Marcia C. Inhorn

Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century

BACKGROUND Infertility is estimated to affect as many as 186 million people worldwide. Although male infertility contributes to more than half of all cases of global childlessness, infertility remains a womans social burden. Unfortunately, areas of the world with the highest rates of infertility are often those with poor access to assisted reproductive techniques (ARTs). In such settings, women may be abandoned to their childless destinies. However, emerging data suggest that making ART accessible and affordable is an important gender intervention. To that end, this article presents an overview of what we know about global infertility, ART and changing gender relations, posing five key questions: (i) why is infertility an ongoing global reproductive health problem? (ii) What are the gender effects of infertility, and are they changing over time? (iii) What do we know about the globalization of ART to resource-poor settings? (iv) How are new global initiatives attempting to improve access to IVF? (v) Finally, what can be done to overcome infertility, help the infertile and enhance low-cost IVF (LCIVF) activism? METHODS An exhaustive literature review using MEDLINE, Google Scholar and the keyword search function provided through the Yale University Library (i.e. which scans multiple databases simultaneously) identified 103 peer-reviewed journal articles and 37 monographs, chapters and reports from the years 2000-2014 in the areas of: (i) infertility demography, (ii) ART in low-resource settings, (iii) gender and infertility in low-resource settings and (iv) the rise of LCIVF initiatives. International Federation of Fertility Societies Surveillance reports were particularly helpful in identifying important global trends in IVF clinic distribution between 2002 and 2010. Additionally, a series of articles published by scholars who are tracking global cross-border reproductive care (CBRC) trends, as well as others who are involved in the growing LCIVF movement, were invaluable. RESULTS Recent global demographic surveys indicate that infertility remains an ongoing reproductive problem, with six key demographic features. Despite the massive global expansion of ART services over the past decade (2005-2015), ART remains inaccessible in many parts of the world, particularly in sub-Saharan Africa, where IVF clinics are still absent in most countries. For women living in such ART-poor settings, the gender effects of infertility may be devastating. In contrast, in ART-rich regions such as the Middle East, the negative gender effects of infertility are diminishing over time, especially with state subsidization of ART. Furthermore, men are increasingly acknowledging their male infertility and seeking ICSI. Thus, access to ART may ameliorate gender discrimination, especially in the Global South. To that end, a number of clinician-led, LCIVF initiatives are in development to provide affordable ART, particularly in Africa. Without access to LCIVF, many infertile couples must incur catastrophic expenditures to fund their IVF, or engage in CBRC to seek lower-cost IVF elsewhere. CONCLUSIONS Given the present realities, three future directions for research and intervention are suggested: (i) address the preventable causes of infertility, (ii) provide support and alternatives for the infertile and (iii) encourage new LCIVF initiatives to improve availability, affordability and acceptability of ART around the globe.

Making muslim babies: Ivf and gamete donation in sunni versus shi’a islam

Medical anthropological research on science, biotechnology, and religion has focused on the “local moral worlds” of men and women as they make difficult decisions regarding their health and the beginnings and endings of human life. This paper focuses on the local moral worlds of infertile Muslims as they attempt to make, in the religiously correct fashion, Muslim babies at in vitro fertilization (IVF) clinics in Egypt and Lebanon. As early as 1980, authoritative fatwas issued from Egypt’s famed Al-Azhar University suggested that IVF and similar technologies are permissible as long as they do not involve any form of third-party donation (of sperm, eggs, embryos, or uteruses). Since the late 1990s, however, divergences in opinion over third-party gamete donation have occurred between Sunni and Shi’ite Muslims, with Iran’s leading ayatollah permitting gamete donation under certain conditions. This Iranian fatwa has had profound implications for the country of Lebanon, where a Shi’ite majority also seeks IVF services. Based on three periods of ethnographic research in Egyptian and Lebanese IVF clinics, this paper explores official and unofficial religious discourses surrounding the practice of IVF and third-party donation in the Muslim world, as well as the gender implications of gamete donation for Muslim marriages.

The worms are weak. Male infertility and patriarchal paradoxes in Egypt.

Male infertility is a major global reproductive health problem, contributing to more than half of all cases of infertility worldwide. Yet women typically bear the social burden of childlessness when their husbands are infertile. This article explores the four major patriarchal paradoxes surrounding male infertility in the Muslim Middle Eastern country of Egypt. There, women in childless marriages typically experience procreative blame, even when male infertility (glossed as “weak worms”) is socially acknowledged. In addition, Egyptian women married to infertile men experience diminished gender identity and threats of male-initiated divorce. Ironically, the introduction of new reproductive technologies to overcome male infertility has only served to increase this divorce potential. Although male infertility also presents a crisis of masculinity for Egyptian men, this crisis often redounds in multiple ways on the lives of women, who ultimately pay the price for male infertility under conditions of Middle Eastern patriarchy.

Ethnography, epidemiology and infertility in Egypt.

Infertility in the developing world has been relatively neglected as an international health problem and a topic of social scientific and epidemiological inquiry. In this study, we examine factors placing poor urban Egyptian men and women at risk of infertility, and we explore the sociocultural and political-economic contexts in which these health-demoting factors are perpetuated. Our approach to the problem of Egyptian infertility attempts an explicit merging of ethnographic and epidemiological research designs, methods of data collection and analysis, and interpretive insights to provide improved understanding of the factors underlying infertility in the urban Egyptian setting.

Medical anthropology and epidemiology: Divergences or convergences?

Despite recent calls for greater collaboration between medical anthropologists and epidemiologists, examples of synthetic, interdisciplinary anthropological-epidemiological research are frankly rare, due in large part to perceptions among medical anthropologists that anthropology and epidemiology diverge considerably in their topics of inquiry, epistemological assumptions, methods of data collection and notions of risk and responsibility for illness. In this article, five of these perceived areas of divergence are examined, with an attempt to reconceptualize them as areas of potential convergence.

Globalization and gametes: reproductive ‘tourism,’ Islamic bioethics, and Middle Eastern modernity

‘Reproductive tourism’ has been defined as the search for assisted reproductive technologies (ARTs) and human gametes (eggs, sperm, embryos) across national and international borders. This article conceptualizes reproductive tourism within ‘global reproscapes,’ which involve the circulation of actors, technologies, money, media, ideas, and human gametes, all moving in complicated manners across geographical landscapes. Focusing on the Muslim countries of the Middle East, the article explores the Islamic ‘local moral worlds’ informing the movements of Middle Eastern infertile couples. The ban on third-party gamete donation in Sunni Muslim-majority countries and the recent allowance of donor technologies in the Shia Muslim-majority countries of Iran and Lebanon have led to significant movements of infertile couples across Middle Eastern national borders. In the new millennium, Iran is leading the way into this ‘brave new world’ of high-tech, third-party assisted conception, with Islamic bioethical discourses being used to justify various forms of technological assistance. Although the Middle East is rarely regarded in this way, it is a key site for understanding the intersection of technoscience, religious morality, and modernity, all of which are deeply implicated in the new world of reproductive tourism.

The "Iranian ART Revolution": Infertility, Assisted Reproductive Technology, and Third-Party Donation in the Islamic Republic of Iran

Infertility is a social onus for women in Iran, who are expected to produce children early within marriage. With its estimated 1.5 million infertile couples, Iran is the only Muslim country in which assisted reproductive technologies (ARTs) using donor gametes and embryos have been legitimized by religious authorities and passed into law. This has placed Iran, a Shia-dominant country, in a unique position vis-à-vis the Sunni Islamic world, where all forms of gamete donation are strictly prohibited. In this article, we first examine the “Iranian ART revolution” that has allowed donor technologies to be admitted as a form of assisted reproduction. Then we examine the response of Iranian women to their infertility and the profound social pressures they face. We argue that the experience of infertility and its treatment are mediated by women’s socioeconomic position within Iranian society. Many women lack economic access to in vitro fertilization (IVF) technologies and fear the moral consequences of gamete donation. Thus, the benefits of the Iranian ART revolution are mixed: although many Iranian women have been able to overcome their infertility through ARTs, not all women’s lives are improved by these technologies.

Right to assisted reproductive technology: Overcoming infertility in low-resource countries

This article examines the high prevalence of primary and secondary infertility in low‐resource countries. Provision of assisted reproductive technology (ART) to overcome both female and male infertility is in line with the reproductive rights agenda developed at the International Conference on Population and Development (ICPD) in Cairo 15 years ago. In addition to the right to control fertility, reproductive rights must encompass the right to facilitate fertility when fertility is threatened. Facilitation of fertility may require resort to ART, among both men and women. Egypt is highlighted as a positive example of progress in this regard.

Interpreting infertility: medical anthropological perspectives. Introduction.

Medical anthropology contributes significantly to the exploration of human reproduction. While infant morbidity and mortality as well as AIDS however have been explored to a great extent by medical anthropologists reproductive morbidity of infertility ectopic pregnancy and pregnancy loss through miscarriage and stillbirth have been largely overlooked by the community. This short paper introduces an issue of Social Science and Medicine focusing upon the cultural ramifications and interpreting the experiences of infertile women in Cameroon India Egypt and the US. The studies demonstrate that infertility for women is usually marked by anxiety and fear normative pressures to conceive social stigmatization and exhaustive searches for therapy which tend to be ritualistic risky and ethically complex. Infertility often affects womens moral identities and the local moral worlds in which they live. The papers will also link the consequences of infertility with kinship inheritance marriage and divorce patterns household residence patterns economic production religion cosmology gender relations and notions of the body health and illness.

The global landscape of cross-border reproductive care: twenty key findings for the new millennium.

Purpose of review Cross-border reproductive care (CBRC), also known as procreative tourism, fertility tourism, or reproductive tourism, is an increasing global phenomenon. This article reviews the expanding scholarly literature on CBRC, with 2010–2011 representing watershed years for CBRC scholarship and activism. Recent findings Terminological debates, missing data, and lack of international monitoring plague the study of CBRC. Nonetheless, it is widely acknowledged that CBRC is a growing industry, with new global hubs, new intermediaries, new media, and new spaces of interaction. Religious bans and legal restrictions have created a patchwork of ‘restrictive’ and ‘permissive’ countries, with law evasion being a primary driver of CBRC. Yet, patient motivations for CBRC are diverse and patients’ levels of satisfaction with CBRC and its outcomes are generally high. Thus, scholarly concern with CBRC as law evasion must be tempered with qualitative studies of positive patient experiences. Summary CBRC can be considered a form of ‘global gynecology’ in which reproductive medicine, tourism, and commerce are converging in the second decade of the new millennium.