1. Prologue
1.1. In 1996, Inhorn is introduced to Dr. Yehia, a popular IVF doctor, and one of his patients, forty-year old Amira.
1.1.1. Amira
1.1.1.1. underwent three years of unsuccessful attempts to conceive a child utilizing the latest reproductive technologies
1.1.1.2. reproductively "elderly"
1.1.1.3. married to a very infertile husband named Emad
1.1.1.4. endured a decade-long search for a solution to her childlessness
1.1.1.5. daughter of a wealthy Egyptian family; an only child raised by a strict grandmother
1.1.1.6. always yearned to have a big family
1.1.1.7. married young to a man she did not love
1.1.1.8. received four abortions from four different doctors and eventually decided on a divorce
1.1.2. Infertility
1.1.2.1. women typically undergo diagnostic laparoscopies
1.1.2.2. doctors prefer laparoscopies to semen analysis because it means confronting the husband
1.1.2.3. husbands reluctant to face serious male infertility problems head on, either in terms of treatment attempts or admission to others that fertility problem is his
1.1.2.4. donor insemination prohibited by muslim religion
1.1.2.5. Egyptian practice of adoption is more like permanent legal fostering of an orphan; yet legal fostering is frowned upon among the elite
1.1.2.6. Qur'an forbids adoption as it is known in the West
1.1.3. God
1.1.3.1. Amira is convinced her childlessness is punishment from God
1.1.3.2. feels a profound absence of children in her life
1.1.3.3. undertook the hajj, a religious pilgrimage to Saudi Arabia
1.1.3.4. dons a veil as a sign of her personal relationship with and duty to God
2. Chapter One: Introduction
2.1. Inhorn dedicates her book to Amira and the other childless Egyptians whose attempts at test-tube babies failed. Inhorn hopes to open a window of understanding into contemporary Egypt.
2.1.1. Egypt
2.1.1.1. provides a particularly fascinating locus for investigation of the global transfer of new reproductive technologies
2.1.1.2. resource-poor and overpopulated
2.1.1.3. fifteenth largest county in the world
2.1.1.4. a nation of nearly 70 million people
2.1.1.5. in 1994 infertility was officially placed on the global reproductive health agenda
2.1.1.6. total infertility prevalence rate among married Egyptian couples = 12%
2.1.1.7. on the forefront of new reproductive technology development in the middle east
2.1.2. Global Demand
2.1.2.1. infertility is a global health issue that affects millions of people worldwide
2.1.2.2. between 50 to 80 million people worldwide may be experiencing infertility at any given time
2.1.2.3. more than half of the global population of infertile people are muslims
2.1.2.4. muslims represent a large percentage of of the populations living in the so-called infertility belt of sub-Saharan Africa
2.1.2.5. reproductive tract infections are the leading preventable cause of infertility
2.1.2.6. in the non-western world tubal infertility is highly prevalent
2.1.2.7. despite the high prevalence of male infertility around the world, infertility is usually considered a "woman's problem"
2.1.3. Social Stigma
2.1.3.1. infertility leads to mental, physical, and social suffering
2.1.3.2. the burden of suffering generally rests on the shoulders of women, whether or not they are the infertile partner
2.1.3.3. infertility has lifelong consequences for women, often making them economically vulnerable
2.1.3.4. in some societies infertile women are suspected of harming other others' children through their uncontrollable envy and casting of the evil eye
2.1.3.5. infertility casts doubt upon a woman's gender identity and prevents her from achieving full status as an adult woman
3. Chapter Two
3.1. Inhorn meets Mikhail and Georgette, and the story of their marriage, their religion, and their efforts to conceive are disclosed.
3.1.1. Mikhail & Georgette
3.1.1.1. different by virtue of their minority status
3.1.1.2. wealthy members of the elite
3.1.1.3. private entrepreneurs
3.1.1.4. undergone multiple IVF and ICSI trials
3.1.2. The Three-Tiered System
3.1.2.1. class-based system of IVF accessibility
3.1.2.2. only the countries wealthy have unfettered access to new reproductive technologies
3.1.2.3. "class" is a contentious issue
3.1.2.4. six class strata as defined by Ibrahim, from the destitute to the fabulously rich
3.1.2.5. a pyramidal class structure exists in urban Egyptian society
3.1.2.6. the three tiers--the elites, the middle class, and the masses--are differentially represented in Egyptian IVF clinics based on degree to which finances constrain them
3.1.2.7. poor Egyptian women essentially barred from undertaking IVF
3.1.2.8. middle-class patients put all of their resources into costly IVF trials
3.1.2.9. test-tube baby making is widely perceived as being "only for the rich"
3.1.3. Upper Class
3.1.3.1. justify their need for repeated trials of IVF and ICSI by virtue of their need for heirs to whom they could pass on family businesses and fortunes
3.1.3.2. they cite Qur'anic passages which deem money and children to be the most precious things in the world
3.1.3.3. test-tube baby making is an exclusive and exclusionary business
3.1.3.4. the biggest problem with IVF is economic
4. Chapter Three
4.1. Inhorn demonstrates how consumers of new reproductive technologies search for knowledge.
4.1.1. Procreative Knowledge
4.1.1.1. problem of procreative knowledge goes hand in hand with class constraints
4.1.1.2. class-based knowledge may conflict directly and profoundly with global versions of reproductive biology
4.1.1.3. acceptance of women's eggs in procreative discourse has only served to heighten the level of blame placed on women for reproductive failures
4.1.1.4. both infertile and fertile women may be condemned for failure
4.1.2. Morality
4.1.2.1. gendered dimensions to moral discourses
4.1.2.2. parenthood is synonymous with "natural"
4.1.2.3. knowledge as well as social mores impinge upon the acceptance of new reproductive technologies
4.1.2.4. misconceptions about test-tube baby making evoke moral questions and uncertainties
4.1.2.5. scientific literacy in the realm of new reproductive technologies in Egypt can only be understood within a moreal framework
4.1.3. Paths to Knowledge
4.1.3.1. three main paths to knowledge
4.1.3.1.1. knowledge acquired from reading books and other printed materials
4.1.3.1.2. knowledge acquired from doctors themselves
4.1.3.1.3. knowledge acquired from exposure to media publicity regarding reproductive technology
4.1.3.2. books in particular seem to play a major educational role for some women
4.1.3.3. issues of impaired knowledge come to the fore even for the infertile elite, particularly in discussions of often misleading success rates
4.1.3.4. for some couples knowledge is power, despite the fact that these technologies provide no guarantee of success
5. Chapter Four
5.1. Inhorn investigates reproductive medicine and religious morality.
5.1.1. Religion
5.1.1.1. Islamic religiosity is increasing in the Muslim world
5.1.1.2. during periods of uncertainty, religion provides an important source of moral legitimization for controversial actions
5.1.1.3. religion represents a fundamental arena of constraint on the practice and use of reproductive technologies
5.1.1.4. moral concerns rest on the inherent rightness or wrongness of new reproductive technologies
5.1.2. Fatwas
5.1.2.1. fatwas issued from Al-Azhar have great weight throughout Arab countries
5.1.2.2. Egyptian government ignored or downplayed other fatwas that do not promote state interest
5.1.2.3. fatwa spells out clearly which techniques in medically assisted conception are permitted and which are forbidden
5.1.2.4. a number of basic guidelines must be followed
5.1.2.5. sperm donation in artificial insemination is strictly prohibited
5.1.3. Contemplating Immoralities
5.1.3.1. Egyptians perceive themselves as morally superior to the Christian West
5.1.3.2. believe the West has lost its moral compass in the pursuit of reproductive technologies that go against god
5.1.3.3. embryo disposal in Egypt is not considered murder
5.1.3.4. few infertile elites regard donation as an acceptable alternative
5.1.3.5. moral concerns weigh hard on the hearts and minds of both IVF patients and physicians
6. Chapter Five
6.1. Inhorn gives insight into Dr. Mohamed Yehia, the movie star doctor, as well as doctor-patient relationships in Egypt.
6.1.1. Providers
6.1.1.1. Dr. Yehia represents new face of Egyptian reproductive medicine
6.1.1.2. some private providers of Western-generated technologies have been exceptionally competent
6.1.1.3. those living in urban areas of the Middle East rely on private practioners
6.1.1.4. plagued by endemic problems
6.1.1.5. private provision of new reproductive technologies is fraught with obstacles and constraints
6.1.2. Quality of Care
6.1.2.1. patients appreciate physicians with finely honed interpersonal skills
6.1.2.2. patients value the importance of doctor-patient relationships in general
6.1.2.3. many critique the general bedside manner of Egyptian physicians
6.1.2.4. trust is engendered through interpersonal competence
6.1.2.5. many infertile patients had horror stories about their experiences within IVF centers
6.1.2.6. medical information is controlled by physicians
6.1.2.7. finding a compassionate, communicative IVF physician who can be entrusted with one's gametes and embryos is a major ordeal for many would-be users of new reproductive technologies in Egypt
7. Chapter Six
7.1. After interviewing Huda, Inhorn discusses the embodiment of what is wrong with privately offered reproductive medicine in the Middle East.
7.1.1. The Inefficiency of NRTs
7.1.1.1. efficacy is a thorny issue
7.1.1.2. problems of efficacy must be dealt with in a global context
7.1.1.3. IVF providers who are entirely unregulated compete for clientele by making extraordinary efficacy claims
7.1.1.4. Egyptian physicians sell false hope to otherwise hopeless patients
7.1.1.5. virtually all Egyptian IVF centers present overarching, inflated percentages
7.1.1.6. success rates are affected by the very quality of care at an IVF center
7.1.2. Game of Inflation
7.1.2.1. quality of care at IVF clinics is variable
7.1.2.2. poor quality of care diminishes success rates
7.1.2.3. success rates are massaged, juggled, twisted, reshaped, or simply lied about in order to appeal to potential patients
7.1.2.4. IVF providers have yet to enact a uniform standard for calculating success rates
7.1.3. Realities of Success and Failure
7.1.3.1. test-tube baby making in the best IVF centers of Egypt s a low-odds proposition
7.1.3.2. a proliferation of low-quality IVF centers in Egypt affects success rate
7.1.3.3. despite inflated claims, infertile Egyptian women remain reflective about the realities of a medical technology that, despite its hype, brings no guarantee of success
7.1.3.4. the price of inefficiency is high and low success rates plague IVF industries
8. Chapter Seven
8.1. Inhorn investigates the physical risks of medical technologies and how new reproductive technologies act adversely upon the body.
8.1.1. Hormones
8.1.1.1. taking hormones is an almost inevitable part of women's lived experience of biomedical infertility treatment
8.1.1.2. with IVF and ICSI hormonal treatments often intensify
8.1.1.3. drug taking associated with new reproductive technologies associated with a daily onslaught of injections, blood draws, and ultrasound scans
8.1.1.4. most women suffer side effects that are downplayed by IVF scientists
8.1.1.5. in Inhorn's study, virtually every woman was prescribed some sort of hormonal medication
8.1.1.6. some hormones produce deadly side effects and life-threatening reactions
8.1.2. Bedding Down
8.1.2.1. once hormones are taken during the first 15 days of treatment, the next 15 days involve a long tortured process of worrying and waiting
8.1.2.2. worry heightens when women move from hospital beds to their beds at home
8.1.2.3. women hope that by remaining still and inactive, embryos will implant rather than abort
8.1.2.4. although encouraged to live normally, most women bed down for a two-week period
8.1.2.5. women fear losing their babies through physical activity that could have been avoided
8.1.3. Suffering
8.1.3.1. in Egypt, test-tube baby making bespeaks a world of embodied suffering
8.1.3.2. Egyptian drug crisis highlights the ways in which powerful structural impediments serve to restrict the reproductive agency of Third World actors who need drugs in order to become parents
8.1.3.3. taking drugs is viewed as a necessary evil, and a source of unhappiness for both men and women
8.1.3.4. gendered suffering accompanies new reproductive technologies
9. Chapter Eight
9.1. Inhorn explores the implications of test-tube baby making for gender, marriage, and family life in Egypt.
9.1.1. Child Desire
9.1.1.1. in Egypt, no adult, male or female, admits to not wanting children
9.1.1.2. pronatalist sentiments cross class boundaries
9.1.1.3. men profess their love of children as much as women
9.1.1.4. many Egyptians express their desire for many children and feel incomplete without the experience of parenthood
9.1.1.5. most women deem motherhood to be a natural part of their lives
9.1.1.6. those who miss out on motherhood are deemed incomplete in their gendered personhood
9.1.1.7. infertility poses an acute crisis for femininities in Egypt
9.1.1.8. male fertility and masculinity has been poorly studied in the Middle East
9.1.2. Connectivity
9.1.2.1. Egyptian marriage is a highly valued and normatively upheld institution
9.1.2.2. Islam extols the virtues of marriage
9.1.2.3. marriage is regarded as protection for both a woman and a man
9.1.2.4. remaining single is socially penalized
9.1.2.5. permanent bachelors and spinsters are rarely found in Egypt
9.1.2.6. marriages are considered fragile and unstable until the birth of children is achieved
9.1.2.7. marriage is for the purpose of procreation
9.1.2.8. love is expected to emerge after marriage through the experience surrounding the birth and parenting of children
9.1.2.9. Egyptian couples faced with infertility and the possibility of permanent childlessness tend to forge a deeper love, affection, and intimacy
9.1.3. Gender
9.1.3.1. gender shapes the experience of infertility
9.1.3.2. the expectation to be a father is not as important a part of the male identity as the expectation to be a mother is of the female identity
9.1.3.3. ICSI is a mixed blessing
9.1.3.4. gender responses to infertility are not culturally invariant
10. Chapter Nine
10.1. The world of test-tube baby making in Egypt, fraught with layer upon layer of stigma, is analyzed.
10.1.1. Top Secret
10.1.1.1. infertility is intensified into a top secret stigma by virtue of participation in the morally ambivalent world of test-tube baby making
10.1.1.2. feelings of spoiled identity among both men and women of all social classes are an almost inevitable part of the infertility experience
10.1.1.3. in Egypt, few men publicly reveal their reproductive failing and allow their wives to assume the blame in either a direct or de facto fashion
10.1.1.4. Egyptian men are freer of fertility scrutiny that is part and parcel of every Egyptian woman's life
10.1.1.5. hasad, or envy, is considered a justified cultural concern
10.1.1.6. Egyptian elites are able to make their infertility problems much less visible by remaining secretive
10.1.2. Disclosure
10.1.2.1. dilemmas of disclosure is affected by the need for secrecy
10.1.2.2. Egyptians are unwilling to be publicly associated with morally disreputable technology
10.1.2.3. patient empowerment through organized support groups has yet to take root
10.1.3. Stigma
10.1.3.1. infertile couples who choose to seek IVF services are doubly stigmatized
10.1.3.2. IVF seekers are compelled to enact elaborate cover-ups
10.1.3.3. choosing IVF or ICSI involves crossing a major psychological and social hurdle