Marcia C. Inhorn, PhD, MPH William K. Lanman Professor of Anthropology & International Affairs

1. Global Infertility & the Globalization of Assisted Reproductive Technologies (ARTs):Middle Eastern Perspectives Marcia C. Inhorn, PhD, MPH William K. Lanman Professor of Anthropology & International Affairs Department of Anthropology & MacMillan Center, Yale University

2. Global Infertility and Assisted Reproductive Technologies • Why is infertility an important global reproductive health problem? • Why are assisted reproductive technologies important, even for low-resource countries?

3. Infertility Demography and Epidemiology • ~15% couples infertile in most societies • 186 million ever-married women (25%) • “Infertility belt” of sub-Saharan Africa • Tubal infertility due to infection: RTIs are primary form of preventable infertility • Male infertility contributes to > half of all cases and is difficult to treat: genetic etiology, requiring ARTs to overcome

4. Male Infertility • Oligospermia (poor count) • Asthenospermia (poor motility) • Teratozoospermia (poor morphology) • Azoospermia (absence of sperm) • Obstructive • Non-obstructive

5. Fertility-Infertility Dialectic • Paradox of “barrenness amid plenty” • Infertility provides a lens through which to explore issues of fertility • Control of infertility rarely incorporated into population and family planning programs • No global guidelines for infertility prevention and treatment

6. Health-Care Seeking • Infertility a leading cause of health-care seeking • Infertile women and men massive users of biomedicine • “Body histories” of unsuccessful infertility treatment • Resort to both “traditional” and “modern” therapy, often simultaneously • Formal health services offer little

7. Marital Consequences:47-country DHS Survey • 14% higher rate of divorce or separation • 21% in Latin America overall; 40% in Nicaragua, Dominican Republic • 15-20% polygyny rates (Yemen to Kenya) • Domestic violence • Verbal and emotional abuse • Exposure to HIV through extramarital sex • Abandonment and prostitution

8. Gendered Suffering:A Woman’s Burden • Blame for the reproductive failing • Emotional responses • Social stigma and community ostracism • Economic impoverishment • Lifelong consequences (poverty in old age) • Death in era of HIV/AIDS • Pernicious form of “reproductive disruption”

9. Adoption Restrictions • “Alternatives” to biological parenthood unacceptable in many societies • Adoption restrictions (eg, in the Qur’an) • Informal fostering in Africa overwhelmed by high number of AIDS orphans • “Excess” babies in Latin America and Asia “marketed” to infertile Western couples • Global infertility intricately linked to global adoption and transnational movements of children

10. Globalization of ARTs • ARTs spread rapidly around the globe in response to difficulties of infertility and adoption • ARTs not transferred into “cultural voids” • Local considerations shape and curtail reception of ARTs in local sites • Need to assess costs and benefits of ARTs in multiple local sites

11. Arenas of Constraint • The various structural, ideological, social relational, and practical obstacles and apprehensions facing ART users • Deconstructs myth that ARTs are “miracle solution” for infertility

12. Stratified Reproduction • Ginsburg and Rapp, following Colen (1995) • “the arrangements by which some reproductive futures are valued while others are despised” • ARTs assist global elites: $2,000 - $20,000 per cycle • Average IVF baby in US: > $60,000 • ARTs rarely subsidized for the poor, who are most at risk of infertility

13. Global Reproductive Tourism

14. Local Moral Worlds • ARTs received, accommodated, and resisted in local moral landscapes • Kleinman (1992), “local moral worlds” accompanying spread of biotechnologies • Kahn (2000), Reproducing Jews: A Cultural Account of Assisted Conception in Israel • In the Muslim world, moral concerns over ARTs run deep

15. Louise Brown 1978 2004

16. ARTs • In vitro fertilization (IVF) • Intracytoplasmic sperm injection (ICSI) • Third-party gamete donation • Embryo donation • Surrogacy • Ooplasm transfer • Preimplantation genetic diagnosis (PGD) • Cloning

17. ARTsin the Middle East

18. Middle Eastern IVF Clinics:2009 Examples • Turkey (pop. 77 million): >115 • Egypt (pop. 70 million): >50 • Iran (pop. 70 million): >50 • Israel (pop. 6 million): 24 • Lebanon (pop. 4 million): 15

19. IVF Clinics in Egypt, Israel, and Lebanon, 2003 • Egypt (pop. 70 million): 50 • Israel (pop. 6 million): 24 • Lebanon (pop. 3-5 million): 15

20. Global Metric • Rapid expansion and considerable dynamism as ART technologies have evolved over time • Test-tube babies’ lives can be seen as “greatest fruits” of ART globalization • However, ARTs have brought moral controversy

21. Research on Infertility and ARTs: Middle Eastern Perspectives • 1988-89: IVF new to Muslim world • 1996: IVF “boom period” in Muslim Middle East • 2003-5: ”Middle Eastern Masculinities in the Age of New Reproductive Technologies” • 2007-9: “Globalization and Reproductive Tourism in the Arab World”

22. Methods • Qualitative (ethnographic) interviews • Muslim IVF patients (husbands and wives) • More than 600 patient couples • Participant observation in 7 IVF clinics • Egypt, Lebanon, United Arab Emirates, and “Arab Detroit, Michigan”

23. Books • Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt (Routledge, 2003) • Reconceiving Middle Eastern Manhood: Islam, Assisted Reproduction, and Emergent Masculinities

24. Sunni Islam and IVF • March 23, 1980: Grand Shaikh of Al-Azhar issues first fatwa on medically assisted reproduction • Al-Azhar fatwa continues to be authoritative for world’s Sunni Muslims • 90% of world’s 1.6 billion Muslims are Sunni • 90% Egyptians are Sunni Muslims

25. Sunni Islam and IVF: Main Points • IVF is permitted, using eggs from wife and sperm from husband followed by transfer of fertilized embryos back to uterus of same wife • Third-party donation is not permitted, whether of sperm, eggs, embryos, uteruses (as in surrogacy)

26. Egypt Iran Kuwait Jordan Lebanon Morocco Qatar Turkey Indonesia Malaysia Pakistan Sperm Donation Prohibited in Muslim Countries: 1997 Global Survey

27. Prohibition of Gamete Donation:3 Reasons • Association with adultery • Potential for future half-sibling incest • Confusion of kinship, descent, and inheritance

28. Meirow and Schenker state: • “In many Islamic countries, where the laws of Islam are the laws of the state, donation of sperm was not practiced. AID is considered adultery and leads to confusion regarding the lines of genealogy, whose purity is of prime importance in Islam.”

29. The Introduction ofIntracytoplasmic Sperm Injection (ICSI)

30. ICSI in the Middle East • ICSI is new “hope technology” • ICSI has restored masculinity • ICSI has led to “coming out” of male infertility • ICSI is now advertised as solution to male infertility • ICSI is fascinating topic of research

31. ICSI and Divorce Potential • What about wives of infertile men? • Wives may have grown too old to produce viable ova • ICSI relies on healthy ova, even in absence of healthy sperm • In absence of egg donation, Muslim couples face four difficult choices

32. Four Difficult Choices • Remain together permanently without children • Legally foster an orphan • Remain together in polygynous marriage • Divorce, so husband can have children with another partner

33. Iran Iraq Lebanon Syria Bahrain Saudi Arabia Afghanistan Pakistan India Shia Islam and IVF

34. Ayatollah Ali Khamanei’s Fatwa • Late 1990s, Supreme Leader of Shia Islam issues fatwa permitting donor technologies • Egg and sperm donation are allowed, but both donor and infertile parents must abide by religious parenting codes • Donor child inherits from donor, as infertile parents like “adoptive” parents

35. Divergences in Shia Opinion • Shia situation complicated • Shia practice ijtihad, which allows individual religious reasoning • Divergences among Shia religious authorities on acceptance of third-party donation

36. Disagreements in Shia Views on Third-Party Donation • Whether child follows name of infertile father or sperm donor • Whether donation is permissible if donors are anonymous • Whether donation constitutes zina if no “touch or gaze” • Whether husband of an infertile woman needs to do a temporary mut’a marriage with an egg donor

37. Shia Views of Sperm Donation • Whether married Shia woman can do mut’a marriage with sperm donor • In theory, only widowed or single women should accept donor sperm • Single motherhood of donor child is socially unacceptable • Iran recently made sperm donation illegal • Still being practiced: “temporary divorce” • Surrogacy has been permitted

38. Third-party Donation in Practice among Shia Muslims • Difficult to meet requirements, especially regarding sperm donation • Yet, Shia couples are beginning to receive donor gametes and to donate gametes to other infertile couples • Donation described as “marriage savior,” helping to avoid “marital and psychological disputes”

39. Egg Donation in Shia-Dominant Lebanon • Fatwa on egg donation boon to marital relations • Waiting lists for donor eggs in Lebanese IVF clinics

40. Sources of Donor Eggs • Other IVF patients • Friends or relatives • American women who travel to Lebanon to anonymously donate eggs

41. Recipients of Donor Eggs • Conservative Shia couples, who may belong to Hizbullah political party • Sunni Muslim patients and travelers from other Middle Eastern countries quietly “saving their marriages” through donor gametes • Secretly “going against” Sunni Muslim orthodoxy

42. Arrival of Donor Technologies in Muslim Middle East • Significant medical transnationalism and reproductive tourism • Mixing of gametes across ethnic, racial, and religious lines • Shia gametes in Sunni bodies • Birth of hundreds of donor babies to devout Muslim couples

43. Shia “Pragmatism” & “Flexibility” • Potential transformation in marital relations among infertile Shia Muslim couples • Rethinking of biological kinship and parenthood • Moral accommodation of previously immoral reproductive acts • Indicator of profound social effects reproductive technologies may engender

44. The Importance of Iran:Ayatollah Ali Hussein Khamanei

45. Ayatollah Ali Sistani

46. Sobering Note • Most infertile Muslim couples will never know joy of making a Muslim IVF baby • ARTs will never be viable solution for world’s infertile poor • Governmental neglect of infertility and ARTs • Infertility is not a life-threatening disease • Is having children a basic human right? • Is access to ARTs a reproductive right?

47. 191 WHO Member States • 48 offer IVF and other ARTs • < 1% of projected need in largest countries (China, Inda, Pakistan, Indonesia, Egypt) • 50% multiple births in Latin American IVF • <15% of projected need in U.S. • Only 36% infertile U.S. women seek infertility assistance, and 1% access ARTs • Infertility and “health disparities”

48. Cost of ARTs • Average cost is $12,400 per IVF cycle in U.S. • Range: $1,300 (Iran) to $6,400 (Hong Kong) • > 50% annual income in most countries • Experiments in state subsidization

49. The Case of Egypt • 5 IVF clinics in government hospitals • Al-Azhar University: IVF clinic for poor • Why? • Pronatalist Muslim country • Marriage and parenthood are virtues • “Cairo Conference” (ICPD 1994) • Remarkable cadre of IVF physicians • FIGO presidents: Gamal I. Serour

50. Childlessness Not a Trivial Matter • Ruins reputations • Ruins marriages • Ruins livelihoods • Ruins physical health • Ruins long-term security