Elsevier

Social Science & Medicine

Volume 56, Issue 9, May 2003, Pages 1837-1851
Social Science & Medicine

Global infertility and the globalization of new reproductive technologies: illustrations from Egypt

https://doi.org/10.1016/S0277-9536(02)00208-3 Get rights and content

Abstract

Infertility is a problem of global proportions, affecting on average 8–12 percent of couples worldwide. In some societies, however—particularly those in the “infertility belt” of sub-Saharan Africa—as many as one-third of all couples are unable to conceive. Factors causing high rates of tubal infertility in parts of the developing world include sexually transmitted, postpartum, and postabortion infections; however, male infertility, which is rarely acknowledged, contributes to more than half of all cases. Unfortunately, the new reproductive technologies (NRTs) such as in vitro fertilization (IVF), which are prohibitively expensive and difficult to implement in many parts of the developing world, represent the only solution to most cases of tubal and male infertility. Not surprisingly, these technologies are rapidly globalizing to pronatalist developing societies, where children are highly desired, parenthood is culturally mandatory, and childlessness socially unacceptable. Using Egypt as an illustrative case study, this paper examines five of the major forces fueling the global demand for NRTs; these include demographic and epidemiological factors, the fertility–infertility dialectic, problems in health care seeking, gendered suffering, and adoption restrictions. Following this overview, a detailed examination of the implications of the rapid global spread of NRTs to the developing world will be offered. By focusing on Egypt, where nearly 40 IVF centers are in operation, this article will demonstrate the considerable constraints on the practice and utilization of NRTs in a developing country on the “receiving end” of global reproductive technology transfer. The article concludes by stressing the need for primary prevention of infections leading to infertility, thereby reducing global reliance on NRTs.

Introduction

Infertility, or the inability to conceive, is a problem of global proportions, affecting between 8 and 12 percent of couples worldwide (Reproductive Health Outlook, 2002). In some societies, however—particularly those in the “infertility belt” of central and southern Africa—as many as one-third of couples are unable to conceive after a year or more of trying (Cates, Farley, & Rowe, 1985; Collet et al., 1988; Ericksen & Brunette, 1996; Khattab, Younis, & Zurayk (1999), Larsen (1994); World Health Organization, 1987a). Factors causing high rates of infertility in parts of the developing world are varied, but tubal infertility due to sexually transmitted, postpartum, postabortive, and iatrogenic infections is widely regarded as the primary form of preventable infertility in the world today (Reproductive Health Outlook, 2002; Schroeder (1988), Devroey, Vandervorst, Nagy, & Van Steirteghem (1994)). Although rarely socially acknowledged, male infertility contributes to at least half of all cases worldwide and is often the most difficult form of infertility to treat (Devroey, Vandervorst, Nagy, & Van Steirteghem, 1998; Irvine, 1998; Kamischke & Nieschlag, 1998). Unfortunately, the so-called “new reproductive technologies” (NRTs) such as in vitro fertilization (IVF), which are prohibitively expensive and difficult to implement in many developing societies, are the only solution for most cases of tubal and male infertility. This is especially true in parts of the world where less invasive donor insemination (DI) technologies are religiously or otherwise culturally prohibited, particularly in countries with large Muslim populations (Blank, 1998; Meirow & Schenker, 1997). Given such cultural restrictions in the face of significant infertility problems, it is not surprising that “high-tech” NRTs to overcome tubal and male infertility are rapidly globalizing, even to resource-poor, developing countries with significant population pressures (Nicholson & Nicholson, 1994; Okonofua, 1996). In such high-fertility settings, where children are highly desired and parenthood is culturally mandatory, infertility is a socially unacceptable condition, leading most infertile couples on a relentless “quest for conception” that may eventually involve resort to NRTs (Inhorn (1992), Inhorn (2002)).

In many societies around the world, infertility is an especially disruptive form of “reproduction gone awry.” The lack of pregnancy and the resulting childlessness are often highly stigmatizing, leading to profound social suffering for infertile couples and infertile women in particular (Sciarra, 1994; Van Balen & Gerrits, 2001; Van Balen & Inhorn, 2001). Yet, rarely has infertility been acknowledged as a serious public health problem in the purportedly overpopulated non-Western world. As a result, few non-Western societies have incorporated the diagnosis and treatment of infertility into their family planning programs, meaning that state-sponsored infertility care remains marginal at best and generally does not include access to or coverage of NRT services (Van Balen & Gerrits, 2001). Yet, adoption—perceived in the West as the “natural” (even if last-resort) solution to infertility—may be culturally or legally unacceptable in many developing societies and may, therefore, not represent a way to solve this intractable problem (Inhorn, 1996).

This article examines infertility as an important global health problem—one that has been largely unappreciated and understudied from both a biological/clinical and social science perspective (Bentley & Mascie-Taylor, 2000; Hamberger & Janson, 1997; Schroeder, 1988; Sciarra, 1994; Van Balen & Gerrits, 2001; Van Balen & Inhorn, 2001). Although infertility is beginning to be recognized as part of the broadly defined global reproductive health agenda emerging out of the 1994 United Nations International Conference on Population and Development in Cairo, no guidelines have yet emerged on how to translate “prevention and appropriate treatment of infertility, where feasible” into concrete strategies, particularly in resource-poor developing countries (Van Balen & Gerrits, 2001, p. 216). Furthermore, many of the infertility studies sponsored by the World Health Organization (WHO), as well as the clinical guidelines emerging from those studies, are now seriously dated (WHO (1975), World Health Organization (1987a), WHO (1987b), WHO (1989), WHO (1991), WHO (1993)), and their impact on the prevention and treatment of the global infertility problem has been marginal (Sundby, 2001).

This article uses the case of Egypt—the site of the UN population conference and of the author's own field research over 15 years—to illustrate why infertility deserves serious recognition as a major global health issue. As will be argued here, it is the very severity of the global infertility problem that underlies the now massive global spread of NRTs to places like Egypt. In particular, this article will examine the five major forces fueling the global demand for NRTs. These include demographic and epidemiological factors; the fertility–infertility dialectic; problems of health care seeking; gendered suffering; and adoption restrictions. Following an overview of these issues, this article will focus specifically on the implications of NRT globalization to the developing world, including Egypt. As we shall see, Egypt has been the site of unprecedented NRT development, with nearly 40 IVF centers in operation by the end of the 1990s, including one state-sponsored public IVF center at the University of Alexandria. However, as a Third World society on the “receiving end” of global reproductive technology transfer, Egypt represents an ideal case study for questioning the Western assumption that NRTs—as supposedly “neutral,” “culture-free” medical technologies to overcome tubal, male, and other forms of infertility—can be “appropriately” transferred anywhere and everywhere. As this article will demonstrate, major constraints on the practice and utilization of NRTs are being enacted on the local level in Egypt, demonstrating the very local cultural and structural implications of global reproductive technology transfer.

Section snippets

Demography and epidemiology

To understand the global demand for new reproductive technologies, one must consider the numbers: Namely, 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

Globalization of new reproductive technologies: illustrations from Egypt

Given the aforementioned issues in the developing world, it should come as no surprise that high-tech reproductive technologies are being marketed to and consumed by those in the developing world on a massive scale. For example, as early as 1994, two Argentine IVF physicians published a multinational study from Latin America examining IVF activity and success rates in 45 IVF centers throughout the region (Nicholson & Nicholson, 1994). At that time, Argentina already had 16 IVF centers, but

Conclusion

Despite the massive globalization of the NRTs, most infertile citizens of developing countries will never take home a test-tube baby, due to the kinds of structural and cultural constraints found in Egypt, as well as in other developing societies around the globe (Bharadwaj, 2001; Handwerker, 2001). On the one hand, this is fortunate, given that the NRTs are clearly not the “miracle solution” for overcoming infertility. As pointed out by numerous feminist scholars (Thompson, 2001), these

Acknowledgements

My deepest gratitude goes to the many Egyptians—including infertile women and their husbands, physicians specializing in infertility and the provision of NRTs, research assistants, faculty and staff members at the University of Alexandria's Shatby Hospital, Ain Shams University's Nozha International Hospital, Nile Badrawi Hospital, and Al-Azhar University's International Islamic Center for Population Studies & Research, and staff of the Binational Fulbright Commission—who have participated in

References (84)

  • S.S. Sheth et al.

    Inappropriate use of new technologyImpact on women's health

    International Journal of Gynecology & Obstetrics

    (1997)
  • D.L. Steinberg

    A most selective practiceThe eugenics logic of IVF

    Women's Studies International Forum

    (1997)
  • J. Sundby

    Infertility in the GambiaTraditional and modern health care

    Patient Education and Counseling

    (1997)
  • L. Abu-Lughod

    The marriage of feminism and Islamism in Egyptselective repudiation as a dynamic of post-colonial politics

  • J.U. Bell et al.

    Effects of lead on mammalian reproduction

  • R. Blank

    Regulation of donor insemination

  • Bennett, S., McPake, B., Mills, A. (Eds.) (1997). Private health providers in developing countries: Serving the public...
  • Bentley, G. R., & Mascie-Taylor, C. G. N. (Eds.) (2000). Infertility in the modern world: Present and future prospects....
  • A. Bharadwaj

    Conception politicsMedical egos, media spotlights, and the contest over test tube firsts in India

  • Boerma, J. T., & Mgalla, Z. (Eds.) (2001). Women and infertility in Sub-Saharan Africa: a multi-disciplinary...
  • A. Bouhdiba

    Sexuality in Islam

    (1985)
  • J.C. Caldwell et al.

    From STD epidemics to AIDSA socio-demographic and epidemiological perspective on sub-Saharan Africa

  • Cates, W., Farley, T. M. M., & Rowe, P. J. (1985). Worldwide patterns of infertility: Is Africa different? The Lancet,...
  • K.M. Curtis et al.

    Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability

    American Journal of Epidemiology

    (1997)
  • C.R. Daniels

    Between fathers and fetusesThe social construction of male reproduction and the politics of fetal harm

    Signs: Journal of Women in Culture and Society

    (1997)
  • C. Delaney

    The seed and the soilGender and cosmology in Turkish village society

    (1991)
  • Devroey, P., Vandervorst, M., Nagy P., & Van Steirteghem, A. (1998). Do we treat the male or his gamete? Human...
  • Egyptian Fertility Care Society. (1995). Community-based study of the prevalence of infertility and its etiological...
  • I. Favot et al.

    HIV infection and sexual behavior among women with infertility in TanzaniaA hospital-based study

    International Journal of Epidemiology

    (1997)
  • P. Feldman-Savelsberg

    Plundered kitchens, empty wombsThreatened reproduction and identity in the Cameroon Grassfields

    (1999)
  • P. Feldman-Savelsberg

    Is infertility an unrecognized public health and population problem? The view from the Cameroon Grassfields

  • S. Fishel et al.

    Reproductive possibilities for infertile couplesPresent and future

  • Gerrits, T. (2000). Studying infertility and STD's among the Macua in Montepuez, Mozambique: A multidisciplinary...
  • T. Gerrits

    Infertility and matrilinealityThe exceptional case of the Macua of Mozambique

  • L. Handwerker

    The politics of making modern babies in ChinaReproductive technologies and the ‘new’ eugenics

  • I.N. Ibeh et al.

    Dietary exposure to aflatoxin in human male infertility in Benin City, Nigeria

    International Journal of Fertility and Menopausal Studies

    (1994)
  • M.C. Inhorn

    Quest for conceptionGender, infertility, and Egyptian medical traditions

    (1994)
  • M.C. Inhorn

    Infertility and patriarchyThe cultural politics of gender and family life in Egypt

    (1996)
  • Inhorn, M. C. (2002). “The worms are weak”: Male infertility and patriarchal paradoxes in Egypt. Men & Masculinities,...
  • Inhorn, M. C. (2003). Babies in global test tubes: gender, science, and reproductive technology in Islamic Egypt. New...
  • M.C. Inhorn et al.

    Infertility, infection, and iatrogenesis in EgyptThe anthropological epidemiology of blocked tubes

    Medical Anthropology

    (1993)
  • Inhorn, M. C. & Van Balen, F. (Eds). (2001). Infertility around the globe: New thinking on childlessness, gender, and...
  • Cited by (211)

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