by virtually every Egyptian adult, it is not surprising that Egypt provides a ready market for the new reproductive technologies. Despite its regionally underprivileged position, Egypt has been on the forefront of new reproductive technology development in the Middle East—a legacy, perhaps, of its long history with Western colonial medicine.⁸ In 1986, Egypt was one of two nations in the region to open an IVF center, and in 1987, Egypt's first test-tube baby, a little girl named Heba Mohammed, was born. By 1996, there were already ten Egyptian IVF centers in full operation or development, out of the approximately thirty-five IVF centers in the Muslim Middle Eastern region as a whole.⁹ But, by the end of the decade, the number of centers in Egypt alone had more than tripled to thirty-six, placing Egypt ahead of even Israel, which boasts twenty-four IVF centers (still the highest number per capita in the world).¹⁰ This explosion of IVF services in Egypt in the course of a decade is remarkable when one considers that a single trial of IVF can cost more than LE 10,000, or approximately U.S. $3,000.¹¹ In 1999, this would have represented more than three times the annual income of an average Egyptian, and it is clearly a large sum of money for even the most affluent Egyptians. In other words, the new reproductive technologies would seem to be out of reach for most ordinary Egyptians. Yet, infertile Egyptian patients are flocking to IVF centers, which face such a great demand for their services that they are chronically short of the powerful drugs, supplies, and even competent medical personnel necessary to carry out IVF procedures.

A critical question thus becomes: What factors explain this local demand for high-cost, high-tech global reproductive technologies in a Third World Muslim country such as Egypt? Or, put another way, why are infertile Egyptians such as Amira so powerfully motivated to try these costly, potentially risky, and often inefficacious technologies? Certainly, to understand the demand for new reproductive technologies in a society such as Egypt requires an analysis of the forces fueling the new reproductive technology “revolution” in many Third World societies around the globe, including the Muslim nations of the Middle East.

The Global Demand for New Reproductive Technologies¹²

Demography and Epidemiology

To understand the global demand for new reproductive technologies, one must consider the numbers: Infertility is a global health issue that affects millions of people worldwide. In fact, no society can escape infertility; some portion of every human population is affected by the inability to conceive during their reproductive lives. The classic definition of infertility is as follows: “For couples of reproductive age who are having sexual intercourse without contraception, infertility is defined as the inability to establish a pregnancy within a specified period of time, usually one year.”¹³ Given this definition, WHO estimates that, on average, 8 to 12 percent of couples—or at least one in every ten couples in developing countries—experience some form of infertility during their reproductive lives.¹⁴ Extrapolating to the global population, this means that between 50 and 80 million people worldwide may be experiencing infertility at any give time, including at least one in every ten couples in the developing countries.¹⁵

Of this global population of infertile people, it is estimated that between 29.4 and 44.1 million, or more than half, are Muslims.¹⁶ Why? Muslims represent a large percentage of the populations living in the so-called infertility belt of sub-Saharan Africa, where rates of infertility reach as high as 32 percent, affecting nearly one-third of all couples attempting to conceive in some populations.¹⁷ Many of these cases of African infertility involve so-called secondary as opposed to primary infertility. Primary infertility means that infertility occurs in the absence of a prior history of pregnancy, while secondary infertility means that infertility occurs following a prior pregnancy (whether or not that pregnancy resulted in a live birth). In the most comprehensive epidemiological study of infertility to date—a WHO study of fifty-eight hundred infertile couples seeking help at thirty-three medical centers in twenty-five developed and developing countries between the years 1979 and 1984¹⁸—Africa stood out as the continent with the highest rates of secondary infertility cases due to preventable causes. Today, women in sub-Saharan Africa continue to remain vulnerable to infertility, both physically and socially, as documented in a recent anthology, Women and Infertility in Sub-Saharan Africa: A Multi-Disciplinary Perspective.¹⁹

Reproductive tract infections (RTIs), including those caused by sexually transmitted gonorrhea or genital chlamydial infections, are the leading preventable cause of infertility.²⁰ RTIs can lead to pelvic inflammatory disease (PID), which results in scarring and blockage of the delicate fallopian tubes. The end result is tubal infertility, which is often solvable only through new reproductive technologies. Indeed, IVF was developed in the late 1970s largely to bypass the need for healthy fallopian tubes.²¹

In the non-Western world, tubal infertility is highly prevalent and is the major reason for the high rates of secondary infertility. In sub-Saharan Africa, for example, the elevated levels of secondary infertility—affecting as many as one-quarter of all women in some societies—are clearly due to infection, which is thought to account for 85 percent of all cases of infertility, or more than double the rates in other regions.²² Nonetheless, rates of infection-induced secondary infertility are also high elsewhere in the Third World—for example, 40 percent in Latin America, 23 percent in Asia, and 16 percent in North Africa, including Egypt. Most of this infectious infertility is due to four sets of factors: (1) sexually transmitted infections, (2) postpartum complications, (3) postabortive complications, and (4) unhygienic health care practices carried out in either the biomedical or traditional health care sectors.

Even though Egypt is immediately to the north of the sub-Saharan infertility belt (which begins in Sudan), all of these factors appear to be at work, leading to significant infertility problems in the country. To be more specific, the aforementioned WHO-sponsored study of Egyptian infertility, based on a random sample of married women ages eighteen to forty-nine in twenty thousand rural and urban households, found that 4.3 percent of women suffered from primary infertility and 7.7 percent from secondary infertility.²³ The higher rates of secondary infertility are clearly linked to tubal infertility, which is the single leading cause of female infertility in the country.²⁴ Pelvic infections leading to tubal infertility in Egypt are attributable to a number of factors, including sexually transmitted diseases (STDs), postpartum and postabortive infections, postoperative infections following reproductive surgeries, pelvic tuberculosis and schistosomiasis (common infectious diseases in Egypt), and a number of harmful traditional and biomedical practices.²⁵ In a medical anthropological-epidemiological study I carried out among one hundred infertile Egyptian women and ninety fertile controls in the late 1980s,²⁶ women appeared to be at significant risk for tubal infertility from a number of sources, including traditional female circumcision practices, as well as inefficacious and even iatrogenic biomedical practices (e.g., dilatation and curettage) commonly employed by Egyptian gynecologists, including to purportedly treat infertility. In addition, in a study examining male infertility outcomes,²⁷ Egyptian men's exposures to heat and chemicals in the workplace, history of schistosomiasis infection, and male smoking (particularly of water-pipes) seemed to place them at risk for male infertility outcomes.

Male infertility is either the sole cause or a contributing factor in more than half of all cases of infertility worldwide, although it is rarely recognized as such.²⁸ Four of the major types of male infertility include oligospermia (low sperm count), asthenospermia (poor motility), teratospermia (defects of sperm morphology), and azoospermia (lack of sperm in the ejaculate), the etiologies of which are poorly understood.²⁹ However, it is increasingly being recognized that men in developing countries who are faced with exposure to environmental and occupational toxicants may be at risk of infertility outcomes. Toxicants of concern include arsenic, heavy metals such as lead, solvents, pesticides, and industrial chemicals.³⁰ In some cases, class-action legal suits have been brought against various multinational corporations by Third World male workers who have been made sterile because of their exposure to synthetic pesticides at their places of work—the most famous case being that of dibromochloropropane (DBCP), which has clearly been shown to cause male infertility.³¹ Furthermore, various lifestyle factors—such as heavy smoking and caffeine consumption, which...

Table of contents

• Front Cover
• Title Page
• Copyright
• Contents
• Acknowledgement
• Prologue
• 1. Introduction
• 2. Class
• 3. Knowledge
• 4. Religion
• 5. Providers
• 6. Efficacy
• 7. Embodiment
• 8. Gender
• 9. Stigma
• 10. Conclusion
• Appendix
• Notes
• Bibliography
• Index