Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt

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Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt by Mind Map: Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt

1. Prologue: Amira

1.1. Amira

1.1.1. Amira was an only child who wanted to have lots of children.

1.1.2. She had her first marriage at a young age but was unhappy in the relationship. This unhappiness caused her to seek four abortions to prevent herself from being stuck in an unsatisfying marriage. This unhappiness would lead to an eventual divorce. This first marriage would only last three years.

1.1.3. Amira's second marriage would be to a handsome, wealthy, kind—but nonetheless seriously infertile—man named Emad, with whom she would unable to have children. Amira underwent a diagnostic laparoscopy, a procedure designed to visualize the condition of her reproductive organs, before the doctors approached her husband. Emad's semen profile showed that both his sperm count and his sperm motility (movement), were “very bad.”

1.1.4. Amira thought of adoption but she felt that an adoption would not be the same as having her own child and would cause resentment among family members. Islamic adoption is different from western adoption because the Qur'an forbids adoption as it is known in the West, for an adopted child in Egypt is not supposed to take the surname of the adopting father. Rather, the Egyptian practice of adoption is more like the permanent legal fostering of an orphan, which is clearly allowed and is even seen as a good deed in the Islamic scriptures.

1.2. Hope

1.2.1. Amira was still hopeful during her sixth attempt to make a test tube baby. She suffered some complications due to the anesthesia but received a cortisone injection to fix it.

1.3. Resignation

1.3.1. After her sixth attempt failed Amira had to decide whether she wanted to try and transfer her four frozen embryos from an IVF clinic she had visited years earlier. She ended up deciding to not go though with the transfer and let her eggs eventually get destroyed.

1.3.2. In the end Amira gave up completely on having a child

2. Chapter 1: Introduction

2.1. Chapter one talks about Inhorn's anthropological research

2.1.1. Inhorn talks about the secrecy of IVF and other new reproductive technologies.

2.1.2. This book provides an extended ethnographic analysis of the constraints on new reproductive technological practice in a resource-poor, non-Western setting.

2.2. Inhorn talks about the specific Egyptian cultural responses to the use of these Western-generated technologies .

2.2.1. Indigenous theories of procreation that reject the notion of women producing “eggs” for in vitro fertilization.

2.2.2. Sunni Islamic prohibitions on the use of third-party donation (of sperm, eggs, embryos, or uteruses).

2.2.3. Local shortages of hormonal medications that lead to “suitcase trading” of IVF pharmaceuticals across national borders.

2.2.4. 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.

2.3. The Global Demand For New Reproductive Tachnologies

2.3.1. Demography and Epidemiology 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. 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. Of this global population of infertile people, it is estimated that between 29.4 and 44.1 million, or more than half, are Muslims. 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. 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. Secondary infertility means that infertility occurs following a prior pregnancy (whether or not that pregnancy resulted in a live birth).

2.3.2. Fertility-Infertility Dialectic and Pronatalism The paradox with those areas of the world where fertility is also the highest—the phenomenon of so-called barrenness amid plenty. However, the explanation for this paradoxical situation is relatively straightforward: Because children are greatly desired in high-fertility, pronatalist societies, women do not regularly contracept, thereby exposing themselves to the risk of sterilizing infections from STDs, unsafe abortions, and postpartum infections following pregnancy.

2.3.3. Gendered Suffering and Social Stigma Given the social, economic, and political pressures to have children in many societies, it is not surprising that infertility leads to mental, physical, and social suffering. Individuals who are infertile, particularly in pronatalist societies such as Egypt, experience profound human suffering and are often willing to do anything, even risking their own lives in the pursuit of physically taxing remedies, in their efforts to conceive.

2.3.4. Adoption Restrictions Although Westerners often tout adoption as the “natural” solution to childlessness, adoption restrictions, both formal and informal, are found throughout many societies of the world, including the Muslim Middle East. The shari c a (the body of Islamic law) contains specific injunctions against adoption based upon the Qur'an, considered by Muslims to be the word of God as delivered to the prophet Muhammad. Official adoption, whereby an orphaned child becomes a legal son or daughter through adoption of the parents’ (usually the father's) surname as well as their acknowledged heir, is not recognized by Islamic law.

2.3.5. Health Care Seeking

2.4. The Local in the Global

2.4.1. The perception by doctors that their advances will be used the same globally and will not be influenced by culture

2.5. Local Actors in Moral Worlds

2.6. Time, Place, and People

3. Chapter 2: Class

3.1. The Coptic Merchants

3.1.1. Mikhail and Georgette are Coptic Christian merchants who have been trying to have a child for 17 years. Mikhail and Georgette are also first cousins

3.1.2. After 2 years of marriage they visited a Coptic hospital and when they were unable to gain answers they were accompanied to England by one of their doctors. In England she met with a Muslim gynecologist who diagnosed Georgette with an ovarian problem known as polycystic ovarian syndrome (PCOS), explaining this infertility-producing condition in a kind of popular parlance as “fat on the ovaries.”Although PCOS has nothing to do with fat, Mikhail and Georgette thus came to understand Georgette's infertility problem as “ovaries that are coated with some fat” that has “blocked the eggs.” Unfortunately, Georgette underwent a surgical operation to “remove the fat” that proved to be iatrogenic, or productive of further infertility problems. Although her fallopian tubes were once patent, or open, the surgery itself produced scarring, or adhesions, which has led to tubal blockage. Thus, Georgette now suffers from two forms of infertility—ovarian and tubal.

3.1.3. Mikhail and Georgette are the oldest patients at Nozha Hospital's IVF center. They have been able to continue using IVF and ICSI due to their well off business.

3.2. The Enactment of Stratified Reproduction

3.2.1. Whether one can afford the high price tags attached to the medications and operations surrounding IVF and ICSI serves to stratify potential Egyptian consumers of these new reproductive technologies (NRTs) into three distinct tiers: Those who can afford these procedures without significant limitation (i.e., the upper class) Those who can afford them but under limited circumstances (i.e., the middle class) Those who can never afford these procedures without a miracle of physician charity (i.e., the lower-class Egyptian majority). Although stratified reproduction is certainly at play in the Western world of test-tube baby making these constraints become truly magnified in resource-poor, lower-income countries such as Egypt, which, like much of the rest of the developing Third World, is positioned on the receiving end of global reproductive technology transfer.

3.3. The Public-Private Divide

3.3.1. Few third-world countries offer public IVF and ICSI treatments for the poor. This is due to the funds being needed for other public health problems

3.3.2. Of the more than thirty-five IVF centers in the region at the time of the 1996 study, only two—one at the University of Alexandria's Shatby Hospital and one at King Faisal Hospital in Saudi Arabia—were public units. While there are no public IVF and ICSI centers in Egypt its neighbor Israel offers a program of government-subsidized new reproductive technologies to its citizens. All Israeli citi-zens—regardless of income level, religion, or marital status—are entitled to unlimited rounds of IVF treatment free of charge, up to the birth of two live children, in the twenty-three public IVF clinics designated for this purpose.

3.4. The Three-Tiered System

3.4.1. The lower class Poor infertile Egyptian women—and those in the lower-middle class stratum just above them—do, on occasion, appear at private Egyptian IVF centers with or without their husbands. Some may make initial visits to IVF centers, often traveling long distances from rural areas, only to realize that the procedures and drugs are absolutely unaffordable. Others attend IVF centers only to undergo artificial insemination, which is a less invasive and, hence, significantly less expensive reproductive technology. Others present to IVF centers hoping to undergo one trial, having either sold off everything they own (e.g., jewelry, household goods, small pieces of land) or borrowed substantial sums from better-off relatives. Still others are the lucky charity cases—usually a woman whose reproductive tragedy has elicited sympathy from a noble IVF physician and who has been taken on as a gratis patient or has been charged only minimal fees.

3.4.2. The middle class Middle-class Egyptian patients are well represented at Egyptian IVF centers today, although in most cases their concerns over the cost of treatment are profound. For the middle class, having enough money to conduct IVF or ICSI, especially multiple times, is the most fundamental arena of constraint, even though this constraint is not as absolute as it is for the poor. For many middle-class patients, IVF remains a one-time proposition, while for others who are able to repeat the procedure, IVF proves financially devastating over time.

3.4.3. The upper class The commonly held conviction that IVF is limited to the affluent in a country where the costs of IVF are unbelievably expensive for the average Egyptian is, in fact, an accurate one. It serves to explain why the typical IVF patient presenting to the Egyptian IVF clinics were upper-middle to upper-class woman whose husband had consented to the procedure.

3.5. Conclusion

3.5.1. Those IVF patients who “don't think of the money at all” are the privileged few—the wealthy upper crust of Egyptian society for whom the costs of IVF are not at all constraining. For the rest, the financial costs of test-tube baby making are among the major limitations, preventing the infertile poor from undertaking IVF altogether, forcing the middle-class infertile to migrate in order to undertake one-shot attempts at IVF, and even limiting the upper-middle class in their ability to repeat the procedure indefinitely or to go abroad if Egyptian IVF clinics fail them. As such, test-tube baby making in Egypt is an exclusive and exclusionary business, serving to prevent many Egyptian test-tube babies from ever being made. That

4. Chapter 3: Knowledge

4.1. The Oasis dwellers

4.1.1. The Problem of knowledge Mabruka suffers from intractable infertility, but she also suffers from significant problems of knowledge, including perceived lack of knowledge about her own infertility case, uncertain understandings of her reproductive biology, fragmentary knowledge of the reproductive technologies utilized in infertility cases such as hers, and the self-recrimination and doubt accompanying the knowledge that something “wrong with her” has held up her marital fertility and happiness. Yet, her own problems of knowledge seem, somehow, more tractable than those of her poorly educated, “traditional” husband, Ragab, who accepts neither Mabruka for who she is(with or without children) nor the new reproductive technologies that have become necessary to overcome her infertility. Ragab, whose misgivings about and misunderstandings of the new reproductive technologies are pronounced, is, according to Mabruka, fairly typical of their lower-income social class in a rural oasis community, members of whom remain deeply opposed to the morally questionable new reproductive technologies being tried in “big cities” like Cairo.

4.2. Problems of Procreative Knowledge

4.2.1. One of the most fundamental constraints on the acceptance of IVF and the other new reproductive technologies has to do with major differences in knowledge about the human body and its procreative processes. This problem of procreative knowledge goes hand in hand with class constraints: Members of the urban and rural Egyptian lower class, such as Mabruka and Ragab, are often prevented by both their lack of access to capital and their deeply held beliefs about human reproduction from pursuing the new reproductive technologies to overcome their infertility. Class-based knowledge in Egypt may conflict rather directly and profoundly with supposedly global—or at least rapidly globalizing—Western versions of reproductive biology that are assumed in the West to be self-evident and hence are taken for granted as “right” and “natural.”

4.3. Morality and Scientific Literacy

4.3.1. Many more infertile Egyptian couples have become willing to enter Egyptian IVF centers as patients because they have come to achieve moral acceptance of these technologies. This increasing acceptance is due, in turn, to the acquisition of scientific knowledge. In other words, knowledge has become a form of power in Egyptian test-tube baby making. Those who acquire the necessary knowledge are much more likely to seek IVF because their scientific literacy has served to allay, in a powerful manner, many of the niggling moral anxieties about the extracorporeality of IVF that continue to haunt lesser-educated Egyptians and prevent them from even contemplating IVF as a form of treatment.

4.4. Acquiring Scientific Literacy

4.5. Paths to Knowledge

4.6. Scientific Literacy in a Mass-Mediated Society

4.7. Conclusion: The Desire for Knowledge

5. Chapter 6: Efficacy

5.1. The "Mother of the Tube"

5.1.1. Huda's father wanted her to become a mother of at least 3 ivf babies so that one might be named after him Huda recounted a long and painful story of iatrogenesis, or physician-induced harm. When she was only sixteen years old and living in the United Arab Emirates with her labor-migrating parents, she underwent a laparotomy, or abdominal surgery, for a painful ovarian cyst. The Swedish female consultant who performed the surgery removed the ovary with the cyst and, through the surgical procedure itself, caused adhesions around the remaining fallopian tube. In short, this surgery, which Egyptian physicians later deemed questionable and even unwarranted, rendered Huda with irreparable tubal infertility and a missing ovary. Despite her preexisting infertility

5.1.2. Huda has a profound distrust of medical experts, especially those gynecologists who have advised her not to undertake IVF. As she explains, Psychologically, I need second opinions, because I suffered from doctors’ mistakes. Psychologically, I need second opinions, because I suffered from doctors’ mistakes. When I was told I need IVF, I went to many doctors, and I went to one in Muhandiseen [a Cairo suburb]. He said, “Trying to remove adhesions is something useless—not good here in Egypt, or anyplace in the world. And IVF is a kind of gambling.” When I asked Huda why a doctor would be so cruel, she stated simply to make [infertile] patients feel very hopeless.”

5.1.3. Huda's concerns about efficacy are manifold. First, she does not believe that Egypt is very advanced in IVF compared to the West, where the technology was developed. For example, one of the questions she posed to me was whether the 25 percent success rate that she was quoted at Nile Badrawi was the “same in America.” In addition to her concerns about Egypt's position in the global arena, Huda is worried about the lack of regulation of Egyptian IVF centers and what she believes are the resultant attempts by many centers to inflate their success rates.

5.2. The (In)efficacy of NRTs

5.2.1. In Huda's story, we find the embodiment of much that is wrong with privately offered reproductive medicine in the Middle East—including the neocolonial reliance on imported European consultants who may have little vested interest in Middle Eastern women such as Huda; unnecessary and iatrogenic surgeries that are a common cause of tubal infertility in the region; 2 nonspecializing physicians who compete for infertile patients such as Huda by dissuading them from trying IVF; IVF physicians who attempt to entice infertile patients such as Huda with grossly inflated claims of success; and the overarching lack of regulation of the private IVF industry, leading to what Huda calls the “scientific dishonesty” of these mostly “commercial” IVF centers. IVF providers who are entirely unregulated compete for willing clientele by making what might be best characterized as “extraordinary efficacy claims”—claims that unsuspecting patients often take to heart. That the majority of Egyptian IVF and ICSI patients, 70 to 80 percent or more, do not become pregnant with these new reproductive technologies is rarely emphasized.

5.2.2. There are several ongoing problems found in IVF centers that are intensified in Egypt The first major factor affecting new reproductive technology success rates involves the characteristics of patients themselves, particularly the woman's age and the couple's diagnosis. Fertility in women generally declines after the mid-thirties; yet, many women seeking IVF and ICSI in Egyptian as well as Western centers are in their late thirties or older. "The age of forty for women using their own eggs [becomes] a rough boundary, beyond which success rates fall to extremely low levels." Women of any age who undergo IVF or ICSI, the type and number of infertility conditions also has a major impact on success. Male-factor infertility and the diagnosis of multiple infertility problems in the woman, the man, or both “bring lowest rates of success,” according to Turiel. Yet, male infertility and complicated cases of so-called multiple-factor infertility are quite common in Egyptian IVF centers and may in fact comprise the majority of cases. The second major factor affecting IVF success rates involves characteristics of the IVF process, particularly the number of embryos transferred to a woman's body during a treatment cycle. As Turiel notes, “Transferring more embryos … increases the pregnancy rate, but it also increases multiple gestations (possibly necessitating selective reduction procedures), 8 pregnancy loss, and obstetric and neonatal complications.” Some Egyptian IVF physicians are willing to “hyperstimulate” a woman's ovaries to ensure that large numbers of eggs are harvested and embryos fertilized. This may lead to ovarian hyperstimulation syndrome (OHSS), a life-threatening condition that occurs when too-high doses of hormonal agents are used to stimulate high-order egg production. Furthermore, in Egypt, those centers lacking cryopreservation facilities are often too willing to transfer any excess embryos to a woman's body to increase the chance that one or more will implant, thereby boosting the clinic's success rates. Even though multiple-order births are greatly desired among Egyptian IVF patients multiple gestations of twins or more are actually much riskier and are prone to the problems, including pregnancy losses. A third issue affecting efficacy has to do with repetition—namely, the need to repeat IVF or ICSI procedures several times before achieving a successful pregnancy. Since individual patients often undergo many treatment attempts, which can extend over many years, reports of live deliveries also need to indicate which cycle resulted in this outcome. That is, how many attempts did a woman go through before the success? A fourth factor has to do with the way in which IVF programs present their success rates. Turiel emphasizes that selecting and comparing only one number, such as the percentage of deliveries out of all embryos transferred, “does not provide a valid evaluation of a fertility clinic.” Most success rates now reported by [IVF] programs present the number of live deliveries (i.e., at least one live newborn) as a percentage of the total number of attempts to achieve this goal during one year. This proportion of successful outcomes, however, depends on which step in the ART [advanced reproductive technology] process is used to define the number of “attempts.” Some calculations inflate the degree of success because they do not include all of the women who began a treatment. In fact, a crucial dimension underlying measures of success is an “attrition rate.” Patients drop out at each stage of an [IVF] cycle for a variety of reasons, physical, financial, and/or the stress of it all. Finally, success rates are affected by the very quality of care at an IVF center—whether “a program has qualified, experienced personnel and a track record open to public scrutiny.” Even in the United States, information needed to complete the [IVF] picture has not been systematically gathered and reported. Patients and their doctors could benefit from more numbers, sharper calculations, more insight into the medical complexities that affect an individual's outcome. Even more disturbing than the lack of adequate statistics is the absence of apparent only years after flagrant medical practices were occurring. 15 Turiel's critique is seconded by American reproductive endocrinologist

5.3. The Egyptian Game of Inflation

5.3.1. most Egyptian IVF providers are engaged in a deceptive “game of inflation,” whereby lower-than-expected success rates are massaged, juggled, twisted, reshaped, or simply lied about in order to appear much better to potential patients. The result is a statistical free-for-all,

5.3.2. Furthermore, a major discrepancy exists between success rates based on “biochemical” versus “ultrasound-confirmed” pregnancies. At Nozha Hospital, Drs. Yehia and Wafik have stopped using the biochemical pregnancy rate as a marker of success because this rate includes many false-positives—women who are not truly pregnant but who appear to be so because of the hormones circulating in their blood following embryo transfer.

5.4. Positioning Egypt in the Discourses of Hope

5.4.1. women and their husbands are more than willing to talk about the many problems they encounter in the land of test-tube baby making. These include, among other things, prohibitive costs, concerns about laboratory mixing of biogenetic substances, and supercilious physicians who mistreat them. But rate inflation, much to my surprise, does not present itself as a major concern. Instead, most of the Egyptian IVF patients I interviewed seemed to adopt a nationalistic stance about the excellence of test-tube baby making in their country, claiming it to be as good as, if not better than, the “most advanced countries of the West.”

5.4.2. Have Egyptian IVF patients, then, been sold a “bill of goods” by the private IVF industry? Are they unwitting cultural “dupes,” entirely unaware of one of the most serious constraints facing them, namely, the low rates of IVF and ICSI efficacy?

5.4.3. Even on the global stage, Egypt is considered, by most Egyptian IVF patients at least, as now offering IVF services that are as successful as those in Western countries.

5.5. Realities of Success and Failure

5.5.1. In this study at Egyptian IVF centers, I asked women about their reproductive histories, including the number of times they had been pregnant and the number of times they had tried either IVF or ICSI. Of the sixty-six women in my study, more than half (thirty-eight women) had never been pregnant,

5.5.2. These seventeen successes, eight of them on the first attempt, emerged out of seventy-seven total IVF or ICSI trials, for an overall ultrasound-confirmed pregnancy success rate of 22 percent.

5.5.3. Clearly then, test-tube baby making in the best IVF centers of Egypt is a low-odds proposition, similar to the reality in the very best centers in the West. With the proliferation of many new, “low-quality” IVF centers in Egypt, the percentage of success at other Egyptian clinics is likely to be even lower, reflecting the kind of technical difficulties described at length in the last chapter. Despite the inflated claims of success that many of these centers are making, infertile Egyptian women and their husbands, for their part, remain reflective about the realities of a medical technology that, despite its hype, brings no guarantee of success. Several Egyptian women I interviewed told me that they tried to buffer themselves psychologically by keeping their expectations low, predicting each time that they would not succeed in order to recover more quickly from what was likely to be a failed trial. Others used “gambling metaphors,” which are also commonly employed by IVF patients in the West,

5.5.4. particularly those who had failed many times, described the “disaster,” “depression,” “desperation,” “frustration,” and “shock” they felt upon receiving negative pregnancy test results. Most of these women were working in high-powered jobs at the time; yet, knowledge of an IVF or ICSI failure typically immobilized them, making their work and life in general seem meaningless.

5.5.5. I went through IVF five times … because I was told, “You have no hope to achieve pregnancy except through IVF.” But I eventually decided to stop meeting any doctors. I was physically and emotionally tired, and I sold all my gold bracelets to pay for the last trial.

6. Chapter 8: Gender

6.1. The Man Who Replaced His Wife

6.1.1. Shahira is the twenty-five-year-old wife of Moustafa, a well-to-do, forty-three-year-old lawyer whose father was once a powerful politician. In addition to his legal practice, Moustafa rents a villa to a foreign embassy and owns a business center (office supplies and copying), which Shahira runs for him. Shahira is Moustafa's second wife, married to him now for ten months. Prior to this, Moustafa was married for seventeen years to Hala, a woman now in her forties whom he divorced two years ago as a result of their childlessness. Moustafa was told by physicians that he suffered from severe male-factor infertility, involving low sperm count and poor motility. He underwent repeated courses of hormonal therapy, none of which improved his semen profile. Ultimately, he and Hala underwent several cycles of artificial insemination using concentrates of his sperm, as well as five cycles of IVF, three times in Germany and twice in Egypt

6.1.2. Shahira may be young but she married Moustafa so he could provide her and her family with security. Due to her father always being away

6.2. Infertility: His and Hers

6.2.1. The story of Moustafa and his two wives can be read in many ways. On the one hand, it may be seen as a tale of callous patriarchy, in which a Middle Eastern man forgoes his marital vows in order to prove his paternity with a younger woman. On the other hand, it can be read as a tale of gendered suffering, in which both Moustafa and his first wife are victims of a cultural system in which hegemonic masculinities and femininities are instantiated through fertility. Viewed from a different perspective, Moustafa's story could be read as a modernist narrative, in which ICSI promises technological salvation to a hopelessly infertile man, who thereby reestablishes his masculinity through the achievement of fatherhood.

6.3. Femininities, Masculinities, and Child Desire

6.3.1. In Egypt, no adult, male or female, admits to not wanting children. This is as true among the highly educated, career-oriented, upper class as it is among the poor women who were the focus of my earlier research.

6.4. Conjugal Connectivity

6.5. Marriage and Divorce in the Age of ICSI

6.6. Conclussion

7. Chapter 9: Stigma

7.1. The Woman with the Secrets

7.1.1. Maisa, now thirty-nine, and her husband, Ahmed, forty-six, have been married but involuntarily childless for seventeen years. Maisa suffers from blocked fallopian tubes, following an unnecessary and iatrogenic operation on her ovaries called a “wedge-resection.” Ahmed has both poor sperm count and motility, as well as evidence of a prostate infection. He underwent two unnecessary varicocelectomies (one on the right testicle in 1984, and one on the left in 1992), which, not surprisingly, were unsuccessful in improving his semen profile.

7.1.2. Maisa's pharmacist brother and her physician cousin are the only members of her family who know that Maisa and Ahmed are undertaking ICSI. On Ahmed's side, no one knows. Like the vast majority of couples in Egyptian IVF centers, Maisa and Ahmed fear the stigmatization and kalam (gossip) that would ensue if they revealed their status as IVF/ICSI patients. Thus, they feel the need to remain secretive, hiding this information from even their closest family members.

7.2. The “Top Secret” Stigma

7.2.1. IVF in Egypt performs a kind of “double stigmatization,” whereby the very treatment designed to overcome an already stigmatizing health condition leads to an additional layer of stigma, secrecy, and suffering. Or, to use the words of the medical sociologist Arthur Greil, 1 the already “secret stigma” of infertility, and especially male infertility, is intensified into a “top secret stigma” by virtue of participation in the morally ambivalent, even disreputable world of test-tube baby making. An attribute that makes [her] different from others in the category of persons available for [her] to be, and of a less desirablekind—in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. [She] is thus reduced in our minds from a whole and usual person to a tainted, discounted one. Such an attribute is a stigma, especially when its discrediting effect is very extensive.

7.3. Dilemmas of Disclosure

7.3.1. The perceived need for secrecy on the part of Egyptian IVF patients leads to what might best be described as “dilemmas of disclosure.” “To tell or not to tell” is the main question, and beyond that, to tell whom and under what circumstances. Couples in the United States who have used DI are forced to make difficult decisions about honesty versus secrecy, and they are often ambivalent and uncertain that they have made the right decision. In Egypt disclosure dilemmas are nonetheless tied indirectly to the issue of donation. Despite the fact that third-party donation is presumably not practiced in Egypt, the Egyptian public believes that donation occurs—either intentionally by unscrupulous physicians and their desperate patients or through careless accidents that happen in IVF laboratories.

7.4. The Stigma of Support

7.4.1. Maisa's emotional isolation at a time of heightened psychological distress is a consequence of two major factors: First the pervasive secrecy surrounding test-tube against the formation of patient support groups Second, the stigmatization of psychological support itself in a society where mental illness and all forms of professional psychotherapy to overcome it are also profoundly stigmatized and stigmatizing.

7.5. Conclusion

7.5.1. In summary, the world of test-tube baby making in Egypt is fraught with layer upon layer of stigma. First, infertility itself is a profoundly stigmatizing health condition. In Egypt, it spoils the identities of both men and women in ways that are deeply felt. Moreover, among women, it strains social relationships vis-à-vis the outright discrimination against infertile women, who are stigmatized by fertile others for their purportedly uncontrollable hasad , or envy. Second, infertile couples who choose to seek IVF services are doubly stigmatized by their association with a morally questionable technology—one associated in Egyptians’ minds withillicit sex, illegitimate offspring, and enduring sin. Hence, infertile IVF seekers feel compelled to enact elaborate cover-ups to protect not only their own moral reputations but also those of their test-tube babies, whose chances for future happiness depend upon top secrecy surrounding their shameful test-tube origins. Finally, the stigma of IVF is complicated by the stigma of psychological support. To wit, in Egypt, infertile IVF seekers are essentially unable to access potentially beneficial psychological services because of the stigma that inheres to psychotherapy itself. Thus, an infertile woman who dares to seek therapy must do so in silence. If not, she risks being labeled magnuna , or “crazy,” the sole condition that psychotherapists are popularly believed to treat. Given the sheer