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A new procreation story : the contested domain of the in vitro fertilization pre-embryo in British Columbia Lee, Patricia M. 1994

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A NEW PROCREATION STORY: TILE CONTESTED DOMAIN OF TIlEiN VITRO FERTILIZATION PRE-EMDRYO IN BRITISH COLUMBIAbyPATRICIA M. LEEB.A. , University of British Columbia, 1987A THESIS SuBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR TIlE DEGREE OFDOCTOR OF PHELOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Department of Anthropology and Sociology)We accept this thesis as conformingthe r uired stahdardTHE UNiVERSITY OF BRITISH COLUMBIAJuly 1995© Patricia M. Lee, 1995Signature(s) removed to protect privacyIn presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of_________________________The University of British ColumbiaVancouver, CanadaDate /ffrJ F/99DE-6 (2188)Signature(s) removed to protect privacySignature(s) removed to protect privacyABSTRACTThe human pre-embryo is emerging as a new cultural category as a result of theprocesses of in vitro fertilization (IVF) technology. The principle purpose of thisconceptive medical technology is to assist infertile couples produce their own biologicalchildren. I argue that three specific discourses, biomedicine, law and feminism, whichhave been selected for this research are generating conilicting and contested debates aboutthe cultural values and meanings associated with the human pre-embryo.The physical separation of the pre-embryo as an independent entity createdexternal to a woman’s body enhances its use in medical treatment, diagnosis and research.This phenomenon has facilitated the manipulation of the pre-embryo in the treatment ofinfertility, preimplantation diagnosis and research into genetically related diseases. Theversatility of the pre-embryo for use in both research and treatment has resulted in agrowing controversy about its potential for altering the natural relations and sequencing ofbiological family organization and about its part in a larger social engineering projectleading ultimately to change in social structure.A combination of anthropological methods demonstrate the centrality of the preembryo in the enlarging controversial debates about new reproductive technologies. Thebiomedical-technical practices of creating, cryopreserving and replacing pre-embryos,which were observed in an ethnographic study of an in vitro fertilization programmeprovides foundational data for analysis of the three discourses. A critical interpretiveapproach in medical anthropology situates IVF technology in its cultural and historicalcontext as part of a continuing scientific fascination with understanding the beginnings oflife. IVF technology is a gateway into a modem exploration ofhuman genetics, using preembryos to probe the essential nature of human inheritance. The traditional debates inUanthropology about the cultural nature of parenthood and the juro-political aspects ofrules and rights in and over people and things have current relevance. They provide acultural understanding about the ability of IVF to re-arrange the biological, putative andsocial relations of parenthood. They reveal the methods whereby legal controls areexerted by groups with different vested interests in children born from IVF and its adjuncttherapies, such as surrogacy arrangements and ovum donation. A feminist anthropologicalperspective explores a recent approach in symbolic anthropology about the culturalmeanings of procreation stories, as expressed by women, based on a particular culturalideology. It reveals the means by which the technologies associated with TVF have thepropensity to fragment and devalue women’s bodies, a strategy which is often endorsed bythe culturally legitimated knowledge ofmedicine and law.Four overarching unmediated oppositions are identified in the analysis of the threediscourses: research science and clinical therapy; experimental risk and routine therapy;ownership (property) and autonomy (persoithood); and technological reproduction(culture) and natural reproduction (nature). The controversies raised by the tensionbetween polarities highlights problems ofmeaning. These are expressed in the discoursesas a struggle over values, which in turn are converted into struggles over power Theyrepresent the new cultural meanings and social consequences which are presentlyemerging in response to new conceptive technologies.mTABLE OF CONTENTSPageABSTRACT iiTABLE OF CONTENTS ivLIST OF TABLES viiiLIST OF FIGURES ixPREFACE: CONCEIVING THE RESEARCH PROJECT x(i) Creating a Feminist Network xii(ii) Off to Foreign Fields at Home xivACKNOWLEDGEMENTS xxiiCHAPTER 1. IN THE BEGINI1ING 1I INTRODUCTION 1(i) What is in vitro fertilization (JVF) technology? 1(ii) The Three Discourses: Medicine, Law and Femini 4(iii) The Context: Infertility and the Reign ofTechnology 6II A CONCEPTUAL CONFUSION: DEFINING INFERTILITY AN])THE CONCEPTIJS 8(i) Infertility as a Terminological Confusion 8(ii) Mixing our Meanings: Redelining the “Embryo” 12ifi THEORETICAL PERSPECTiVES 15(1) Critical Interpretive Medical Anthropology 16(ii) From an “Anthropology ofWomen” to Feminist Anthropology 21(iii) A Feminist Approach to Discourse Analysis 231V THE BRITISH COLUMBIA WF PROGRAMME 27V CHAPTER OUTEINE 30CHAPTER 2. MEANINGS OF CONCEPTION: FROM TRADITIONAL KINSHIPSTUDIES TO NEW PROCREATION STORIES IN ANTHROPOLOGY 33I CONCEPTION THEORIES: TRADITIONAL DEBATES ABOUTPROCREATION IN ANTHROPOLOGY 34(i) Virgin Births and Concepts ofPaternity 34II KINShIP AN]) BIOLOGY 36(1) Cultural Constructs ofBiological Processes 36(ii) (3enitor/Genetrix: :Pater/Mater: Problems ofParenthood 37(iii) Categorizing Parents: Some Cognitive Models 39ifi PROCREATION STORIES: RECONSTRUCTINGKiNSHIP AN])FAMILY 41ivIV THE POLITICO-JURALAPPROACH IN ANTHROPOLOGY .44(i) Rights in Rem, Rights in Personam 45(ii) Twin Universes: Persons and Things 46V GENDER STUDIES AND REPRODUCTION IN ANTHROPOLOGY 49(i) Moving Reproduction from “Off-Centre” 49(ii) Legal Anthropology and Relations ofPower 51VI CONCLUSION 54CHAPTER 3. THE MEDICAL DISCOURSE: THE HISTORY OF EMBRYORESEARCHAND THE BIRTH OF IVF TECHNOLOGY 56I FROM “FAILURE TO GENERATE” TO “CONCEPTION IN AWATCH GLASS” 58(i) Classical Greek Models ofProcreation 58(ii) Preformation Theories 60(iii) Theories ofOvulation and Embryo Development 61(iv) The Egg Hunt: The Access to and Ethics ofEmbryology Research.. 63II 1W AND EMBRYO TRANSFER: NEWWAYS OF MAKiNGBABIES 66ifi A CHRONOLOGY OF INFERTILITY AND GENETICSCREENTNG TECHNOLOGIES 711V THE MEDICAL DISCOURSE OF INFERTILITY AND SUCCESS:PROBLEMS OF DIAGNOSIS AND CURE 76(i) The Discourse ofEpidemiology ( Population Studies) 76(ii) The Numbers Games 78(iii) “A Take Home Baby”: Measuring the Rhetoric of”Success” 80V THE CAUSES OF INFERTILITY: MERGING STANDARDMEDICAL, PUBLIC HEALTHAND ENVIRONMENTALDISCOURSES 82(i) The Standard Medical Discourse 82(ii) The Environmental Discourse 84VI AN 1W PROGRAMME IN BRITISH COLUIVIBIA 87(i) A Short History 87(ii) The Current Situation of 1VF in Vancouver 94(iii) An Uneasy Separation 98VII CONCLUSION 99CHAPTER 4. THE MEDICAL-TECHNOLOGICAL DISCOURSE:CREATINGANDFREEZINGPRE-EMBRYOS 102I PREPARING FOR THE SUPEROVULATION PROCESS 103(i) “Ladies-in-Waiting”: Coming “on board” 103(ii) Counseling the Clients 105(iii) “Calling the Pergonals”: Calling the Shots 107VII THE OOCYTE RETRIEVAL OR THE “EGG PICKUP” .112(i) The Routinization ofA F[igh Drama.112(ii) The “Egg Pickup” 115ifi A WINDOW OF OPPORTUNITY: INTO THE LAB 117(i) A Mecca ofMachinery 117(ii) “Egg” Care 120(iii) Insemination and Syngamy: Technology versus Nature 121(iv) Cleaving Embryos: Watching, Waiting and Wastage 123(v) The Embryo Transfer 1271V FROZEN IN TIME AND SPACE: FREEZiNGPRE-EMBRYOS 128(i) A Chilly Climate 129(ii) More than Enough: Freezing Choices 131(ili) It’s Just a Matter of Time 135V IDENTIFYING RISKS AND ACKNOWLEDGING THECOMPLICATIONS 138VI CONCLUSION 141CHAPTER 5. THE LEGAL DISCOURSE: THE CASE FOR THE PRE-EMBRYO... 145I CANADIAN VALUES AN]) GUIDINGLEGAL PRINCIPLES 146II PERSON OR PROPERTY: PRECEDENT SETTING CASESIN THE UNITED STATES 148(i) Reos 149(ii) Davis v. Davis, Kass v Kass and Jones v. York 150(ili) Oocyte and Embryo Donation 154(iv) Fetal Tissue Commerce and Research 155ifi CREATINGA CANADIAN LEGAL FRAMEWORK FORREGULATING PRE-EMBRYOS 156(i) The Context ofCanadian Health Regulation 156(ii) Canadian Commissions and Committees for Regulating NewReproductive Technologies (NRTs) 1581V THE CANADIAN ROYAL COMMISSION ON NEWREPRODUCTiVE TECHNOLOGIES (CRCNRT) 163(i) Damaged Pre-embryos and Wrongful Life Suits 165(ii) A Regulatory Agency 166(iii) Donating and Selling 168V LEARNING FROM THE PAST: GUARDING AGAINST THEFUTURE 169(i) The Eugenics Heritage 170(ii) Judicial Interventions: Maternal/Fetal Disjunctures 172(iii) Corporate Protectionism: A New Eugenics 176VI CONCLUSION 177viCHAPTER 6. A NEW PROCREATION STORY:FEMINIST DISCOURSES FROMTFIE MARGiNS 1801 NEW REPRODUCTiVE TECHNOLOGIES: AWOMEN1ISSUE 185(i) In Whose Best Interests: Resisting Technology 185(ii) The Enterprise Culture: Fragmenting Women’s Bodies 191(iii) The Art of the Possible: A Modern Space/Time Warp 193(iv) “Granny Pregnancies”: A New Resource Management 198II REPRODUCTiVE RISKS 202(i) A History ofMiracle Drugs and Devices and Reproductive Errors .. 204(ii) Risky Business: Superovulation and Fears ofOvarian Cancer 208ifi POSSESSION OR PERSONS? THE POLARIZED LANGUAGEOF RIGHTS DISCOURSE 210(i) Property for Personhood: Searching for the Middle Ground 212(ii) “Wrongful Life” and “Rights to Life” 217IV REPRODUCING DISABILITY: A FAULTY PARADIGM 220(i) Defective “genes”, women as “defective”: Choice and Coercion 220(ii) The Woman in the Body 222V CONCLUSION 227CHAPTER 7. THE PRE-EMBRYO AS SYMBOL:ON THE TE[RESHOLD OFNEW BEGINNINGS 229I SCIENTIFIC RESEARCH AN]) CLIKICAL PRACTICE 233II ROUTINE AN]) RISK 237ifi PROPERTY AN]) PERSON 2421V REPRODUCTIVE TECHNOLOGY (CULTURE) AN]) NATURALREPRODUCTION (NATURE) 248V CONCLUSION 254BIBLIOGRAPHY 256GLOSSARY OF MEDICAL TERMS 287COMMON ABBREVIATIONS 291APPENDIX A. THE HUMAN PRE-EMBRYO:VERSATILITY OF CREATING FAMILIES 292APPENDIX B. UNIVERSITY OF BRITISH COLUMBIA. P/F PROGRAMSCHEDULE OF FEES AN]) CHANGES 295vuLIST OF TABLESTable PageTable 1. University ofBritish Columbia IVF ProgrammeOutcome Statistics 1985- 1994 92Table 2. Indications for Treatment from 1989 to 1992 94Table 3. Number ofEmbryos Remaining in the Freezer Tanksper year between 1989-1994 133vi”LIST OF HGIJRESFigure.PageFigure 1 Four Photographs of in vitro fertilization embryos xxixPREFACECONCEiVING TIlE RESEARCH PROJECTThis research is the culmination of an on-going exploration, which has been inprogress since the early days of the in vitro fertilization (1VF) programme in Vancouver,British Columbia. It predates the establishment of the Canadian Royal Commission onNew Reproductive Technologies (hereafter referred to as CRCNRT).1 During this time,there has been a widespread transformation from use of simple 1VF procedures to treatinfertile couples to an explosion of conceptive and genetic screening applications. While Ihave been most interested in the Canadian experience, biomedical research is internationalin scope and impact. The dominant American developments and those of otherindustrialized countries, notably Britain, European countries and Australia, havecontributed to the Canadian experience.My interest in IVF has spanned the transition from a general Canadian lack ofpublic awareness about reproductive technologies during the l980s, to the development ofmass media explorations of them. I have witnessed in press and in action a feministground swell from a limited, timid, but sometimes radical response, to a concerted,educated and provocative intrusion into Canadian social and political policy. It is probablethat, if it were not for the persistent feminist lobby concerning NRTs, public and politicalinterest would not be provoked at all.New Reproductive Technologies is often referred to by the acronym NRT. It is a termwhich covers the whole range of conceptive and contraceptive technologies, preimplantation and pre-natal screening technologies, embryo research, recombinant DNAand cloning. The medical community more often refers to the conceptive technologies bythe acronymART, assisted procreative technologies.xIn 1982, the fledgling field of reproductive surgery, which included thedevelopment of an 1VF programme, was being established in British Columbia, At thetime, the developments in 1VF treatment appeared to be reminiscent ofmysterious sciencefiction “hi-tech”. The concept that the “disability of infertility” was being culturallyconstructed to tie in with a new medical treatment, piqued my long-standing interest invarious physical disabilities. Initially, I had intended to study infertile couples’ responsesto a new therapy, and I was naively unaware that the field of 1VF was going to explodeinto a terrain fraught with so many social, cultural, legal and ethical implications.However, even at this time some of the early feminist critiques ofNRTs (Holmes,Hoskins and Gross 1981, Arditti eta! 1984, Corea 1985) were being published. Membersof the Feminist International Network for Resistance to Reproductive and GeneticEngineering (F]NRRAGE)2 were warning of the dangers of these technologies forwomen’s health. These criticisms went largely unheeded and unheard outside feministcircles. In 1987, an international conference was organized by the Office of the Status ofWomen in Montreal, Canada. Even ten years later these concerns, whether published(Basen et al 1993) or presented in the media, mainly by the National Action Committee onthe Status of Women (NAC), are frequently portrayed as “fringy”, alarmist scaremongering in the face of continuing developments in well-funded techno-science.2 In 1984 a feminist network of international resistance, critique and analysis of NRTsknown under the acronym F1NNRET was formed and organized its first feministconference against the technologies in 1985 in West Germany. The participantscondemned much of the reproductive and genetic techniques as violating women’s dignityand challenged their racist and eugenic ideology. Two months later at an emergencyconference in Sweden, women from twenty countries met to devise strategies to resist thetechnologies. At this time FINNRET became FINRRAGE. A series of feministconferences followed in Belgium, Australia and Austria. (Arditti et al 1989:xix-xx).xiIronically, it was these social activist Canadian women, mainly academics, who inthe first place fought for the formation of CRCNRT, in order to explore the complexitiesof these technologies for Canadian society.3 This lobby did not include in its ranks anyanthropologists, let alone feminist anthropologists. However, one anthropologist wasincluded among the seven commissioners called to CRCNRT.4(i) Creating a Feminist NetworkTn 1989, when the Commission was formed, my nascent interest in feminism wasfanned into flames when I became an active member of West Coast LEAF, the BritishColumbia branch of the Legal Education and Action Fund (LEAF).5 It was here that Iwas introduced to what seemed to me a revolutionary dynamic interaction between legaltheories and practical action (Bayesky 1988). I discovered that law was not some remotefield of knowledge for an intellectually brilliant few, but could be an action-oriented fieldof awareness about legal issues concerning women’s lives. Attending LEAFs firstA nation-wide intensive lobby by women’s groups, the Canadian Coalition for a RoyalCommission on New Reproductive Technologies, over a two year period, secured thecreation of the Commission in October 1989. See notes 5 and 6 in Eicliler 1993:218 for ast of the organizations involved and the politicians who supported the lobby.A mixed blessing for anthropology has been that anthropologist, Suzanne RozellScorsone was selected. She is a spokesperson for the Archdiocese of Toronto on familyand women’s issues, and is the Director, Office of Catholic Family Life. ‘While shecontributed a perspective on the complexities of kinship and family, subjects which havebeen salient to the discipline, her focus represents a traditional model of family relations.These are at odds with much of the feminist critique. See her commentaries appended toie Commission Report (CRCNRT: 1053-1146).Legal Education and Action Fund (LEAF) is a national, non-profit, advocacyorganization founded in 1985 to secure equal rights for Canadian women as guaranteed bythe Canadian Charter ofRights and Freedoms (1981). Its two-fold mandate is to arguetest cases before the Canadian courts, human rights commissions and government agencieson behalf of women, and to provide public education on the issue of gender equality(LEAFs Speakers Kit 1990:3).xliConference on Women and Equality under the Charter of Rights, Equality 4 Years Later(April 14/15 1989), I saw how many women in so many diverse areas of life could cometogether to work on equality issues and to look for legal solutions by attempting to changelaws that were gender discriminatory.It was through LEAF’s Speaker’s Bureau that I came to represent LEAFs viewsand resources with the newly formed Vancouver Women’s Coalition on ReproductiveTechnologies (VWCRT). This ad hoc group, representing a multitude ofwomen’s groupsin Vancouver, was concerned with educating themselves and others about NRTs. It wasprimarily a self-help group, with an outreach programme to help prepare women to writebriefs to present to the Royal Commission on NRTs when it met in Vancouver for threedays ofpublic hearings in November 1990. Along with other VWCRT members I assistedin the preparation and presentation of a submission on feminist issues, which weconsidered vital for the Commission to address. This submission was more moderate thanhad been intended originally, because the National Action Committee on the Status ofWomen’s submission, presented in Ottawa ahead of the Vancouver hearings, had raisedconsiderable public ire. It had called for a complete halt to 1VF. Fearing that a backlashagainst Canadian feminists might result, our submission attempted to raise the issues in aless controversial manner. In retrospect it was not as usefid as it might have been.My interests in 1VF, legal interpretations, feminist responses and the rights of thedisabled matured to the point where I considered that representation of all of thesediscourses was important to understanding a new medical technology. I becameconcerned with finding a way to combine the practice of feminist activism with criticalanthropological theory. While I realized that there were discourses, as well as “discourseswithin discourses” (Cannell 1990) that were important to a filler understanding of all thexmissues, I could not do justice to all of them. Thus I felt secure in concentrating on thosediscourses about which I had already gained some insights.Over time and informally, I had established networks through a snowball effectwith health care workers and academics in the field of IVF, with legal scholars, and inparticular feminist legal scholars and feminist activists. I also came to meet throughVWCRT, feminists who were interested in the concerns of the disabled about NRTs.Therefore a further focus to my study became a growing awareness of the ramifications of1VF not only for the treatment of infertility as a disability, but for its potential iatrogeniceffects. It seemed that on occasion certain aspects of the technology could cause furtherdisabilities for women and their potential children. So disability, infertility and risk seemedinextricably linked, such that IVF treatment could become both the cure and cause ofdisability.(ii) Off to Foreign Fields at RomeThe observation ofmedical procedures and most of the interviews with health careworkers for this study was conducted at the University of British Columbia in vitroFertilization (IVF) Programme. During the majority of my research, the programme wasbased at University Hospital, Shaughnessy site, in Vancouver. Further observations weremade later at the new facility in Willow Pavilion, Vancouver Hospital, which opened onApril 29th 1994.My exposure to the practical world of hospitals and TVF procedures had beenpredated by my own training and practice in the field of rehabilitation medicine and myfamilial connections to the world of reproductive surgery. Through my maniage to anobstetricianlgynaecologist, whose clinical practice was focused on infertility problems andin whose office I worked on occasion, I came to the research with a detailed knowledge ofxivthe tests involved in the infertility “workup”. I also had some background familiarityabout the IVF procedure and the formation of an 1VF programme in Vancouver. I knewpersonally a few of the 1VF staff and I had the opportunity to attend a number ofAnnualConferences of both the Canadian Fertility Society and the American Fertility Society. Iknew the British Columbia drug representative for Serono, the multinational company,which markets WF drugs, and I had attended as a guest some of the no-expense-sparedjunkets put on by the company at major conferences. My fascination with the marketingstrategies of Serono, its wealth and power and tenacious iiiffltration into all parts of theNorth American infertility business had led me down a dead-end lane, when I naivelyattempted to study the company’s practices. The door slammed closed on what I thoughtwas a realistic research project, when I attempted to obtain the Annual Reports of thecompany.Another problem with access was that contrary to my expectations that my personalconnections would facilitate my entry into the medical aspects of the research project, Ifound the reverse to be true. In my initial orientations to the IVF programme, I wasgreeted with cautious ffiendliness and my research proposal was treated with skepticism.Despite all of the formal ethical clearances from both the University of British ColumbiaSocial Science and Humanities Screening Committee and the University Hospitals EthicsCommittees, there was an implicit sense of ambiguity among the staff about my role in mywanting to observe the IVF procedures and to interview them.A methodologically related problem of access was one familiar to feministanthropologists. Early studies on the “anthropology ofwomen” had shown how male biasis transferred to the field project, such that what men say is deemed important. I foundfrom my research in a hospital setting, where men in senior positions of power werelargely inaccessible to me, that it was the women who were more service oriented whoxvwere more available to speak with me. Perhaps, the reason that it was easier for me tospeak to female health providers rather than male physicians and administrators, reflectsthe value put on my research as a female researcher by those in powerfiul positions.Conversely, it may have been my own erroneous assumptions that these people would notwant to take time to speak to me. In part, this problem relates to the bias which Moore(1988:186) identifies as inherent in Western culture, which assumes a hierarchical andunequal nature of gender relations.6During my initial forays into the hospital, I experienced David Serber’s dilemma ofdoing research in a government bureaucracy in that “the process of gaining access was acontinual activity” (1981:79). A university hospital treatment and research programme isa type of bureaucracy. Like Serber, I used an interview schedule composed of 15 generalquestions, which “served as guides to the issues and areas studied as well as a means ofredirecting often rambling and personal discussion by informants” (ibid). These questionswere reminiscent of Spradley’s (1979) “grand tour questions”, which could be relined into“mini tours” later. Whenever possible I used focused observations of events, followed byinterviews of the participants in order to obtain background knowledge and individualperceptions of what took place (Serber 1981:79). While the exploratory interviewstechnique was a successfiul strategy, the interview schedule proved to be methodologicallymore complex. I had devised a generic questionnaire, which I had adapted so thatparticipants could address some of the topics, but not others, according to theirspecialized knowledge. Often I had to explain the reasons behind the questions, which onoccasion led to illuminations for the participants about other points ofview.6 Moore cites the work ofRogers 1975, Dwyer 1978 and Leacock 1978.xviThe interviews with the other target groups, such as lawyers, feminist activists,disability rights activists and other interested health professionals, were all conducted inVancouver. This fieldwork took place between June 1993 and May 1994. However, thedocumentary research was a cumulative project, which was started in September 1987,when 1VF was just beginning to come into the public purview. I assembled materials frommedical associations such as the Canadian Medical Association, the British ColumbiaMedical Association, Society of Obstetricians and Gynaecologists of Canada, and theAmerican Fertility Society, in which I became an active member in 1990. I became aninveterate clipper of newspaper articles and a subscriber to feminist news sheets andjournals, such as Kinesis, and the Journal of the National Association of Women and theLaw (NAWL). As the publications proiiferated, so did my ifies. I attended every meetingheld in Vancouver with “reproductive technology” in its title. So my network of contactsgrew commensurate with my files.My original intention in the late 1980s had been to study patients’ experiences ofinfertility and their participation in an TVF programme. However, the difficulty of gainingaccess to the opinions of clients became insurmountable, because they are often perceivedas emotionally vulnerable and in consequence their experiences have been poorlydocumented. The medical director of the IVF programme, who subsequently left to workat Pacific Fertility Services in San Francisco, had made it clear to me that he believed Iwas asking to study an over-researched and emotionally fragile population.This experience was reminiscent for me of studies in anthropology about gettingpast, the gatekeepers (Hammersley and Atkinson 1983, Berreman 1962) and the discussionof the vested interests that people in positions of power in institutions often hold overwhat constitutes valuable research (Daniels 1967). In reality, the intended project couldhave been significant because so few studies on experiences of infertility and 1VFxviiprocedures had been done to date, especially in Canada, with the exception of those bysociologists Williams (1988, 1989a, 1989b) and later Matthews and Matthews (1993), aswell as Eicffler’s (1988, 1989) critique ofNRTs focused on the sociology of the Canadianfamily. Currently, a few studies are being published which have been conducted byCanadian anthropologists, which in one way or another relate to the Report of theCRCNRT, now often referred to as the Baird Report, after its chairperson.Anthropologist commissioner Scorsone has produced six dissenting opinions which wereappended to the Report. Feminist anthropological researcher, Tudiver’s (1993b) study onprenatal screening was commissioned by CRCNRT. The outline of a pioneer study on theeffects ofNorplant in Canada (Tucliver 1994), a study focused on procreation metaphorsin CRCNRT briefs (McDonald 1994) and a combined anthropological and sociologicalcollaborative study (Habib and Weir 1994) based on research for the Canadian AdvisoryCouncil on the Status of Women were all presented at a session of the 1994 AnnualMeeting of the Canadian Anthropology Society in Vancouver.At the time ofmy frustrated effort to interview patients involved in the UniversityofBritish Columbia 1VF programme, the clinic was preoccupied with establishing itself ata new site and with the new director. Although the medical director was unwilling tofacilitate my research at this time, I did succeed in obtaining permission to conduct someexploratory observations. I spent time in the 1VF waiting room in Shaughnessy Hospital,where patients arrived daily to give blood samples in connection with the pharmacologicalsuperovulation protocols. These tests enabled both the critical timing of and conditions7 . ... ..for the oocyte retneval process for fertilization. At this time I had some informalI use the scientific term oocycte(s) or ovum(ova) throughout this text interchangeably.(See glossary) If the word “egg’ is used to describe these gametes, it is used in apejorative sense or in anecdotal quotes. I avoid jargon wherever possible.xvmconversations with P/F staff and shortly after I was able through a personal contact toconduct an in depth interview with a couple, who had successfully completed the 1VFprogramme. Some ofthis preliminary ethnographic research informs this thesis.With the passage oftime and the swift changes in the institution of 1VF clinics andtheir adjunct therapies throughout Canada, this project has presented more challenge that Icould ever have envisaged. It has revealed accounts which I would not have uncovered ina more circumscribed project. These have led me to question the power differentialswhich are constructed on the basis of certain forms ofintellectual property. I take theapproach that anthropologists have always been interested in the perspectives andpractices ofmarginalized peoples, and that a feminist anthropology is one critical way ofaddressing the gendered nature of inequalities, which percolate throughout all aspects ofsociety. They have particular relevance to the gendered nature of IVF technology, whichis played out on the controversial discursive terrain ofNRTs.MXFigure 1 Four Photographs of in vitro fertilization embryosIn vitro Fertilization andEmbiyo Transfer by Don P. Wolf (editor) 1992.Blenum Press: New York and London. Pp. 224.xxA. Two cell cumulus. Two cell embryo 16 hours post insemination (P1) with nucleatedblastomeres and two polar bodies in fertilization droplet.B. Two cell embryo. Same embryo as in A, 19 hours P1, after removal of excess spermand corona cells. Optimal magnification 50 times.C. Four cell embryo. Same embryo as in A and B. 34 hours P1.D. Six to Eight cell embryo. 42 hours P1. Optimal magnification of C and D. 100 times.ACKNOWLEDGEMENTSI owe a considerable debt of gratitude to my advisor, Dr. Elvi Wliittaker forassisting in the intellectual conception and growth of this thesis. Without her constantsupport this project could not have been accomplished. I am grateful to Dr. NancyWaxIer Morrison for her encouragement and attention to rigorous scholarship and to Dr.William McKellin for his continued advice on critical issues that emerged as the thesisdeveloped. I thank Dr. Giffian Creese for introducing me to feminist theory and therebyaltering the way in which I viewed the world. I am indebted to the members of theUniversity of British Columbia IVF Programme, who took the time and interest to speakto me about their various endeavours, and for agreeing to be interviewed during their busyschedules. I thank the many lawyers, feminist scholars in several disciplines and feministcommunity advocates who so graciously assisted me in my comprehension of legal,feminist and disability rights issues. I am grateful to Virginia Appeli, Dr. Jill Fitzefl,Browen Mears, Dr. Ken Bassett, Dr. Patricia Kachuk, Dori Bixler, Dr. Evelyn Nodwelland Daniel Holmburg for their willingness to discuss and read my work in progress and fortheir continued support in many diverse ways. To Nic, ever my strongest critic andsupporter, I owe a debt of gratitude for introducing me into the unfamiliar terrain ofmedically assisted procreation and for his enduring patience and love. My graduatestudies would not have been possible ifmy family had not been willing to reorganize theirlives for my benefit. To my children Dominic, Tim, Chris and Becky, I dedicate thisintellectual endeavour in token ofmy lifelong respect for learning and scholarship.The funding for this research was made possible by University GraduateFellowships, for which I am most gratefuLxxilCHAPTER 1IN TUE BEGINNING...I INTRODUCTION(i) What is in vitro fertilization (IVF) technology?This research examines the complex social and cultural understandings that areemerging from the medical and technological ability to create human preimplantationembryos, pre-embryos,’ through in vitro fertilization (hereafter IVF) technology. In vitrofertilization involves fertilization of human gametes, that is sperm and oocyte (egg), byplacing them together in a petri dish (in glass). This is performed artificially outside thefemale body, in the laboratory, in contrast to in vivo, inside the body, where normallyconception occurs through sexual intercourse. The term IVF treatment incorporatesseveral medico-technical phases. First, the medical procedure involves altering a woman’shormonal system in order to produce multiple ova (eggs). Second, the surgical procedureentails retrieval of the ripe ova from her stimulated ovaries for the external fertilizationprocedure. Finally, the resultant embryo(s) are manually replaced into the uterus of thewoman who plans to gestate the resultant fetus(es).1 Throughout this thesis I use the term “pre-embryo” to describe the preimplantationembryo, which is produced through IVF technology, in order to distinguish it from the“embryo”, which term is normally applied to a conceptus that has implanted in a woman’suterus. The term “embryo” is commonly used when describing the 1VF embryo, so wherethis term occurs in the text, it is commensurate with the pre-embryo.1Initially, IVF was developed as a therapy to assist couples who were experiencingreproductive difficulties in producing their “own” biological child. It is one among anumber of new reproductive technologies, often referred to as NRTs.2 Many of theseadjunct technologies have been developed as refinements and as other options to thetraditional IVF procedure, thus expanding the enterprise into a variety of complex choicesfor patients and practitioners. These options for infertility treatments beyond the simplemodel include third party parenting, such as surrogacy arrangements and gamete donation,research on preimplantation embryos and commercialization of reproductive products andservices. These applications have developed far beyond that which could have beenenvisaged when 1VF first became an option for infertility treatment. They presentsignificant implications for the social realm and pose interesting questions foranthropological inquiry about the pre-embryo as an emerging social category and thecomplex social and cultural meanings surrounding its status. Analysis ofthe debates aboutartificial procreation offer a challenge for anthropological analysis. As Melhuus rightlypoints out:there is evidence that values are being contested, and a struggle over valuescan be legitimately contested as a struggle over power... .what is interestingin this struggle over values is the meanings given to the consequences ofthe new reproductive technologies (1992:306).I pose the question: What does it mean for women that medical technology hasdeveloped to the point where pre-embryos now can be created and manipulated outside of2 Reproductive technologies (NRTs) are rife with acronyms, to which I will refer andexplain throughout this text. The alphabet soup of drugs, ART (Assisted ReproductiveTechnologies) or APT (Assisted Procreative Technologies), and diagnostic and conceptiveprocedures include HCG, HMG, GnRH (drugs) and procedures such as IVF, DI (AID),SUZI, GIFT, ZIFT, POST, PROST, and ICSI (see Glossary ofMedical Terms).2a woman’s body? Infertile couples3 and their health care providers, lawyers, ethicists andtheologians, feminists of various persuasions and disability rights activists are producingcontesting and competing discourses, which view NRTs, such as IVF, as individuallyenabling, or conversely, individually and collectively disabling. Dialogical processes areproliferating and creating NRTs as complex polyvocal representations.4The cunent social bias towards the technological imperative and the therapeutic“quick fix” in medical care have tended to efface the real experiences of infertile couplesparticipating in IVF therapy. Sometimes, in their efforts to conform with socialexpectations of parenthood and the socially perceived importance of the biological familyunit, infertile couples become coniplicit partners in a technology with poor success rates.They do this in the belief that it is a routine procedure, which is understandable since IVFtechnology has been institutionalized so swiftly. While ostensibly claiming to help cureinfertility, IVF is in reality an arbitrary procedure, which on occasion provides babies forsome infertile couples.TVF has another important function beyond the provision of children for those whocan afford an expensive health service, which in Canada is not covered under provincialmedical plans. By the late 1980s, there was evidence that surplus embryos were beingcreated and stored routinely through IVF. This almost limitless supply ofpre-embryos canbe used in an infinitely creative research environment for numerous projects. These3 Zola (1993) points out that people with disabilities should not be characterized as nouns,such as the “drun1c or “the welfare bum”. Throughout this text I avoid the tendency torefer to people, who are unable to conceive a child as “the infertile”. I qualif,r infertilitywith a noun as it appears less discriminatory.4 Clifford discusses the representation of the conilictive domain of discourse in modemsociety where “many voices clamour for expression” (Clifford 1986:15). In this he usesBakhtin’s (1981) notion of dialogical processes proliferating at discursive sites such asethnographies and novels.3projects seek to better understand how the processes of human fertilization andimplantation occur, the generation of knowledge about the human genome, the possibilityof eradicating some genetic disorders and finding treatments for diseases such asneurological disorders and cancer.A fascination with the potential problem of what is going to happen to all thoseunneeded pre-embryos has led me to focus my thesis on the complex social relationssurrounding the 1VF pre-embryo itself Therefore I wish to explore and to comprehendthe variety of ways in which the pre-embryo is being constructed as a new culturalcategory through its reification as a legal, medical and social entity. What does the preembryo mean not only for the people who work most closely with it in providing IVFservices, but to those people who engage with it or analyze it from varying degrees ofabstraction?(ii) The Three Discourses: Medicine, Law and FeminismIn this thesis I examine three selected discourses, biomedicine, law and feminism,5which I believe to be representative of the polyvocality about the cultural valuesassociated with the creation of extra corporeal embryos. These discourses are highlyspecific in their themes and orientations. I fully appreciate, however, that none of thediscourses represented in this thesis is monolithic; that each discourse is composed of avariety ofpoints ofview, embraced under a single epistemology. To begin with I explore5 In this thesis I allude to other discourses, such as the experiences of infertile people andcertain other theological debates, which are equally important, but which I have chosennot to discuss in depth. In particular I recognize the significance and range of intellectualreasoning about NRTs that might be delivered from the standpoint of the major religions,as well as some of the ethical debates posed by biomedical ethicists about personhood.These more rightly belong as the subject matter of other types of theses.4the professional, authorized discourses of medicine and law, which dominate and arelegitimated in social institutions. Then I readjust the anthropological lens to focus on thediverse representations of feminism, endorsed by feminist activists, feminist scholars, legalfeminists. I include that element of the disability rights’ movement, that espouses afeminist approach, whose activities spurred the call for a Royal Commission on NTRs.Likewise I examine those discourses of IVF service providers, which are less oftenconsidered. While these may not be overtly aligned with feminist issues, they do representa perspective which is particularly sensitive to women’s health and social issues. In thismanner I believe these discourses to best represent the marginalized views about theimplications for women of pre-embryo production. The three discourses provide theempirical evidence which is necessary to demonstrate how power is manifested at manydifferent levels of society. It reveals “the links between the competing discourses ofchurch, state, the medical profession and feminists ofvarious persuasions as well as thosewho, for whatever reason, are ‘silent” (Melhuus 1992:3 07).The proliferation of artificial procreation techniques, of which IVF serves as agateway technology to other applications, has raised uncertainty about the cultural valuesand meaning of these technologies. The ambivalence experienced in relation to theirmeanings calls into question our well-established notions of parenthood, the family,kinship relations, bodily integrity and the marketing of kinship through transmission ofreproductive products and services.5(lii) The Context: Infertility and the Reign of Technology6The social construction of infertility as a disease in the developed world and thesubsequent ability to create human 1VF pre-embryos emerged at a historical moment thatwas ripe for the modem capitalist idea of “infertility-as-disease” control. This conceptstands in marked contrast to the more pressing global problem of “fertility-as-disease”control (Arditti, Klein and Minden 1984). The trend towards acceptance of IVF and itscorollaries has led swiftly to routinization of this form of treatment for an increasingnumber of infertility problems. The demand for a Canadian Royal Commission on NewReproductive Technologies (CRCNL&T), specifically called to examine the social, political,economic and ethical challenges raised by a variety of new and not so new reproductivetechnologies in Canada, was a social indicator of a political and public awareness that theimplications ofthese technologies were complex. It was evident that there were importantramifications for situating NRTs in the socio-economic context of Canadian health careand society in general. Furthermore, the cultural construction of “infertility-as-disease”opened the door to medicalization of what was previously a personal and social problemofthe inability to produce children, which had social ramifications about the importance oftraditional family life.Paradoxically, a series of medical technologies such as the use of fibre optics invisualizing internal organs, the ability to capacitate sperm and provide a nutrientenvironment for in vitro embryos had all become possible in the 1970s. This enabled aninnovative technical circumventory treatment to certain pathologies related to infertility, inparticular, obstructed or absent fallopian tubes, to be surgically performed on women who6 attribute this phrase to Reiser 1978.6were unable to conceive.7 In an arbitrary manner 1VF quickly became the panacea fortreatment of diverse pathological or unknown causes of infertility.During this time frame other social developments had occurred, which favoured agrowing clientele of Canadian people wishing to use 1VF technology. Since the 1960s,birth control methods in the developed world had finally given women a degree of controlover their reproductive bodies and the birth rate continued to drop. Birth mothers wereincreasingly deciding to keep their babies. The difficulties of raising adopted children hadbecome apparent and the problems of cross-cultural adoptions, in particular First Nationsbabies and international adoptions, were shown to be fraught with cultural, social andethical dilemmas. The overall result was a diminishing availability of adoptable babies, andin particular white babies.These factors in conjunction with individualistic desires of infertile couples toproduce their own biological children helped promote a technology which on occasionachieved this result, but which generated new unforeseen social issues. The consumerism,the individual enterprise that Strathem sees evident everywhere in the late twentiethcentury in the Enterprise Culture8 (l992b: 10), is evinced in a new generation ofwould-beparents. The individualistic desires of these couples to produce their ‘own children’ isbalanced by their intent to delay childbearing until careers and economic security areestablished (Crowe 1987). However, for many women increases in sexuallycommunicable diseases (STDs and AIDS), unexplained, environmental and iatrogenic7 The CRCNRT (1993) report has stressed that this diagnosis is the only one which itbelieves to be indicated for P/F treatment, which should then be funded by healthprovincial plans.8 Strathem notes that the Enterprise Culture is a term used to describe the policiespromoted by the Conservative Party in Britain in the 1980s, which was not only a politicalproduct tied to advertising but “it is as much constitutive of a cultural revolution as of thepolitical will of an electorate” (1992b: 199-200).7factors of infertility have been confounded further by a “biological clock” that threatens tolimit their customary expectations (Modell 1989). The “try harder” (Phillips 1985),“work longer”, “wish more” (Williams 1988) mentality has pushed infertile couples intodemanding more medical services, even Wit means paying for them privately.U A CONCEPTUAL CONFUSION: DEFINING INFERTILITY AND TUECONCEPTUSA perennial research problem encountered is that work can only proceed whencertain terminological confusions have been resolved. Early on in the research process itbecame apparent to me that WI was to make sense of the IVF technology and its ability tocreate pre-embryos, I had to be clear about definitions and classifications. Both the terms“infertility” and “embryo” were used in different ways by legal, medical and feministcontributions to this study.(i) Infertility as a Terminological ConfusionInfertility is a universal concept, which has been the subject of not only muchpersonal anguish, but has on occasion changed the course of human history. Biblical andhistorical commentaries have chronicled myths, legends and accounts of infertile couplesbeing blessed with children, then going on to found nations through God’s grace;monarchs falling from grace and major constitutional upheavals ensuing; and even wholecultures having suffered from historical periods of sub-fertility (Mullens 1990:21).In its modern sense, infertility is a confusing term, because it is unclear as towhether it is referring to a disease, an impairment, a disability, or a handicap. The term“infertility” is generally understood to mean the biological inability of a sexually cohabiting8couple to produce their own genetic children to form a social family. The nature of itsclassffication as disease, illness, disability, impairment or handicap is, however, moreproblematic.In North America, the commonly accepted medical delinition of infertility is oneyear of unprotected coitus without conception in non-sterilized couples (Speroff et al.1984). The World Health Organization suggests two years as a more realistic time frame.The distinction between primary (never having conceived or given birth) and secondaryinfertility (having some condition which has reversed a proven ability to procreate) is animportant one to make. Likewise, there is a difference between the inability to conceiveand the inability to maintain a pregnancy, due to recurrent pregnancy loss9. The overallgloss of the term denotes the inability to produce live children and in modern Westernsociety, there is incontrovertible evidence that there is an expectation by newly maniedcouples that they will have childrenJ0In the last forty years the term infertility has increasingly entered the Westernlexicon. It is what Lakoff (1987) would call a prototypic term,’ which can beunderstood differently in different circumstances. Whether infertility can be classified as9 I am grateful to Dr. Mary Stephenson, a gynaecologist experienced in the treatment ofrecurrent pregnancy loss, who advises the use of IVF in long-standing persistent cases, forpointing out this distinction for me.10 A United States’ study (Glick 1977), for which no Canadian equivalent exists,demonstrates that 95% ofnewly married American couples expect to have children. JaneGaskell’s study of British Columbia adolescents suggested similar responses (Gaskell1988).11 Lakoff ‘s (1987) theory of natural categorization, describes how the human mindcreates human categories in terms of prototypic cores of meaning, which he calls“idealized cognitive models” (ICMs) or cluster models. These may have fuzzy boundariesas the prototypic features become more ambiguous the fhrther outwards the sharedfeatures extend. He examines the category “mother” in English as a prime example.9a disease, a disability, a handicap or an impairment depends both on the circumstancesand on who is speaking.Medical anthropologists would agree that disease is culturally constructed and thatbelief systems in Western biomedicine, such as reproductive beliefs and practices, aresituated within the power struggles of the broader society. Currently, Good (1994) hasbeen examinmg the problems of the semantics of the term “belief’ in anthropology, fromthe late nineteenth century to the present. He argues that the analysis of culture as beliefboth reflects and helps to reproduce an underlying epistemology and a prevailing structureof power relations (1994:21). He explains how medical anthropologists have subscribedto this practice by using “beliefs” as a category in two contradictory ways in their culturalaccounts. Most often they label as cultural beliefs those medical conditions for whichbiological theories have the most authority and least often for those where biologicalexplanations are subject to challenge. He points out how commonly medicalanthropologists have understood the cultural variation in beliefs about disease, that is“illness behaviour”, but have been counter-intuitive about disease itself as a culturaldomain because:Disease is paradigmatically biological; it is what we mean by Nature and itsimpingement on our lives. Our anthropological research thus divides rathereasily into two types, with medicine, public health, and human ecologyproviding models for the study of disease and its place in the biologicalsystem, and social and cultural studies investigating human adaptation andresponses to disease. Its takes a strong act of consciousness todenaturalize disease and contemplate it as a cultural domain (ibid: 2).Kleinman has used the explanatory model (EM) construct as a means of makingcoherent sense of the cultural features that affect people’s health behaviours. He hasexplained the dichotomy between illness and disease and how medical treatment becomesrationalized in this way:10Disease refers to a malfunctioning of biological and/or psychologicalprocesses, while the term illness refers to the psychosocial experience andmeaning of perceived disease. Illness includes secondary personal andsocial responses to a primary malfimctioning (disease) in the individual’sphysiological of psychological status (or both)... Constructing illness fromdisease is a central function of health care systems, a coping function andthe first stage in healing (Kleimman 1980:72).The identification of a specific physical impairment or health condition as a“disability” or “handicap” will likewise vary from one culture to another, as well asbetween social classes and ethnic groups within a single society. The World HealthOrganization 1980 (hereafter referred to as WHO) has made a classificatory distinctionbetween impairment, disability and handicap and thereby has promoted “the growingtendency to view disablement as a social phenomenon which exists on a continuum”(Williams 1991:517). Williams envisages this universalization of disablement as aresponse to a number of health care changes, among which are an aging population andattendant chronic morbidity and a choice of technological fixes. According to data from a1986 Canadian census, it is estimated that 4.2 million Canadians have a classified disabilityof some sort.’2WHO (1980) defines an impairment as “any loss or abnormality of psychological,physiological or anatomical structure or function”. A disability then is “any restriction orlack (resulting from impairment) of ability to perform an activity in the manner or withinthe range considered normal for a human being”. A third gradation, handicap, is “adisadvantage for a given individual, resulting from an impairment or disability, that limitsor prevents the fulfiliment of a role that is normal.. .for that individual”. Wendell (1989)has criticized these distinctions and suggests the use of the term “disability”, because it is a12 Census published by The Globe and Mail in a supplement New Attitudes: Thechanging lives ofpeople with disabilities (December 3 1993 :C1).11phenomenon socially constructed from biological reality. For the purposes of this thesis, Irefer to infertility as a disability.(ii) Mixing our Meanings: Redefming the “Embryo”The cultural construct of the “embryo” also raises categorical problems. One ofthe early issues that arose with the technological ability to create pre-embryos in vitro wasthe choice of term that should be used to describe this new entity. If it was to becomepossible to categorize the pre-embryo, then it had to be uniformly classified. Whereas oneperson might refer to an “embryo” as an early fetus, another person might be describing ajust created zygote. It is important to be clear at the outset about the subtle distinctionsthat a term can make. The term “pre-embryo” is the one adopted by the Ethics Committeeofthe American Fertility Association (hereafter referred to as AFS) in a recent supplementon ethical considerations (AFS 1994). The retired Chairperson of CRCNRT hascautioned against inappropriate use of terms to describe early developing human tissueand advocates the use of the strictly biological term “zygote” to describe the preimplantedembyro (Baird 1994). 13Any discussion of the pre-embryo must take place within the context of the socialrelations that surround it. For practical purposes, or at least without the aid of a highresolution microscope, the pre-embryo is non-existent. Only in relation to certain peopleand in certain circumstances does it take on a reified existence of its own. It meansnothing to itself, but it evokes multiple meanings to those with an interest in it. The13 In a recent lecture in Applied Ethics at UBC, Baird explained the importance for ethicalpurposes of calling the preimplantation embryo by its correct embryological term“zygote”, because of its totipotentiality. Any cell in a zygote up until about 14 days afterfertilization has the potential to become the “true” embryo and subsequent fetus (Baird1994).12perspective taken by different interest groups has ascribed this conglomeration of humantissue with or without certain vested interests and rights.Any conceptual analysis about the pre-embryo must identi1,’ the informationconveyed by the word, whether in a scientific or non-scientific context (Regan 1980). Avariety of terms have been used to categorize the cluster of human cells, whether createdin normal conception or technically through 1VF. These include the embryo, fertilizedegg, pre-embryo, pro-embryo, morula (a microscopic raspberry), conceptus, zygote,blastocyst, pre-implantation embryo and fetus. However, the term “embryo” has beencommonly used to refer to all stages from the time of fertilization on, at least since theintroduction of the teaching of practical embryology at the University of Cambridge in1883. Authors ofmany renowned textbooks have adhered to this practice (Biggers: 1990).I also found it to be the term most commonly used by participants in this research, as wellas by contributors to Proceed with Care (1993), the report of the Canadian RoyalCommission on New Reproductive Technologies.The words embryo and the closely related term fetus have been in use since thefourteenth century,14but it was not until 1986 that the compound words pre-embryo andpro-embryo were introduced independently to describe human cells, during the firstfourteen days of development (Biggers 1990:1). Biggers argues from his archival researchof relevant medical texts, that the definition of these terms alludes to phases in a14 Biggers argues that the words embryo and fetus have been used in four ways;synonymously (1594 Oxford English Dictionary), categorically to identifS’ two successivedisjoint phases of prenatal life (Webster 1828), to identify a subclass of embryo calledfetus (Shorter Oxford Dictionary 1947) and to identify a subclass of fetus called embryo(Mayne and Mayne 1875). All four usages implied that an embryo existed from the timeof conception or, since 1879, from the time offertilization (1990:1).13continuous process called the life cycle, which are arbitrary, and have been coined not onscientific grounds but for public policy reasons.The term pre-embryo was adopted simultaneously in 1986 by the EthicsCommittee of the A]FS and the Voluntary Licensing Authority for Human in vitroFertilization and Embryology (hereafter referred to as VLA) in Britain. In Australia, in1985, the termpro-embryo was suggested to the Australian Senate Select Committee onthe Human Embryo Experimentation Bill. Whereas the termpre-embryo was a new term,the term pro-embryo was an old botanical term. Both, however, referred to the phaseprior to the development of the primitive nervous streak at fifteen days and the stagenormally associated with implantation in the uterus. During this phase each cell in thecluster is totipotential, meaning that it can develop into either a “real” embryo onimplantation, or part ofthe extra-corporeal support to the embryo, such as placenta. Onlyon implantation will the cells begin to differentiate.Both the terms pro-embryo and pre-embryo had been arrived at on a moral basisby the Wamock Committee in 1984 and the Ethics Advisory Board of the U.S.Department of Health, Education and Welfare in 1979, respectively. The reason was toensure that no human pre-embryo created through IVF should be maintained beyondfourteen days, or used as a research subject beyond that point. This marks the time atwhich differentiation begins to occur with the development of the primitive nervous streak(Biggers 1990:3).While both the VLA and AFS ethics committees agreed that prior to fourteen daysafter fertilization, the human prenatal organism should be accorded a different order ofmoral value than at later stages, they did so for different reasons. The VLA’s reason wasto enhance communication with non-scientists and to clear up the sloppy practices ofusing the word embryo for the entire product of the fertilized egg (McLaren 1986). The14AFS wanted to accord special moral status to the pre-embryo during “the special andunique biologic era” up to fourteen days post-conception (Jones and Sclirader 1989:189).Jones and Sclirader (1989) and Grobstein (1988) base their arguments on a scientificinference, which asserts that the pre-embryo has reached a special place in biology andalso in the scale of increasing moral status, that they believe is contiguous with humandevelopment. Biggers (1990) rejects this assignation of moral values on arbitraryterminology. He suggests preimplantation embryo as a less ambiguous term to recognizethe phase prior to implantation. In this case the pre-embryo has only existed for abouttwo days and will only be at the two to eight cell stage. It is smaller than a grain of sandor the period at the end of this sentence.I have chosen to use the term pre-embryo for the purposes of this thesis, not forany moral reason, but to make it clear that I am referring to the fertilized egg during the invitro fertilization process, prior to its transfer back to the woman who will gestate it.While I agree with Baird that zygote is a suitable term to reflect the stage of development,I wish to distance myself from this biological determinism and therefore use the term preembryo to imbue it with significance as a cultural as well as a biological construct.UI THEORETICAL PERSPECTIVESThis thesis integrates some aspects of the critical interpretive medicalanthropological approach with discourse analysis viewed through the lens of a feministanthropology, which reframes kinship theory in terms of new procreation stories. Thisstrategy keeps women central to the analysis, while presenting the technology of IVF in ahistorical and cultural context. The contested debates surrounding the application of 1VF15technology and its adjuncts is represented by the analysis of the three specific and salientdiscourses of tecimo-medicine, law and feminism.Together the three theoretical approaches provide a framework from which toexamine the complexities of IVF technology and its creation, the pre-embryo, asdemonstrated by a Western Canadian IVF programme associated with the University ofBritish Columbia. A critical medical anthropological approach focuses the debates on thepolitico-economic aspects of provision of a delisted medical service, which despite itscosts is becoming the treatment of choice for infertility problems. The description of theshort and little understood physical world ofthe pre-embryo, during its extra uterine phaseis presented through an ethnographic account of the Vancouver 1VF programme. As anexample of an ethnography of science and technology, it situates the pre-embryo within aparticular cultural and historical context. The discourse analyses expresses a variety ofopposing interests about the cultural values of creating pre-embryos. It places the preembryo within a network of social relations constituted of those people with a vestedinterest in its creation. While the discourse analysis makes explicit the fimdamentaldifferences in relations of power and hierarchy, a feminist anthropological perspectiveexamines the gendered dimensions ofthe phenomenon of separating a pre-embryo from its“natural” relations in a woman’s body. Despite its physical invisibility, it is reified and canbe culturally constructed as a valued entity in its own right.(i) Critical Interpretive Medical AnthropologyThe critical interpretive approach which has been embraced by mainstreamanthropology is concerned with social life as “fundamentally conceived as the negotiationof meanings” (Marcus and Fischer 1986:26). This approach has been taken up by somemedical anthropologists, who have begun to analyze beliefs and practices of medical16systems in terms of “the way in which all knowledge relating to the body, health and illnessis culturally constructed, negotiated and renegotiated in a dynamic process through timeand space” (Lock and Scheper-Hughes 1990:49). This theoretical positioning provides aresearch framework which can incorporate elements of political economy, socialconstructionism and phenomenology.Health care has frequently been discussed within the framework of politicaleconomy (Navarro 1976; Doyal 1979). The latter according to Ortner llrst emerged in theUnited States in the l970s (1984:139). Medical anthropologists have used politicaleconomy to discuss class relations and the capitalist system in relation to studies ofbiomedicine’s effects on other cultures healing systems (Taussig 1980; Singer, Baer andElling 1986). Scheper-Hughes and Lock(l986) and Lock and Scheper-Hughes (1990)have suggested the critical interpretive approach as a possible unifjing paradigm, becauseit reconciles the polemicism between culturological and political-economic perspectiveswithin medical anthropology (Johnson and Sargent 1990).A critical as opposed to a clinical perspective is advantageous in order tounderstand the distribution of power and wealth and its effects on health and healing(Morgan 1990). It explains the mechanisms of social control, capital accumulation,systemic legitimation and reproduction of class, racial and gender inequalities (Baer,Singer and Johnson 1986). It also stresses the importance of remaining grounded ingeographic, historical and cultural specificity, especially because the Western scientificendeavour is itself a product of such contexts (Mulkay 1979; Toulmin 1982; Baer 1982;Lock and Gordon 1988).Furthermore medical anthropology’s critical interpretive perspective rejects thehegemony ofpositivistic science and replaces it with a focus on negotiated meanings, in anattempt to explore the notion of what Turner (1986:2) refers to as “embodied17personhood”. This is the way in which the relationship of cultural beliefs connects withhealth and illness in the sentient human body (Lock and Scheper-Hughes 1990:50).My research heeds Young’s warning about the research bias that facts are oftenuncovered as a result of the interaction between the researcher and the researched. Thetendency for epistemological scrutiny to be suspended for Western social science andmedicine has to be addressed (Young 1982:260). Therefore, in this research I have had todeal with my own cultural assumptions about family construction as being preeminentlybiological and the place of infertility in that scheme; as well as preconceived notions thatmedical interventions, however technological and experimental, will provide solutions toproblems and lead to cures.This study incorporates the critical interpretive approach in order to make sense ofa western health care phenomenon, the technological treatment of infertility and its byproduct the human pre-embryo. It also enables the union of the otherwise disparatethreads of the personal experiences, economic, legal, biomedical and feminist issues aboutpre-embryos, which have been assembled through my ethnographic explorations anddocumentary research. In other words, I contextualize the “local knowledges” I havecollected in this research within the historical context of national and internationaldevelopments in NRTs. The Euro-American cultural imperative to create biologicallyconnected families appears rational in a society that values individualistic consumerism,even to the point of gaining status from assets, such as children. This may seem illogicalin contrast to the majority of the world’s population which has hardly started to get togrips with fertility problems; a world that is full of children living in dire poverty, whoappear by Western standards to be neglected. But paradoxically, the point that issometimes missed by well-meaning aid agencies is that large families with many children,in the developing world are valued for other reasons - for example children’s contribution18to the family economy, their support for parents when elderly in societies without socialwelfare nets and for a variety of religious reasons.The motives behind promotion and provision of I\IF babies appear comprehensiblewhen a “hi-tech” infertility therapy in located within the political economic framework ofthe self.serving complicity of the industrial medico-techno-pharmaceutical complex.Given the gendered, racial and classist aspects ofNRTs, it becomes apparent why only therich in the developed world have access to such technology, and conversely, why it is thepoor and racially disadvantaged of the third and fourth worlds, who provide the rawmaterials (ova, sperm, embryos, organs etc.) and the services (experimental bodies forhuman contraceptive drugs and device trials, gestational surrogacy), which make thesetechnologies possible. Corporate consumerism in the case of NRTs shifts from the retailtrade sweat shops of Asia to the fragmented medicalized bodies, who happen to bepredominantly women, especially poor women.Anthropologists have been noticeably absent until very recently from the critiqueabout the paradox of “infertility-as-disease” control in the developed world and the morecritical “fertility-as-disease” control in the developing world. In the 1980s some studiesexamined cultural adaptations to infertility problems in Affica (DelVecchio-Good 1980;Boddy 1988); and studies published in the economic and ecological development literatureaddressed issues concerned with women’s health and lifestyles (a few examples are Hill1988; Mies et a! 1988; MoCormack 1988 and 1989, Raikes 1989). Currentlyanthropologists are beginning to focus on issues of overpopulation and “fertility-as-disease” control in global studies, noting that “infertility-as-disease” control is aparticularly advanced capitalist concept (Inhorn 1994). Combining ethnography withepidemiology has produced a few studies on cultural responses to infertility in Egypt(hihorn 1994; lithorn and Buss 1994). Of course, Turner’s (1969) symbolic analysis of19infertility practices among the Ndembu is still a useful anthropological classic. In Britain,in response to the Human Fertilization and Embryology Act 1990 (hereafter referred to asHFE), a number of anthropological responses (Wolfram 1987; Strathem 1992(a),1992(b)) have been documented, which link the English kinship system with therecommendations of the Wamock Report and HFE Act. As yet little attention has beengiven to anthropological interpretations of the complex kinship dimensions, and inparticular the gendered aspects of the new reproductive technologies.Finally, the critical interpretive approach in medical anthropology brings togethernot only the contributions of social constructionists and neo-Marxist political economists,but phenomenologists also. The bodily experiences ofwomen through the life cycle, oftenseen as medical metaphors, have been the subject matter of studies by anthropologists andsociologists (Sontag 1978; Martin 1987; Beyene 1989). The silent pain of infertility,particularly for women, is projected through metaphor (Sandelowski 1986) and thesymbolism of monthly grieving as a ritual process (Williams 1988). Often for infertilecouples the negotiated meanings result from ambiguous responsibility in the doctor/patientrelationship on couples undergoing infertility treatments (Becker and Nachtigall 1991).The lived experience of a physical and emotional roller coaster for women who undergothe 1VF procedures project the personal anguish of repeated desperate attempts to achievea pregnancy (Modell 1989; Sandelowski 1991).The use of a critical interpretive medical anthropology in its fullest sense is limitedin this thesis in that, as I explain in the preface, I was unable to gain access to thosesilenced voices so important to the negotiation of meaning, principally those peopleundergoing IVF technology. Firsthand, rich subjective accounts of personal experiencenot only would have helped overcome subjective/objective dichotomies, but would alsohave contributed to a fully rounded ethnographic account of a medical technology. In this20thesis, I have attempted to include other unauthorized voices - those ofwomen who, whilenot personal participants in the technology, have very real concerns about it for the healthand welfare ofwomen. This view acknowledges issues for women, based on race, class,disability and sexual orientation, which as yet have received little attention in theanthropological literature in relation to new reproductive technologies.(ii) From an “Anthropology ofWomen” to Feminist AnthropologyThe subject “woman” is largely ignored in the cultural fascination with IVFtechnology and the production ofpre-embryos. This thesis attempts to give recognition tothe ways in which reifjing pre-embryos often leads to the marginalization of women’sproblems and to the disappearance of “the woman in the body” from the acceptedsymbiotic relationship between a woman and her pre-embryo/fetus. The development of afeminist anthropology has provided a method that ensures women are kept central to theanalysis.Feminist anthropology emerged out of the “anthropology of women” in the early1970s, in an attempt to give recognition to the problems whereby women wererepresented in anthropological texts (Rohrlich-Leavitt et a! in Reiter 1975). “The‘anthropology of women’ was part of this process of questioning theoretical categories,and of emphasizing the way in which theoretical suppositions underpin data collection,analysis and interpretation” (Moore 1988:186). The early feminist anthropologists hadfound that the initial solution to eradicating male bias in the discipline by simply addingwomen into the traditional equation simply did not solve the problem ofwomen’s analyticinvisibility. This bias would not go away, because antbropologists were themselves heirsto the sociological tradition of treating women as essentially uninteresting and irrelevant(Rosaldo 1974:17). Defining sex/gender roles was viewed as the necessary step to rework21the universal category “woman” and thereby to construct women’s topics as essentially asinteresting as men’s topics. MacCormack and Strathern (1980) and Ortner and Whitehead(1981) have demonstrated how “woman” as an empirical category has to be analyzed, notassumed, in the same way as categories such as “marriage’, “family” and “household”, allofwhich are culturally and historically specific. In this manner the theoretical trajectory ofthe “study ofwomen” was shifted to the “study ofgender”. 15Anthropology and feminism have both had to cope with the concept of“difference”. As feminist anthropology developed, the problems of identifying the realdifferences between women’s situations, experiences and activities globally had to befaced. New theoretical constructs were required to recognize “otherness”, based on thedifferential experiences shaped by gender, class and race. Researchers, who are “womenof colour”, are now challenging the western bias, the ethnocentrism of anthropology’scolonialist past and point to the racist assumptions ofmuch anthropological theorizing andtexts. All too often there is an assumption that the anthropologist is white, in the sameway as in the past it was assumed that the anthropologist was male.16 Thus, exclusion byomission is still exclusion.Moore (1988) advises that we need to reformulate the privileging of the femaleethnographer and the power relations of the ethnographic encounter, because althoughwomen in all societies share similar problems and experiences, these are camouflaged by15 A useful volume edited by M. Strathern, Dealing with Inequality: Analyzing genderrelations in Melanesia and beyond (1987), takes a number of theoretical perspectives,including feminism, to approach the concepts of inequality and agency in gender relations.16 This same point was explained to me by Sunera Thobani, the first woman of colourpresident of the National Action Committee (NAC) on the Status of Women, in thatfeminist assumptions about women’s inequality have reflected that of white, educated,middle-class feminists, thereby excluding by omission the variety of discriminations againstwomen based on race, class and sexual orientation. These assumptions are beginning tobe related to the differential use and access ofNRTs.22different experiences worldwide with respect to race, the colonial experience, the rise ofcapitalism and the effects of international development projects. She maintains that thefeminist anthropology of the future will therefore not only be involved in reformulatinganthropological theory, but also in reformulating feminist theory. She advocatesthat the feminist critique in anthropology has been, and will continue to be,central to theoretical and methodological developments within thediscipline as a whole. The basis of the feminist critique is not the study ofwomen, but the analysis of gender relations, and of gender as a structuringprinciple in all human societies (Moore 1988:vii).In this research I make explicit the gendered dimensions of a critical interpretivemedical anthropological approach in relation to the creation ofthe pre-embryo.(iii) A Feminist Approach to Discourse AnalysisA feminist approach to discourse analysis focuses on the mniner in which power isproduced through processes of knowledge acquisition. This is accomplished through aplurality of discursive practices. These practices often make “scientific” claims to “truth”,which have the effect of excluding, marginalizing or constructing as deviant otherdiscourses of human activity and thought (Boyd 1991). Therefore, dominant discoursesalways have the effect of silencing suppressed ones.Foucault’s scholarship on discourse analysis has been instrumental in revealing thelink between knowledge and power, as well as the politics of knowledge (Foucault 1980).It is commonly accepted wisdom that some powerful discourses, such as law andmedicine, claim to speak the truth and thus exercise political power in a society that valuesthat notion of truth. Smart claims that this is the case for law, because law does not, norneed not, make scientific claims to truth (Smart 1991:195-198). It can disqualiFy“subjugated knowledges”, such as women’s knowledge (ibid: 196). Boyd explains how23discourse theorists stress that power is constructed in and through language becauselanguage as discourse always embodies a standpoint or claim to truth. In reality, we arealways in the “process of absorbing and filtering the various discursive fields weencounter, which introduce to us the competing ways of giving meaning to the world(Boyd 1991:326). We are always trying to make sense out of what Soper calls “ahierarchy of discourses” (Soper 1990:241).Critical comparison of multiple sources of evidence provides a method foruncovering the common ground of events and experiences which are recognized andvalidated in disparate discourses. Therefore the collation of such discourses provides anethnographic or “thick” description, regardless of the fact that the articulation ofcompeting discourses may result from significantly different understandings of the culturalevent, behaviour or category in question. Tyler has explained in his postmodem approachthat contemporary ethnography can act as “a superorclinate discourse to which all otherdiscourses are relativized and in which they find their meaning and justification” (Tyler1986:122). This study explores the knowledge claims of the three highly specificdiscourses I have selected by means of giving voice to those complex and contestedunderstandings which are being constructed about the pre-embryo as a newly emergingcultural category.Within each of discourses I examine there is no one monolithic discourse. Nursesuse knowledge frames that are different from doctors, whose knowledge is different frombiologists, social workers and so on. Lawyers who use critical legal theory may wellconstruct the law in a different way from mainstream practicing lawyers. Feminist lawyersformulate their understanding from a critical approach that espouses feminism. Feministsmay subscribe to a number of theoretical approaches, socialist, liberal, radical, humanistic,critical race theory. Some may be scholars, others social activists. Each view tints the24understanding of cultural issues in a slightly different hue. However, regardless of thesubtle persuasions, each of the major discourses subscribes to a common epistemology, beit biomedicine, jurisprudence or concerns about gender inequalities. Each is bound by itsepistemological umbilical cord to its major profession, discipline or view of the world. Inthis sense anthropologists are no less suspect, as Whittaker’s (1981) discussion of thenature of ethics and the clisjunctures of the collection and interpretation of fieldwork datasuggestedPerhaps it is enough to say at this stage that, to acquire knowledge and tointerpret it with humanity seem to be ethical requirements of the humanendeavour. A beginning answer may lie in developing further theanthropology of anthropology (Jarvie 1975, p.2&l), and in assuring that‘the epistemological and ontological presuppositions be made explicit’(Salomone 1979, p. 57). An ultimate answer may lie in a consensus on anepistemology sympathetic to the ethos and responsibility of anthropology.Perhaps, meanwhile, the only adequate answer lies, as it does forKierkegaard, in indefinite and continual questing (Whittaker 1981:449-450).Foucault’s concept of discourse based on the knowledge/power nexus is being usedby many feminist scholars as a means of opening up ways of thinking about power andprivilege in society in terms of discourse analysis. Recently, Canadian feminist legalscholars, Gavigan (1988) and Boyd (1991) have adopted this approach in order to replaceideology with experience. In looking at some of the ways in which the law discriminatesagainst women, they take up the postmodemist challenge to the assumption that ideologymasks the variety of experiences in women’s lives, many of which are largelyunrecognized. 1717 Gavigan (1988) explains that the notion of ideology of motherhood hides the trueexperience ofmothering, while Boyd (1991) examines this in relation to child custody andsuggests that in thinking about multiple experiences and possibly multiple ideologies, wewould do well to examine wider ranges of discourses. Their argument is that all the25Foucault’s work has also informed the work of feminist scholars such associologist, Dorothy Smith and philosopher, Nancy Fraser, who have developed novelways of looking at dominant and oppositional discourses. They link feminist activism andanalysis of expert discourses, in order to create new hybrid publics and arenas of struggle(Fraser 1989:11). They believe that by synthesizing theory and practice, this is a potentialmeans of empowering women. Perhaps there is no better way to view this strategy than inthe proliferating feminist and feminist disability rights discourses which combine feministtheory with the gendered aspects of daily living. In the context of NRTs, the powerstruggles between dominant and subjugated discourses are made clearly apparent.Fraser has constructed a model of social discourse, which is designed to bring intorelief the contested character of “needs talk” in social welfare societies (1989:160). Shesituates power in “the institutional fabrication and operation of expertise” (ibid: 11), usingFoucault’s (1980) concept of knowledge/power. Similarly, Smith envisages power asembedded in the “ruling apparatus” (1987:160), such as government, law and professionalorganizations, as well as the discourses of texts, which interpenetrate multiple loci ofpower. Thus power percolates “capillary-like”, to use Foucault’s term, through oureveryday experiences. She calls this strategy “institutional ethnography”, which exploresthe social relations that peoples create through their daily practices. This researchsubscribes to a feminist ethic (Whittaker 1994a) which explores the power relationshipsimplicit in the authorized discourses of medicine and law. Through their colonizingintellectual knowledges and institutionalization of commonly accepted practices, they havevoices of parenting, beyond the legal model built on the nuclear, heterosexual, stable,middle-class, white model need to be heard.26the capacity to subsume and repress those other discourses, such as feminist and disabilityrights discourses, which struggle to be articulated and heard.W TILE BRiTISH COLUMBIA 1YF PROGRAMME18There is only one 1VF programme in British Columbia, the most western of theCanadian Provinces.’9 The mountainous terrain broken up by long valleys of rivers andlakes accommodates many remote communities with limited medical facilities. Thereforemany British Columbians receive specialized medical care in Vancouver, the largest city,which is located in the most south-westerly corner ofthe Province, forty miles north of theCanadian/United States border. The majority of the tertiary referral services in BritishColumbia are based in the University of British Columbia teaching hospitals complex,which serves a provincial population of approximately four million people. The IVFprogramme is a unique infertility technology service within the Division ofEndocrinology,and among a number of specialized tertiary referral services,20which are included withinthe University ofBritish Columbia Department ofObstetrics and Gynaecology.18 The use of the term programme describes the protocols, the processes that a patientundergoes to produce multiple ova and that the gametes undergo to become pre-embryosand their subsequent transfer back to the woman for gestation.19 Tn the summer of 1995 a new private 1VF is scheduled to open in Vancouver, close tothe Vancouver Hospital. Its medical director is a reproductive surgeon, who has run asuccessful Ontario programme. Some of the specialized staff presently working at theUniversity programme have decided to work for the private clinic, which will offer moreinnovative infertility treatments.20Artificial donor insemination (AID), a relatively low technology service, is also availablethrough one programme offered by a Vancouver obstetricianlgynaecologist working inconjunction with an andrology laboratory at the University of British Columbia. Otherobstetricianlgynaecologists also provide the service with frozen sperm distributed by27The Vancouver programme is among only fourteen in existence in Canada,2’thesame number of 1VF clinics that are available in the San Francisco area. Although thepopulation base per facility may be similar, the Canadian reality is one of enormousgeographic spread. For example, there are no programmes available in New Brunswick,Prince Edward Island, Newfoundland and Manitoba. The British Columbia facility wasfounded in 1982, in response to the growing interest in infertility technology, with theintent ofprovision of services under the auspices of the University of British Columbia asan experimental programme. It claimed the distinction of producing the first 1VF baby inCanada, a boy, who was born on Christmas Day, 1983. This was the only success duringthe early phase of the programme, as the programme closed for more than two years in1983, while it reorganized and relocated. It commenced services again, in May 1985, innew premises at the University Hospital, Shaughnessy site, where its treatment facilitieswere spread out again in different locations within the hospitaLIn its thirteen years of existence, the programme has never possessed a permanentintegrated location; it has changed hospital facilities three times, has been administered bythree medical directors and three nurse co-ordinators. However, throughout its uneasysperm banks outside of the province. The Department also provides sexual medicine andrecurrent pregnancy loss programmes.21 In Kyoto, Japan, in September 1993, the International Working Group for Registers onAssisted Reproduction reported that in 1991, 10 Canadian clinics reported to theCanadian IVF Registry, which is co-ordinated by Dr. Arthur Leader, professor ofObstetrics and Gynaecology at the University of Ottawa. 175 clinics reported to theUnited States IVF Registry (Fluker and Ho Yuen 1993:883). There are 50 registeredprogrammes in the United Kingdom, according to the Interim Licensing Authority (1991).28existence, the composition of the medical staff and the laboratory director has remainedthe same. The majority are university appointed geographic fill-time professors.22The director of the gamete laboratory is also a full professor in charge of researchand graduate students in embryology. He receives a retainer for his responsibilities inoverseeing the laboratory and its staff Two women physicians were appointed later to thecore of male physicians. The remainder of the staff IVF and operating room nurses,laboratory biologists, social worker/counselor are all female employees. In general, mostof them have been with the programme for many years. The head biologist and the socialworker were employed when the programme moved to the Shaugbnessy Hospital site in1985.Interestingly, one of the main competitors for the growing number of BritishColumbians seeking infertility services is Christo Zouves, who was the first permanentmedical director and who moved to Pacific Fertility Services in San Francisco in 1990.This clinic offers many innovative services and since many of the patients on the waitinglist for the University of British Columbia IVF programme knew Zouves, he had nodifficulty in luring them to his programme through a number of sophisticated marketingstrategies. Similarly, two new programmes in Washington State have adopted similarmarketing strategies. Despite these competitors, the University programme has remainedfaithfiul to its mandate of providing IVF in its most conservative form to heterosexualcouples, living in stable relationships, using their own gametes, and with the resources topay for a medical service, which is not provincially funded.22 A geographic fill-time (GFT) professor is a designation given by the university tophysicians whose primary responsibility is teaching students and conducting research.They are permitted to provide restricted services to patients, for which they areremunerated through the provincial Medical Services Plan.29V ChAPTER OUTLI1{EIn Chapter 2, I discuss how anthropologists are no strangers to the ways in whichcultures construct understanding about the meanings of the beginnings of human life.While comparative studies preoccupied earlier generations of scholars interested intraditional kinship patterns, since the sixties the focus has turned towards an examinationof how Western, so called developed societies, understand their kinship arrangements.More recently, with the emergence of feminist anthropology, a methodological correctivehas taken place to factor women’s experiences into the picture. This reappraisal in genderstudies has produced accounts of procreation stories, which demonstrate how womenmake sense of their reproductive capacities; and how their cultural ideologies to a largeextent direct their lives, including their procreative lives. The new procreation storieswhich are emerging from the use of new reproductive technologies, have profoundimplications for the category “woman”.In chapter 3, I show how the innovation of 1VF technology has not just suddenlybecome significant, but rather is a link in an ancient and tenacious chain of fascination withhuman fertilization and conception by generations of predominantly male scientists. Ipresent a chronology of infertility treatments which have emerged from simple IVFtechnology, as well as some of the new genetic screening technologies which are on theresearch horizon. An account of the prevailing medical discourses about definitions ofinfertility and success rates in relation to problems of diagnosis and cure are followed byan historical overview of the only infertility programme in British Columbia. Icontextualize the Vancouver IVF programme as I experienced it against a backdrop ofprovincial health care reforms and hospital disruptions.30In Chapter 4, the medical discourse of IVF is represented in a “thick description”ofthe typical IVF processes of the particular programme I studied, from superovulation tooocyte retrieval, to pre-embryo creation and often to the stage of deep freezing As anattempt at an ethnography of a medical scientific technology, the research conductedduring the summer and fall of 1993 in the University of British Columbia Hospital,Shaughnessy site, and later at Vancouver Hospital and Health Sciences Centre, provides aclose up view ofmedical procedures that are little understood and seldom observed.Grounding in the medical discourse forms the basis for the legal discourse that isdiscussed in Chapter 5. It focuses on the social and historical place that law has played inattempting to designate an appropriate status for the pre-embryo. The socio-legalconstruction of it as either potential person or property has resulted in interesting legalcases in the United States. In Canada, the status of the pre-embryo is emerging throughdecisions in other jurisdictions and the value that Canadians put on their health caresystem and the decisions ofnumerous committees and commissions that have attempted toregulate the use ofpre-embryos.The challenges to the mainstream legal rhetoric are presented in Chapter 6 by legalfeminist commentaries which identit’ how the law often misrepresents the effects ofassisted procreative technologies for women’s health and welfare. A polyvocality ofopinions about the effects of NRTs for women are expressed in a feminist discourse,which makes women central to the analysis Given the unsavoury Canadian history ofmanipulation ofwomen’s bodies and eugenic policies targeted at certain groups in society,feminist and feminist disability rights discourses are cautionary about the effects of reifyingthe pre-embryo at the expense ofwomen’s autonomy.In Chapter 7, I conclude that that there are four overarching issues which link thethree discourses. These issues are framed in terms of tensions between polarities, which is31a common tendency in Western thought. The situation of the pre-embryo as a newlyemergent cultural category highlights these oppositions which have been previouslybidden. When the status of the pre-embryo is viewed from the standpoint of a vacillationbetween opposing cultural constructs, it make evident the reason for cultural debate.32CHAPTER 2MEANINGS OF CONCEPTION: FROM TRADiTIONAL KINSHTP STuDIESTO NEW PROCREATION STORIES IN ANTHROPOLOGYThe new procreation stories which are emerging around P/F technology may beexamined along two axes of anthropological thought. One direction has demonstrated achange of interest from traditional kinship studies towards new inquiries into procreationbeliefs. The other direction has illustrated a reorientation of structural studies emphasizingthe juro-political aspects of society. Even today, the long-standing ideas and debates thatanthropologists have argued under the rubric of kinship and family studies have relevancefor modem studies concerning beliefs and practices about medically assisted procreation(Strathem 1992b). They challenge us to rethink our preconceptions about kinshiprelations and the structure of the family, which is “not a concrete institution designed tofulfill universal human needs, but an ideological construct associated with the modemstate” (Coffier, Rosaldo and Yanagisako 1982:25). If the state’s interest in familyformation relates to ensuring social stability, then it must be argued that it must also havean interest in regulating the complexities of family arrangements. The permutations offamily relations produced by the expanded applications of 1VF are becoming increasinglymore complicated and as such represent a challenge to government and law.Ideas about symbolism and procreation beliefs, concepts of parenthood, kinshiprelations, delinitions of family, the rights, obligations and duties vested in the property andpersonhood aspects of people, all represent cultural constructs that anthropologiststraditionally have channeled into kinship studies. The value of studying these ideas hasgiven kinship a privileged place in anthropology. It explains, in part, why anthropologistsstudied what they did and why sometimes they wore blinkers, which made them culturally33blind to their ethnocentric biases. It also explains in part why until the 1960santhropologists’ approaches to biology and kinship have been predominantly juro-political,rather than focused on the cultural variations in procreation beliefs. A change in directioncan be seen along two avenues, one stemming from Schneider’s work on the culturalmeaning of kinship, which led to comparative studies of conceptualization theory and theother a re-assessment of the distinction between public, juro-political domains in whichmen are the dominant actors and the domestic sphere, traditionally treated as women’ssphere of activity.I CONCEPTION TREORIES: TRADiTIONAL DEBATES ABOuTPROCREATION INAI4TI[ROPOLOGYAnthropological debates about the cultural understandings of the significance ofhow human life begins have littered the historical anthropological landscape since thenineteenth century debates on the nature of kinship and the possible evolution of socialorganization from matriarchy to patriarchy. The early theorists (Bachofen; Morgan;McLennan and Engels) in reaching a consensus that ignorance of paternity was a featureof primeval society, had brought a closure to any empirical conlirmation. In the earlytwentieth century, conjectural history began to be replaced by cultural relativity, and thedebates re-emerged from the discoveries of some ethnographers (Sharp, Malinowski,Kaberry and Austin) of contemporary peoples, living in matrilineal societies, such as theAustralian Aborigines and the Trobrianders, who appear not to recognize paternity.(i) Virgin Births and Concepts of PaternityBy the late 1960s another round of debates emerged about the significance ofkinship and the relationship between scientific biological knowledge and the culturalconstruction ofbiological processes. These controversial debates which raged through the34pages of Man between 1967 and 1969 were ignited by Leach’s provocative paperpublished in 1967 (reprinted Leach 1969), in which he discussed whether or not “primitivepeoples” were ignorant of the facts of physiological paternity. The spirited discussioninterchanged by Leach and Spiro, aided and abetted by Powell, Dixon, Burridge,Schneider, Douglas, Needham, Wilson and Schwimmer, attempted to resolve within theirown ethnocentric frameworks some of the strange cultural practices and ideas of thepeople they studied.Leach (1969) claimed that rather than ‘primitive peoples’ being ignorant ofthe factsofphysiological paternity, it is anthropological ignorance and not the Frazerian contentionof “native’s childish ignorance” (Frazer 1914:5:102). Leach argued that(d)octrines about the possibility of conception taking place without maleinsemination do not stem from innocence or ignorance; on the contrarythey are consistent with theological arguments of the greatest subtlety...they constitute a set of variations around a common structural theme, themetaphysical topography of the relationship between gods and men”(Leach 1969:86).He focused on Trobriand Islands’ society, as a cultural example of beliefs thatdisavow physical paternity. Here, a baloma, a matrilineal ancestor, who decides to returnto the substantial world, impregnates a woman through her head. Both Malinowski andPowell had recorded confirmation by informants that matrilineal dogma asserted that malesemen was a quickening agent and therefore the male contributes physically to the formingrather than the genesis of the wife’s offspring (ibid). In matrilineal societies, such as theTrobriands, formal dogma of kinship denies the father any status as genitor, thereforephysiological paternity, whether it is understood or not is irrelevant (Powell 1968:651).This is in direct contrast to Judeo-Christian doctrines ofgenitor, as I shall explain shortly.Leach has pursued the argument that common-sense determines that it isimprobable that genuine ignorance about physiological paternity should be a cultural factanywhere. Furthermore he wonders why alleged “ignorance” of physiological paternity35should be deemed “primitiveness” in early ethnographic studies, while miraculous birth ofdivine or semi-divine heroes is a characteristic of “higher” civilizations. Dionysus, son ofZeus, is born to a mortal virgin, Semele, and Jesus, son of God, is born to a mortal virgin,Mary, are but two among numerous examples from the pantheons of gods. Frazer (1914)and Hartland (1909-10), while viewing these as survivals from an earlier primitive stage,considered investigation of theology of higher religions, including Christianity, as notamenable to anthropologists. The discussants in Man seemed to exhibit a similar inabilityto compare the limitations of their own ethnocentric Christian belief system.11 KINSHIP AND BIOLOGY(1) Cultural Constructs of Biological ProcessesAnthropologists have had difficulty maintaining a theoretical distinction betweenkinship and biology. Channeling folk beliefs into kinship studies to the exclusion of thebiological facts of life may in part be explained by the discipline’s past domination by legalaspects of kinship. “Procreation was felt to be a fact ofnature or biology and kinship wasfelt to be the social recognition and structuring of these ‘real’ true biological relations asthey were known or knowable” (Delaney 1986:505).The theoretical position that the roots of kinship were located in the biology andpsychobiology of reproduction were asserted by Goodenough (1970) and Spiro (1977).However, Schneider (1968(1980)) in his symbolic approach to kinship provided a culturalaccount of kinship as a system of symbols and meanings. He focused his concern on thedefinitions of the units and rules which make up the culture of American kinship, ratherthan the description of patterns of behaviour. He identified sexual intercourse asAmerica’s central symbol ofthe culture, which can be seen both as a set of biological facts,as well as cultural notions and constructs about those biological facts. These constructs36include not only the cultural system of the formal life sciences which explicitly examinethose biological facts, but also the informal ethnoscientific construction of beliefs aboutbiological facts. Both are models of the reality based on the biological facts. ButSchneider makes the thrther distinction that certain cultural notions are expressed orsymbolized by those cultural constructs which depict the biological facts. He states that“Sexual intercourse and the attendant {psycho biological} elements which are said to bebiological facts, insofar as they concern kinship as a cultural system, are of this order.Kinship is not a theory about biology, but biology serves to formulate a theory aboutkinship” (Schneider 1980:115, his emphasis). Thus meaning is given to biological facts,such that they are transformed into cultural constructs, which then constitute a model forcommitment, which Schneider calls diffuse and enduring solidarity (ibid: 117).Clearly there has been a lack of consensus by anthropologists in defining kinship,1and it becomes even more problematic to juxtapose it with biology. Different societiesdefine “consanguinity” in various ways. In modem Western societies there is a notion thatcertain relationships are biological as well as social, expressed through the sharing ofcommon blood. In North America, Schneider found that kinship could not be discussedwithout the symbolic representations of “blood relations”.(ii) Genitor/Genetrix: :Pater/Mater: Problems of ParenthoodA major contribution of kinship theory has been the illumination of the distinctionsmade not only between descent and fihiation, but also between pater and genitor.Although the paternity controversy on a superficial examination seems to be aboutconception, it is not; rather it is about patrilateral filiation. This is a cultural strategy used1 See Chapter 8 in Barnard and Good (1984) for a discussion of the various approaches.The authors concur that “(k)inship is not mere biology.. .it is a phenomenon of an entirelydifferent order” (1984:184). They define kinship as “a systematic body of categories, ofrules expressed in terms of these categories, and of behaviour described in terms of thesecategories and assessed with reference to the rules” (ibid: 186).37as a means ofkeeping descent lines straight and ensuring that social rights and obligationsare preserved. It defines how maniage recognizes the obvious biological association ofthe progeny of a woman with her aflines, her husband’s kin. It is about legitimizingoffspring and legal paternity. It is about the cultural variety of ways that rights andobligations are institutionalized across generations (descent) and between lineages(affiance). For example, in the case ofAustralian Aborigines, patrilateral liliation is about“the relationship between the woman’s child and the clansmen of the woman’s husband(which) stems from the public recognition of the bonds of maniage, rather than from thefacts of cohabitation” (Leach 1969:87).Similarly the debates about the definition of family and marriage have centered onthe legal recognition of children rather than on the procreation relations. Gough (1971)noted the limitations of the classic anthropological definition of maniage as “a unionbetween a man and a woman such that children born to the woman are recognizedlegitimate offspring of both parents” (Notes and Queries 1951 quoted in Gough 1971).For example, the Nayar institutionalized the concepts of marriage and paternity, whichwere probably significant factors in political integration, by giving ritual and legalrecognition to both concepts (Gough 1971).2 She found the same to be true for the Toda,who used the pursutpimi ceremony, through infant marriage or payment of cattle, toestablish legal paternity, because marriage rites were insufficient for this purpose (PrincePeter cited in Gough 1971).In the early years of anthropological fieldwork Rivers’ (1914) insights into studyingthe genealogies ofthe Murray Islanders led him to make the distinction between biologicaland social paternity. Later comparative kinship studies (Barnes 1964, 1977; Schneider2 Gough (1971) uses the example of talirite and sambandham among the Nayar. Theformer, the ceremonial maniage of a pre-pubescent girl to a man, with whom she does notnecessarily cohabit or engage in sexual relations links matrilineages through interpersonalrelationships and affinity. The latter ensures legal recognition of paternity for a woman’schildren regardless ofwhether or not their paternity is known.381984) addressed this paradox of conceptualizing parenthood and how it related to kinshipterminology. Barnes extended River’s classification, in order to make the triple distinctionbetween pater, genitor and genital father. This strategy reveals how social ideology atthe politico-jural level defines the status of “fatherhood” and “motherhood”. Whereas it iscommonplace to distinguish between pater, the social father, and genitor, the putativephysiological father, it is also necessary to distinguish genitor, the person who is believedto be the physical father of the child from the genital father, who actually “supplies thespermatozoon that impregnates the ovum (Barnes 1964:297). Also Barnes (1977) wasthe first to investigate this contrast between cultural interpretations of motherhood andfatherhood. He showed how the category motherhood is shaped by fatherhood, and notvice-versa, through clearly interpretable events in nature. Strangely, or perhaps not sosurprisingly, this effect continues to be replicated in the value placed on fatherhood overmotherhood in the confusion about parenthood with new reproductive technologies(Stolke 1986; 1988). Riviere’s axiom perhaps sums up the situation best “genealogies aresocial and cultural constructs, and not biological pedigrees” (1985). Anthropologicalunderstandings about parenthood and kinship as they relate to NRTs could have provideduseflul insight for all the commissions and committees that have attempted to address thesecomplex cultural constructs.(lii) Categorizing Parents: Some Cognitive ModelsTheoretical insights into human categorization, based in cognitive science,psychobiology,4as well as sociology are beginning to help clarify some of the paradoxesThe same distinction may be made for the category ‘mother’, in the case of a gestationalsurrogate. She is a woman, who gestates the child of another’s woman’s embryo andtherefore has no genetic connection with her offspring. Socially, it is assumed that she istie genetic mother because she is pregnant with the fetus.Studies in psychobiology discuss the primary bond between a child and its mother ormother-surrogate. Currently Fox’s (1993) study of surrogacy and the Baby M case argues39in Western thought. Keesing’s cognitive psychology and cognitive science modelmaintains that ‘what we have called kinship represents cultural glosses placed by differentpeople on the bonding that they have recognized as fundamental to and constitutive of ournature as humans” (1993:4).Human categories have been described by Lakoffs (1987) complex, semiotic model(ideal cognitive model), which Keesing has extended to the category “mother”. Hedevelops a convergent model ofmother (birth mother, genetic mother, nurturing mother,marital mother and genealogical mother), which forms an experiential cluster. However,base models in the prototypical case also increasingly diverge as Keesing shows byexamples in modern science, as well as institutionalized adoption and fosterage (Keesing1993:7). Real mother, stepmother, surrogate mother, adoptive mother, foster mother,birth mother, donor mother, are all mother, because of their relation to the ideal case.Using this logic ofprototypy, he similarly delines “father” by the example that “the conical‘father’ is gemtor and pater and authority figure and mother’s husband” (ibid: 10).Currently, McKeIIin (1994) is applying similar models of cognition and culture to theprototypic term “brother” in Managalase society, in order “to account for the deviationsfrom classical logic [which] will help us understand the ways individuals generalize andcreate images of others” (1994:26).The complexities of parental relations are drawn out by the redelinition of thepeople who perform different aspects of the roles of fathers and mother, which are nowmade possible by some ofthe new reproductive technologies (see Appendix A). They addto those complex arrangements already established through blended families, adoption andfosterage. When reproductive brokers and clinics also get involved in this venture, thefor the primary bonding of the mother-child relationship, expressed by gestation, birth andearly nurturing.40legal and social situations become even more complicated, as can be seen in some of theAmeñcan legal cases about control of pre-embryos and children born from surrogacyarrangements.5ifi PROCREATION STORIES: RECONSTRUCTINGKINSHIP ANDFAMILYRecently, anthropologists have been examining the procreation beliefs of differentcultures within the context of specific cultural world views. It has been argued that someof the earlier debates about virgin births and paternity by anthropologists, as we havealready seen, might have reached a different conclusion had they focused on the symbols,meanings and beliefs about procreation and about how life is thought to begin as“embedded in and integrated with an entire system of beliefs about the world” (Delaney1986:306). Nevertheless, earlier arguments do reveal some interesting ideas about theconceptual problems about social and biological parenthood.While Delaney (1986) does not contest Leach’s distinction between physical andmetaphysical realities about paternity, she argues that he fails to see the consistencybetween them and thereby misses the fundamental issue that “(T)he anthropologist’s task isto try and understand what the concept of paterrnty is” (ibid:501, my emphasis). For herthe significance is that paternity is about begetting, and maternity means bearing, andtherefore paternity means that the male role in the production of children is understood asthe generative and creative one (ibid).The case of Baby M is the best known example. A vicious and protracted legal battleraged over who were the nghtflul parents of a baby born from a contractual surrogacyarrangement between the Sterns, with Mr. Stern being the biological father, and MaryBeth Whitehead, the “surrogate”, who was both the biological and gestational mother. Atbirth she wished to become the social mother, which led to problems ofbreach of contractwith the Sterns (Fox 1993).41Unlike the matrilineal societies discussed earlier, in Western and Middle Easternsocieties that subscribe to a monogenetic meaning ofpaternity, a child is believed to be theresult of Hone father, one blood”. Coffier (1986) and Delaney (1986, 1991) havedemonstrated this in terms of the relation of rights and obligations to cultural ideology inmodern Turkish and Andalusian societies. The child is thought to originate from thefather’s seed planted in his wife, who is then symbolized as the nurturing field. Forexample, rural women’s folk ideas about procreation are essential for understanding everyaspect of Turkish cosmology. They affect not only the structure and meaning of family,marriage and kinship, but also village society and national identity. These ideas areexpressed through the communal and fundamental understanding of the distinctivedifferences between male and female roles in procreation:The important distinctions between inside and outside, open and closed,encompassed and encompassing, close and distant, are symbolicallyintegrated in the conceptual model of the female body, which representsand expresses the lateral, spatial, and material dimensions of existence.The male role, conceptualized as generative, originating, essential, andlinear, defines these various dimensions. Who you are is related to whereyou came from. Identity is a function of origin, and origin is the source oflegitimacy. This is as true at the social level as at the personal, for thesocial order is felt to be dependent on and legitimized by the founder-father(ata) (Delaney 199 1:283).A monotheistic theory of human creation, as exemplified by Islam, Judaism andChristianity, underpins a monogenetic theory ofprocreation. In this view men produce thedivine spark of life, which is carried on from Adam through generations of fathers andsons. Men are symbolized as flames, women as embers. “Procreation is a “sacredmission” , but the divine life-giving element is transmitted in the seminal emission”(ibid:288). This line of thinking continues to be substantiated even in some modern42Turkish scholarship.6 The monogenetic theory connects kinship and biology, whetherIslamic or Christian, by symbolizing the persistent assumption in western thought ofmalecontrol over the children of the women to whom they are married. It ignores the meaningof procreation for women and the cultural scripts which make sense of their experiences.It also explains the tenacious hold of paternal rights in connection with fetuses and preembryos. It presents a clear symbolic message about who owns the conceptual moment ofhuman life.7Studies by feminist anthropologists (Collier 1982, Delaney 1986, 1991, Luker1984, Ginsburg 1987, 1989, Rapp 1989), which construct procreation beliefs based onspecific world views have appeared in the anthropological literature in the past decade.They have focused on some of the contested domains of reproduction, such as abortion,adoption, recurrent pregnancy loss, infertility and amniocentesis, a prenatal screeningtechnology.Luker (1984) and Ginsburg (1987, 1989) have used strategies, such as life histories,to show the emergence of new social movements and personal narratives. Both authorsshow how the dissonant moral views on abortion are constructed on certain ideas aboutsexuality, individuality, child care and family life. Each faction in the abortion debatedraws on cultural discourses to engage popular support. Other new procreation storiesabout pregnancy loss, infertility and adoption are also beginning to appear in theanthropological literature. Some of these accounts demonstrate how conventional andconservative notions ofparenthood and family continue to be reinforced. Modell’s studies6 “The flesh, the bones, the muscles, the blood, the brain, and indeed all the faculties andthe whole complicated and yet wonderfully coordinated machinery of the human body isall potentially contained in less than a millionth part of a drop of {seminal} fluid”9V[uhammed Khan 1962:186-187 quoted in Delaney (1991).Notions ofpower and control are inscribed into language and images, such as when thepioneers of P/F, Steptoe and Edwards are called the “fathers” of the first F/F baby andare seen holding Louise Brown in the first moments of her life. The British Governmentfilmed the birth on August 24th 1978. (National Film Board ofCanada, 1992)43(1986; 1989) on adoption and infertility found little challenge to the accepted culturalinterpretations of parenthood and family, despite the use of an advanced medicaltechnology. In the case of infertility treatments, she describes the interpretations ofparenthood by both patients and physicians, framed in terms of “odds” of a pregnancywhen enrolling in an IVF programme in the United. States. She discovered that “(U)nlikeother technological and social accommodations to infertility and involuntary childlessness,IVF upholds cultural values about the family, sexuality, and the proper relationshipbetween parents and child” (Modell 1989:135). While she reserves the conventionalmeanings of IVF to the simple model of a technology assisting biological reproduction formarried couples, she concludes, and I agree with her, that the “challenge of IVF toconventional meanings will come on other issues: the definition of a pregnancy and of aperson” (ibid) in the context of its other expanded applications, such as surrogacyarrangements, ovum donation and genetic research.1V TUE POL1TICO-JURAL APPROACU IN MTIEROPOLOGYIn today’s political climate of controversial reproductive issues, it is impossible todiscuss NRTs without contextualizing them in their political and legal regulatoryframework. In general, the power oflaw reinforces powerful discourses such as medicine.Emerging critical legal, feminist legal and race theory scholarship is attempting to producelegal reforms which may correct some past injustices. Gendered inequities have exertedand continue to exert social and legal control over women’s reproductive bodies andpractices. Likewise, critical legal and feminist anthropologists, interested in the politicojural aspects of cultures for the purpose of ensuring social stability, are attempting torefocus the vision of traditional anthropologists. The relevance of anthropologists’ pastinterests in thinking about categories of people as either persons in their own right or as44someone else’s property is significant in considering how the pre-embryo might be sociallyand legally categorized as more like person or more like property, or as something of anentirely different order. It may provide new illuminations for thinking about pre-embryosin relation to women’s bodies both in terms ofbodily autonomy and the persistent geneticassumption that because “one-half of the biogenetic substance of which the child is madeis contributed by the genetrix, and one-half by the genitor. .lEifty percent comes from hismother and fifty percent from his father at the time of his conception, and thereby is his“by birth” (Schneider 1968 (1980):23). “His by birth” implies all of the attendant legalrights and responsibilities to a man’s offspring.(i) Rights in Rem, Rights in PersonamSince Sir Henry Maine and Henry Morgan’s early works on ancient law,anthropologists have long understood that the western legal system is based on the rightsof ownership, that is the interests that people place on what they own. The idea thatstatus (j)ersonhood) is coiiflated in the social character ofproperty has been well examinedin kinship studies. A.R. Radcliffe-Brown (1952) early distinguished the relationshipbetween rights in and over persons and rights in property:(a) Rights over a person imposing some duty or duties upon that person.This is the jus in personam of Roman law. A father may exercise suchrights over his son, or a nation over its citizens.(b) Rights over a person ‘as against the world’, i.e. imposing duties on allother persons in respect of that particular person. This is jus in rem ofRoman law in relation to persons.(c) Rights over a thing i.e. some object other than a person, as against theworld, imposing duties on other persons in relation to that thing.The rights classified under (b) and (c) are fundamentally of the same kind,distinguished only as they relate to person or to things, and are of adifferent kind from those classified under (a) (Radcliffe-Brown 1952:33).45Henrietta Moore puts a more modern slant on Radcliffe-Brown’s characterizationof marriage as the acquisition of rights in women by the husband’s kin group. “Theserights can be of two kind: in personam (rights in the wife’s labour and domestic duty) andin rem (rights of sexual access)” (Moore 1988:64-65). In rem equates with totalownership in a person or an object, which is Radcliffe-Brown’s (b) and (c). Thus men arepresumed to have the right to ownership and control over their wives’ bodies.Through these concepts Radcliffe-Brown explained succession and thetransmission of property, with reference to the laws and customs of non-Europeanpeoples, in terms of transference of certain rights. Associated with rights are obligationsand duties that descent group members exert over each other, towards the group as awhole, as well as over other sorts of relatives and objects (Barnard and Good 1984:72).These jural strategies have the effect of keeping patrilineal and matrilineal succession andinheritance records straight, in the absence of coded laws.Historically, the Western legal system has made a clear distinction between what isconsidered “person” and what is considered “property”. Over time through a process ofinclusion, certain groups of non-persons, who were considered someone’s property, haveattained personhood status; for example, slaves, women, children and the mentallychallenged.(ii) Twin Universes: Persons and ThingsA fundamental problem which has arisen in discussion about the pre-embryo is thedifficulty in categorizing it as “person” or “property”. Such attempts to categorize haveled to varying degrees of cultural ambivalence. Not only are there misunderstandingsabout how to label the developing human entity through its different biological processes(as discussed in chapter 1), but also about the very nature ofwhat it is and therefore abouthow it might be treated. Is it more like property or more like person, neither or should itfit some as yet undesignated in-between category? Is it an entity that may be given away,46or sold, or does it have some inalienable quality that makes either of the aforementionedirreconcilable. These are some of the complex problems which have challenged legalthinking and led to complicated court cases (see chapter 5).Fundamental notions about “person” and “property” have remained extremelytenuous in Western thought and in the intellectual pursuits of generations ofanthropologists interested in law and society. The approach in social anthropology tomaniage was heavily influenced by jurisprudence, as anthropologists made the connectionbetween property and marriage (Bloch 1975, Goody 1976, Goody and Tambiah 1973cited in Moore 1988:64). Levi-Strauss (1969) envisaged women as a form of propertywhich members exchanged in marriage arrangements between descent groups, with theexpress purpose of forming ties of affiance through the practice of exogamy. Kopytoff(1986) is among a long distinguished lineage of anthropologists, who have explorednotions of rights in and ofpeople and rights in things. Their roots are based in the ancientpast ofRoman Law as disseminated by Sir Henry Maine in Ancient Law (1861). This textwas widely read and influential in informing generations of anthropologists, and “even inthe mid-twentieth century his formulations of social and legal evolution continued as atouchstone for new integrative theories” (Starr 1989:346).8The twin concepts of “persons” and “property” are fundamental to ourunderstanding of the radical disjunction between the “individual” and the “thing”, betweenthe “subject” and the “object” in the western tradition. The fact that these terms areculturally and historically entrenched in this tradition and not universals has been pointedout by a number of anthropologists writing in the early 1980s about the place ofwomen asobjects in non-European societies (Hirschon 1984, Strathern 1984, Whitehead 1984). A8 Starr cites Fried 1967; Gluckman 1965:113; Nader 1965:25, 1978; Colson 1974; Moore1978:63.47re-examination of their assumptions led them to revise their views to see the womenwhom they studied as agents oftheir actions.Anthropologists (Appadurai 1986; Kopytoff 1986), who have examined thecultural perspective of the social biography of things, have also questioned the bipolarthought processes of what constitutes person or property, subject or object, in Westernsociety as a cultural phenomenon, which is alien to much non-western thought.In contemporary Western thought, we take it more or less for granted thatthings - physical objects and rights to them - represent the natural universeof commodities. At the opposite pole we place people, who represent thenatural universe of individuation and singularization. This conceptualpolarity of individualized persons and commoditized things is recent and,culturally speaking, exceptional (Kopytoff 1986:64).Kopytoff has pointed out that there is a predisposition in Western thought,intellectually based in classical antiquity and Christianity, to separate “things”, through aprocess of commoditization, and “people”, through a process of individuation orsingularization. Anthropologists, of course, have realized that this conceptual dichotomyis by no means a universal. Kopytoff concurs with Durkheim in that what is individuatedor singularized is sacred.And i1, as Durkheim (1915; original publication 1912) saw it, societiesneed to set apart a certain portion of their environment, marking it as“sacred”, singularization is one means to this end. Culture ensures thatsome things remain unambiguously singular, it resists the commoditizationof others; and it sometimes resingularizes what has been commoditized(ibid 73).The most blatant example in the early modern European state was the neglect ofthis distinction in the practice of slavery. Only with the abolition of slavery in the Westwere slaves, in particular male slaves, resingularized to the status of persons. But it wasto take until the early twentieth century through the struggles of the suffiage movementfor women to be fully included into Canadian society as “persons” in 1929 with all the48contingent individual rights. Earlier they were considered, as were their children, the legalpossessions of their husbands, without the right to control ownership ofproperty, or retaincustody of their children on divorce. The legal status of children is even changingnowadays as laws are recognizing certain children’s rights as separate from parentalcontrolHowever, for “(W)hatever the complex reasons, the conceptual division betweenthe universe of people and the universe of objects had become culturally axiomatic in theWest by the mid-twentieth century” (ibid 84). Kopytoff sees the abortion debate as thebest example ofthis polarity between the universes ofpeople and things:It is best exemplified in the cultural clash over abortion, which has raged onthroughout the twentieth century than it ever was in the nineteenth, andthat this clash should be phrased by both sides in terms of the preciselocation of the line that divides persons from things and the point at which“personhood’ begins (ibid).V GENDER STUDIES AND REPRODUCTION IN ANTIEROPOLOGY(i) Moving Reproduction from “0ff-Centre”9The proliferation of gender studies in anthropology, since the 1970s, has served torevitalize feminist scholarship on reproduction. Often considered as “a “woman’s topic”,the study of reproduction by anthropologists has never been central to the field” (Ginsburgand Rapp 1991:311). Up to this time, previous research had addressed comparativestudies focused on the variety of beliefs surrounding a wealth of reproductive behavioursworldwide. However, Ginsburg and Rapp (1991) point to the trend in anthropologytowards a political economic approach, which incorporates the central insight about “theOff-centre is Franklin, Lury and Stacey’s (1991) term.49many ways that power is both structured and enacted in everyday activities - notably, inrelations of kinship, maniage, and in inheritance patterns, rituals and exchange systems”(1991:3 12). In this way attention is given to both local and global politics ofreproduction, including state and other powerful institutional controls, such asmultinational corporations and international development agencies. The authors claim thatby examining the multiple levels on which reproductive practices, policies,and politics so often depend... such a synthesis {of local and global} canreframe the way anthropologists study this subject, and move theinvestigation of reproduction to the centre of anthropological inquiry(ibid:3 13).Situating 1VF therapy within the global and local political economy of healthprovides an overarching framework for examining the current ‘local’ and ‘global’ strugglesover delining the pie-embryo’s emerging status through the discursive practices of thosewith different vested interests. New versions ofmodern procreation stories are emergingfrom these discourses, which add to those other stories, which have been identifiedrecently by anthropologists. They make explicit how issues surrounding 1VF and preembryos often reinforce the old stereotypical ideas of male control over reproduction andhow in privileging previously marginalized voices, that feminist cautions about theconsequences of assisted procreation for women are beginning to be given legitimacy.This study attempts to validate those unrecognized, subordinated views.Some feminist anthropological studies (Coffier, Rosaldo and Yanagisako 1982)have suggested that we rethink the traditional ways that anthropologists have thoughtabout kinship and family. In the past, because procreation beliefs were subsumed withinkinship studies, which theories were given a privileged place in anthropology, procreationstories were poorly represented. Here exists an interesting analogy between the dominantlegal-jural focus in the discipline as represented in kinship studies, and the under-represented power dimensions of women’s interpretations in procreation stories.Currently, we are witnessing a similar pattern with male-dominated interest in the science50and technology of artificial procreation and embryo research. The research oriented focusrests on providing an ideal environment for creating embryos, which then can bemanipulated in a variety ofways. This strategy has the facility to eclipse the gynaecentricstory of women’s repeated attempts to reappropriate control over their reproductivecapacities, which reinforces the symbiotic relationship between a woman and herembryo/fetus. Metaphorically, the male nurturer becomes “technology” (culture), whilethe female nurturer remains “woman” (nature), waiting to be tamed, or rather controlled,by culture. Thus paternity and maternity continue to be socio-legally constructed withNRTs in a particular form ofpower struggle in western society.As noted earlier, there has been a long tradition of debates in anthropology aboutthe meanings ofpaternity and maternity. They have largely been constructed in terms ofjuro-political factors, rather than the historically and culturally situated meanings. Afternearly a century ofmyths and misrepresentations about conception issues, gender studiesin anthropology are now providing a corrective, which provides significant insights intothe power relations within assisted procreative technologies.(ii) Legal Anthropology and Relations of PowerA new generation of anthropologists (Starr and Coffier et a! 1989) interested inlegal studies have taken up that challenge and advocate treating “law as the symbolicrepresentation of interests of particular groups, especially those groups in power” (Starrand Coffier 1989:24). They do not subscribe to the claim that law maintains order insociety. They conceptualize “law as a historical product rather than as a universalcategory” (ibid). Along with their colleagues in mainstream and medical anthropology,10 These medical anthropologists include those who attended the symposium sponsoredby the Wenner-Gren Foundation for Anthropological Research in Portugal in 1988. Theyreflected on the past and present historical developments in medical anthropology andcollaborated on a volume edited by Lindenbaum and Lock (1993), in which they linkedthree previously unrelated domains of anthropological inquiry; human biology, the cultural51legal anthropologists are taking up the challenge to examine the circumstances, whichaccording to Polier and Roseberry’s (1989) illuminations, have created a world thatappears to be ahistorical and without structure.Over thirty years ago, J.A. Barnes’ argued that social anthropology should take thepolitical struggle as given and examine how in that struggle various institutions includingthe law are used (Barnes 1961:194). Recently, legal anthropologists have breached subdisciplinary boundaries and have revitalized the field of legal anthropology byconceptualizing law and legal forms as historical products “embedded in and created bothby particular historical circumstances and by interrelationships between local, national andinternational events” (contributors to Starr and Coffier 1989:24). In recognizing theasymmetry of power relationships and temporality, Starr and Collier (1989) no longerisolate the “legal” as a separate field of study. Instead, they refocus their analysis to widersystems of social relations, which elucidate the relationship between social action, culturalideology and economic conditions.June Starr argues that “{A}nthropologists should never have let the ancientRomans speak to us for so long in the accents of nineteenth century Europeans” (Starr1989:365). In her re-examination of Maine’s scholarship, she maintains that heextrapolated often mistakenly from Gauis’ text Institutes to assume that Roman womenhad a considerable degree of control over their persons and their property in the secondcentury A.D. Coveting a position in the Indian civil service, Maine seemed less aware ofthe continuing perpetual tutelage ofwomen in his own countiy)1construction of knowledge and power relations. Some revisionary accounts wereproduced, which uncovered “the processes by which certain forms ofknowledge achieve aioral legitimacy and appear to be part of the natural order” (ibid:xiii).Starr footnotes that “Before 1881, British women could hold property only in the formof a trust, so that male trustees and guardians had the true decision-making powerconcerning sale, investment, and so on. Thus in Great Britain in that period there were52{A}ncient law knows next to nothing of individuals...The Romandistinction between the Law of Persons and the Law of Things.. .thoughextremely convenient, is entirely artificial... The separation of the Law ofPersons from that of Things has no meaning in the infancy of the law.. .it ismore likely that joint ownership, and not separate ownership, is the reallyarchaic institution (Maine 1861:152-153 quoted in Starr 1989).However, he makes a strange reversal in thinking by going on with the patriarchal claim:On a few systems of law the family organization of the earliest societyhas left a plain and broad mark in the life-long authority of the Father orother ancestor over the person and property of his descendants, anauthority which we may conveniently call by its later Roman name ofPatriaPotestas (ibid).This thesis examines the part which is being played presently by law in building alegal understanding about the pre-embryo by privileging it as a new independent socialcategory, divorced from its universally perceived symbiotic relationship with thegestational “woman”. I question how it is that law has unknowingly become theaccomplice to a set of circumstances which by raising the prolile of the pre-embryo as inneed of regulation, has both submerged and polarized the previous symbiotic relationshipwith a gestational woman How has this affected the control that a woman had over herbodily integrity in relation to her conceptus? In rei1,ring the pre-embryo to give it a “life ofits own”, how has this assisted the trend towards shifting the pre-embryo from potentialperson to circulating property?certain parallels to times in classical Rome. Between 1881 and 1887 the MarriedWomen’s Property Act became law in Britain, giving female British citizens the right tohold property directly in their own name and to make decisions concerning sale, alienation,purchases, and the like” (1977:35 8).53Vi CONCLUSIONA variety of issues that anthropologists have studied throughout this century haverelevance for a modern study of the pre-embryo as a new social category. Traditionaldebates about concepts of paternity, which later led into symbolic studies about culturalconstructs of biological processes have a particularly modern application in how tointerpret the underlying cultural significance ofpaternity and NRTs. Kinship studies haverevealed that juro-political statuses in societies without coded laws conflate personhoodwith the social character of property. Along with the transmission of certain rights(succession) and property are rules and duties that people exert over each other. Thesocial structure is maintained and the social relations are expressed as responsibilitiesamong relatives In complex modern, Western society built on individualistic andnuclearized family ideals, there is a tendency for this cultural construct to become buried.But I argue that the fimdamental values have consonance with the continuedpreoccupation about the relevance of biological connections. In terms of some of theconceptive technologies, and moreover because of them, it is important to know who isresponsible for whose children.Studies in symbolic anthropology undertaken by feminist anthropologists havetaken an approach that shows how procreation stories told by women are an integral partof a culture’s cosmology. Procreation beliefs are constitutive of all aspects of a society.Similarly, reinterpretation of the juro-political by feminist legal anthropologists suggestthat law be viewed as historically and culturally situated. The law is a symbolicrepresentation ofthe vested interests ofparticular groups ofpeople, most notably those inpower. Thus the maniage between the institutions ofmedicine and law is a particularlypowerful and persuasive one. This study takes from the intellectual treasure troves ofanthropologs past in order to discuss a very modern and perplexing problem in Canadiansociety. How should we interpret the pre-embryo created through a conceptive54technology, IVF, in terms of its status as person or property, its own rights or others’rights over it?55ChAPTER 3TILE MEDICAL DISCOURSE: TUE hISTORY OF EMBRYO RESEARCHAN]) TILE BIRTH OF 1VF TEChNOLOGYThe human embryo has a long history of use in medical science. It has not just“suddenly become morally significant through the innovation of in vifro fertilization”(Yoxen 1990:28). A fascination with understanding the begimiings of life has involvedgenerations of researchers obtaining access to embryonic and fetal materials, which untilvery recently has been limited by their enclosure within women’s bodies, except on rareoccasions of abortion and still births. In this thesis, I argue that experimental curiosityabout embryos has led to a technological imperative to manipulate women’s reproductivecapacities, often to the detriment of bodily autonomy. Increasingly, while embryos havebecome subjects, imbued with potential personhood, women’s bodies have becomeobjects, reproductive research sites. The old research goals live on in the newtechnologies with an advancing level of technological sophistication and finesse. Themedical construction of infertility as a disease has provided an avenue to the use of anarray of new technological innovations, and has created not only “last chance babies”(Modell 1989), but more importantly an endless supply of supernumerary pre-embryos fornew research programmes aimed at solving the ultimate questions of DNA structure andgene expression.Medical commentaries about the mysteries of conception reiterate a theme that hasbeen well documented since classical times. Indeed there has been a long tradition oftheoretical and empirical medical discourse about human embryological development.This discourse is thousands ofyears old. According to encyclopedic sources56magical beliefs about fetuses in many primitive cultures also appear in theEuropean aichemical tradition and in cabalistic writings, and the extensivediscussion of embryology in early Chinese and Indian natural philosophyand medical theory, before describing the ideas of Greek biologists likeAristotle and Galen, which retained their influence until at least thesixteenth century (Needham 1934 cited in Yoxen 1990:30).The next wave ofmedical interest in embryos were the conception models, whichoccurred with the preformation theories of the late seventeenth and eighteenth centuries.By the early nineteenth century these were giving way to empirical scientific research onfemale ovulation and embryo development, based largely on animal studies. This led intothe most recent explorations into the origins of life, heralded by the new way of makingbabies with TVF and embryo transfer. It has proceeded in short order to a chronology ofinfertility treatments, which have become increasingly available in Canada as elsewhere,mostly in the developed world over the past fifteen years. They are based on a concernfor providing treatment for people with a number ofmedical problems resulting in inabilityto produce children. The medicalization of infertility and the availability of technologicaltreatments has resulted in the escalating use of conceptive technologies, some with verypoor success rates. However, fascination with embryological research has continued,while little attention has been paid to environmental or social causes of infertility, let alonea thorough scientific evaluation of the potential iatrogenic effects of those infertilitytreatments presently available.The current medical discourse about pre-embryos can be seen most clearly in thepractices of an 1VF programme. In this research an ethnographic component is presentedof one such programme, offered by the University of British Columbia, in WesternCanada. It is located at the tertiary referral centre in the University Hospital, Shaughnessysite in central Vancouver. It is the only 1VF programme available in the province and57provides a unique example of a stable programme, which has been in effect since 1982.1It represents the most traditional model of 1VF therapy, offering only standard IVFprocedures to couples living in stable heterosexual relationships. It has continued to existdespite a crumbling health economy, represented by hospital closures, health personnellayoffs and the rebuilding of a community based health model. The description of the 1VFprogramme’s structure and service delivery, as it existed in 1993 at the time of thisresearch, forms the basis for later discussions ofmore innovative technologies.I FROM “FAILURE TO GENERATE” TO “CONCEPTION IN A WATCHGLASS”(i) Classical Greek Models of ProcreationAristotle’s largely unknown and recently translated treaty On Failure to Generatewas devoted to the subject of human fertility. Aristotle has been considered one of theworld’s lirst students of human fertility. However, he subscribed inconsistently to anumber of conception theories. He refuted the prevalent view held by most Greekscholars, such as Plato, Hippocrates and Anaxagoras, that women were merely thenutritive receptacle for the developing fetus, which was created entirely from the maleseed (Temple 1994). This belief reinforced the lineage structure that there could be nodescent from the mother.Aristotle also refuted the prevailing theory on “pangenesis” proposed byHippocrates that sperm derived from all parts of the body. Instead he believed thatwomen as well as men were responsible for conception and also “contribute seed”.1 In July 1995 a private clinic, Genesis, opened in Vancouver.58Aristotle’s logical, yet unsubstantiated beliefs had been preceded by the eccentric views ofthe mystic poet-philosopher Empedocles and by Democritus. Empedocles believed thatwhile each parent contributed to the heritage of the child, the two portions had been tornapart and the bits reunited in the womb. Democritus compared sexual intercourse to anepileptic fit and that conception was like a “collision of seed” from both males and females(ibid: 33).Aristotle’s logic was flawed in that he also entertained the folk theories ofhis time,such as the notion of parthenogenesis (see glossary). This idea was imparted to him bymidwives with whom he fraternized and was based on the Egyptian cult of Osiris.Therefore a virgin birth was labeled “an osiris”. Aristotle took this phenomenon no lessseriously than the later Christian ideas that arose from the same Egyptian source. Theseideas have been much discussed by anthropologists (Leach 1969, Delaney 1986, 1991).Aristotle also theorized that the retroverted uterus impeded conception. Althoughhe did not subscribe to Plato and Hippocrates’ beliefs in a wandering uterus, which “getsdiscontented and angry and wandering in every direction closes up the passages of thebreath and obstructing respiration drives them (women) to extremity” (Timaeus quoted inTemple 1994:3 5), he did think that the uterus might be capable of some movement.The dominant procreation model that still had currency up until the Renaissancewas a theory of simultaneous development of all parts of a new human life, labeledepigenesis. It was subscribed to by Aristotle, Hippocrates and Galen, but refuted by Platoand Aeschylus.The weakness of the theory was that it did not satisfactorily explain howsuch a complicated process as the creation of life took place. A rivaltheory to that of epigenesis was that of preformation. Some early writerslike Plato and Aeschylus argued that a miniature embryonic life was afreadyin place within the parent - like an egg - and embryological developmentonly consisted ofgrowth, not creation” (McLaren 1984:22).59(ii) Preformation TheoriesBy the late sixteenth century the model of epigenesis was being challenged bypreformation theories. McLaren (1984), in his study of the perceptions of fertility inEngland from the sixteenth to the nineteenth century, recounts how these theoriesimagined a single parent, a homunculus, afready in existence. It was not created, butrather started to enlarge on conception. However, it was to take more than a century forthis paradigm shift to occur.Firstly, Wiffiam Harvey, physician to Charles I, sought in vain to discover thehuman egg. He has often been called the founder of embryology with his work Degeneratione animalium (1651). A coninñtted Aristotelian, Harvey subscribed to the viewthat if an embryo was the result of the mixing of menstrual blood and semen on coitus,then it should be possible to find an embryo in the uterus soon thereafter. Neither findingthe homunculus or semen in the uterus, Harvey returned to epigenetic theory, resolvingthat the egg was the product and not the cause of conception. He rationalized “that theformation of embryos occurred through some sort of non-material influence of the malesemen that eventually caused the appearance of a fertilized egg in the uterus” (Yoxen1990:31). This beliefwas to persist in Albertus Hailer’s later claim that the ovum becamemodified in the uterus and not on its journey through the oviduct (Bodemer 1971).The lengthy paradigm shift to the preformation theories of the late seventeenth andeighteenth centuries, emerged on the Continent in the light of new empirical medicalevidence. The human reproductive system, particularly the female system, was comingunder intense scrutiny with the growing interest in the study of human anatomy anddissection. The breakthroughs came in the mammalian research. Marcello Malpighideveloped a more sophisticated view of conception based on his work on chick60embryological development. Remer de Graaf discovered the fofficles, later known asGraafian follicles, which he erroneously identified as mammalian eggs. However, themammalian egg was not to be found for another one hundred and fifty years, untildiscovered in 1827 by Karl von Baer. During all this time there was a growing scientificconsensus that a woman’s body contained her miniature offspring.The preformation theories took two forms, both of which implied a monogenetic(monoparental) idea of a miniature contained in either sperm or mother’s egg. The Ovists’arguments related by analogy to egg-laying animals, while animalculists subscribed to thediscovery by Anton van Leeuweithoek in 1677 ofmicroscopic beings in semen (McLaren1984:23). Thus Ovists held that the miniature was contained in the female egg, while theanimalculists argued it existed in the spermatozoa.2The historical variations on the ovist theory are numerous:Thus in John Case’s The Angelical Guide (1697) are references to thehuman egg being shaken by the sperm into the fallopian tubes; JohnBlondel went so far as to refer to semen as mere manure for the ovum;Alexander Hamilton in 1871 declared that the child existed in the ovariesand the act of generation was ‘only the means intended by providence tosupply it with life’; and William Cullen’s edition of Albertus Hailer whilereviewing conflicting theories on generation held that the foetus was onlyexcited into life by the ‘seminal worms’ (ibid).(iii) Theories of Ovulation and Embryo DevelopmentThe birth of modem embryology began in the second decade of the nineteenthcentury. Von Baer discovered that ovulation in mammals (in this case his ffiend’s dog)2 McLaren footnotes “a third and even more bizarre school of thought, that of the“panspermists”, who argued that all beings were created by God at one moment in time,that such tiny beings were suspended in the atmosphere and that they past from the air intothe man and then into the woman and then were born” (1984:159). There is a markedsimilarity in belief here with the Trobriand Islanders belief in the air or water born childspirits, baloma, described by Maiinowski (1932).61results in a mature egg in a fluid-filled sac on the ovarys surface. But it was to take nearlyanother century until American physician, E. Allen and colleagues in 1919 linked ovulationwith the menstrual cycle, when they recovered a human ovum.Meanwhile during the mid-nineteenth century, an interest in how embryosdeveloped and continually reorganized their structure had led to experimental research onmammalian embryos, particularly rabbits. In 1880 Walter Heape, a Cambridgephysiologist had transferred rabbit embryos from one animal to another on a needle tip(Steptoe and Edwards 1978). This contradicted a commonly held view in animal breedingand proved the function of the uterus to be a nurturing structure, unrelated to “hereditaryimpressions”. At this time research on agricultural animals and medical research on humanreproduction were making similar connections, particularly in understanding the action ofhormones on reproductive physiological processes.The growing collections of embryos, both mammalian and increasingly human atvarious stages of development, provided an inexhaustible supply of research materiaLThese collections were stored in hospitals in both Europe and the United States in thelatter half of the nineteenth and early twentieth centuries. They aided researchers inunderstanding fetal development and tissue differentiation. These research collectionshave parallels in the present proliferation of banks of cryopreserved pre-embryos, whichare not needed for embryo transfer. They present tempting sources of undifferentiatedhuman pre-embryonic tissue, which may provide researchers with less complex access thanthat recounted by Yoxen:However, the important point at this stage is to note that, althoughexperimental embryology expanded significantly in the second half of thenineteenth century with dissections and investigations of animal andamphibian embryos, and although slightly later work in reproductivephysiology threw light on ovulation and gestation, work on humanembryos was necessarily limited to the dissection of dead or dying62specimens obtained in hospital. It was in effect an extension ofcomparative anatomy (Yoxen 1990:33).By the beginning of World War 1, the strategy of embryo collections funded byendowments had the effect of both systematizing and centralizing the sub-specialty ofembryology through access to post-implantation embryonic specimens. A modernresearch institute was established in Baltimore based on Franklin Mall’s embryo collectionsand funded by the Carnegie Institution. In Mall’s (1913) plea for an Institute of HumanEmbryology, he argued that a large collection of embryos, competent staff and the bestequipment would help solve problems in many areas, including physical anthropology(Mall 1913 cited in Yoxen 1990:34). Later this collection was transferred to the MedicalSchool at the University ofCalifornia at Davis.Within half a century, researchers such as Corner, the first director “could drawupon unrivaled archival and technical resources in human embryology to develop hisinterests in the interactions between the physiology of reproductive hormone secretion,uterine function and human development” (Yoxen 1990:3 5). These discoveries providedthe background knowledge that would be preparatory to the development of thetechnological intervention, which was to become IVF.(iv) The Egg Hunt: The Access to and Ethics of Embryology ResearchIt has been conjectured (McLaughlin 1982; Corea 1985; Yoxen 1990) that accessto embryonic material was assisted by the loose guidelines about informed consent frompatients and ethical research practices. Morals of the new systematic embryonic researchappeared to treat as irrelevant the circumstances, such as miscarriage, surgery or still birth,whereby human fetuses or post-implantation embryos had been retrieved. In particular theresearch practices of gynecologist, John Rock and pathologist, Arthur T. Hertig were63suspect. In the late 1930s, they retrieved fertilized ova from women, upon whom Rockoperated for surgical sterilization and hysterectomy. In what they termed the “egg hunt”,they scheduled the time of surgery to occur a little later than the time the patient wouldovulate, in the hope of retrieving an embryo from the fallopian tubes or uterus. In somecases surgery was “delayed for several months whilst the women returned to the hospitalas charity patients bearing temperature charts, from which the date for surgery wascomputed” (Yoxen 1990:36).Procuring embryos from “volunteer” poor women, who were receiving charitymedical care at the Free Hospital for Women in Brookline, Massachusetts, occurred underdubious circumstances (Corea 1985:101). Although they had consented to surgery, it isdoubtful whether they were aware of the destined use of their unfertilized or fertilized ovaby researchers whom Corea refers to as “pharmacrats”.3At the time, a journalist, Loretta McLaughlin revealed the reason why prestigiousdoctors were given admitting privileges at the charity hospital and did not charge theirpatients any operating fees. A hospital appointment “provided almost absolute researchfreedom, far less interference than at the larger, Harvard-affiliated hospital in Bostonproper” (McLaughlin 1982 quoted in Corea 1985: 101). Tn this way researchers obtainedcarte blanche to experiment on human ova, which they hoped might be fertilized, aspatients were asked to keep a record ofwhen they had engaged in sexual intercourse priorto surgery.This surge of experimental research activity reached its zenith in the late 193 Oswith an interest in extra-uterine fertilization, known as in vitro (in glass) fertilization. InCorea catalogues a long list of scientific articles, which report on attempts to retrieveand experiment on women’s ova. She comments that in these studies there is littleevidence that women consented to the retrieval of their eggs, or even knew they had beenremoved (Corea 1985:135).64an article in the New England Journal ofMedicine (1937), by Anon, “Conception in awatch glass”, there was an implication that Rock and Pincus’s research might lead to acure for infertility caused by obstructed fallopian tubes. It was believed that Rock was theauthor ofthe article (Yoxen 1990:36).In the early 1940s, Rock and his assistant Miriam Menkin were “attempting tofertilize human ova, obtained from Rock’s hysterectomy patients, using semen from Rock’sjunior doctors” (ibid). Rock, a devout Roman Catholic met with criticism from Bostonsociety, leading him to abandon his research in favour ofwork on the development of oralcontraceptives, which proved to be equally controversial research.65II. 1YF AND EMBRYO TRANSFER: NEWWAYS OF MAKING BABIESIn the post Second World War years research took off in a variety of directions,which culminated in the successful application of IVF to treat some forms of infertility.Research on concocting a culture medium for ova to mature and a means of capacitatingsperm was a necessary prelude to extra-uterine fertilization. While Hertig investigateduterine and embryonic abnormalities, physiologist Gregory Pincus, who had worked inEngland on animal studies, was involved in hormonal regulation and the maturation of ovaprior to ovulation (ibid:35). Along with other researchers, Hertig went on with theresearch, reporting that success had occurred in fertilizing thirty-four human ova, retrievedfrom two hundred and ten women (Hertig 1959:202-211). In the same year, 1959, Changdescribed an experiment in which he fertilized mammalian ova in vitro (Adams 1982).Also in the fifties, successful freezing of sperm, retaining fertilization ability, hadbecome possible in the United States. Access to inexpensive, anonymously donated spermprovided both a source of sperm for studies of capacitation in in vitro fertilizationresearch, and also led to the opening of sperm banks for artificial insemination by donor(AID) (Achilles 1988). In England these banks derived from altruistic donations, whereasin the United States they soon reverted to a profit motive. Increasingly it became a meansof economic subsistence for impecunious male students and welfare recipients (Titmuss1971).Chang’s success at fertilizing ova was not replicated for another decade. The ovaextracted from female mammals, namely rabbits, mice and rats were frequently immatureCapacitation of sperm usually occurs in the female genital tract, where the spermssurface acquires the ability to penetrate the zona pellucida, the outer layer ofthe ovum.66and research into various culture mediums was necessary to mature the ova prior tofertilization (Adams 1982).Edwards, a British physiologist, who later worked with Steptoe to produce thefirst 1VF baby, conducted research in the mid-1960s in the United States. He did this inresponse to his frustrated search for research ova in England (Edwards and Steptoe 1980).Feminist critic, Corea (1985) exposes what she maintains was Edwards’ truepreoccupation with maturing human ova and how he used women in his unquenchablethirst for developing new fertility procedures. She narrates how this concern is oftenrevealed in his collaborative book A Matter ofLfe (Edwards and Steptoe 1980).First, as a graduate student, he had worked with mice. After he had“bombed” their ovaries with hormones, he had learned a good deal aboutthe way eggs ripen. Later, while researching in another field, “the eggswere always there in the background beckoning me on to my real work”.Occasionally he dreamed of eggs.He arranged for various gynecologists to call him when they thought theymight have ovarian tissue to “bequeath” him. He would go to the hospitaLWhile the physician cut into the woman’s body, he would stand, maskedand gowned, holding his sterile glass pot “the receptacle for the preciousbit of superfluous ovarian tissue”.Dr. Edwards needed more eggs. He never had enough. He “scoutedaround” for them and tried to rally more doctors to his cause.” He “cameaway empty handed”. His sources “dried up”. Human eggs were slowcoming my way, he wrote “despite the fact that I had struck up ffiendlyrelations with some of the gynecologists at Cambridge’s AddenbrookesHospital” (Corea 1985:105).Between 1960 and 1965, Edwards worked on a time sequence for human ovamaturation, linally reporting that early fertilization of human ova in vitro had beenachieved, with all the necessary tests for procedural safety against chromosomalabnormalities (Edwards eta! 1969). Between 1966-1967, he worked in the United States67on two occasions conducting a number of experiments on capacitating sperm. On the firsttrip he used husband sperm collected post-coitally to place in culture with human ova. Onthe second visit he persuaded female patients to volunteer for further bizarre experimentsin capacitation, this time using donated sperm. Thus in collaborating with Americangynecologists(he) collected bits of ovarian tissue, extracted eggs from the tissue, ripenedthe eggs, collected sperm (from whom he does not say, but in otherexperiments, he had used his own), put them into porous chambers, andfound women volunteers who would allow the chamber to be inserted inthem at night and removed in the morning” (Corea 1985:106-107).All this experimental research on capacitation and nutrient media paved the wayfor a breakthrough to provide him with a reliable source of ovarian material to test hismethods of in vitro fertilization with human ova. A new surgical procedure provided himwith unfertilized ova directly retrieved from ovaries removed from female patients duringroutine gynaecological operations. No longer would he have to hunt for sources ofovarian tissue or fertilized donated ova. Afier reading an article by Steptoe, a Britishgynecologist, who had pioneered the use of the laparoscope to visualize the femalereproductive tract in surgery, Edwards launched his collaboration with Steptoe in 1968.Steptoe gave Edwards the ova that he removed surgically. Within a year the first successwith fertilizing human eggs in vitro was claimed.6Edwards and his student Bavister had found the right fluid medium, dubbed“Barrs magic culture fluid’ (a mixture of the pair’s own sperm) in which the ova wouldWhen Edwards had spent sleepless nights over this experiment, his wife had questionedim about whether the sperm could escape from the membrane. But he thought not!Corea comments in a footnote that results in this field are always contestable. AnAmerican, Pierre Soupart, working with fertility specialist Howard Jones in Baltimore{wiiere coincidentally Edwards had worked in 1966} has also been credited with havingbeen the first to fertilize a human ovum (1985:138).68continue to grow for a few hours (ibid: 108). When Edwards, Bavister and Steptoe (1969)published their early results, the first round of ethical controversy ensued with theexperiments being condemned by the Archbishop of Liverpool (Singer and Wells1984:15). Ethicists Singer and Wells describe the early problems encountered as thetechnology was applied to women, who were prepared to undergo 1VF treatment.It took four years of fiddling around with hormones, before the firstpregnancy occurred - and then this turned out to be an ectopic pregnancy;that is, the foetus was not growing in the womb but rather in whatremained of the patient’s Fallopian tube. In this situation, the foetus has noroom to grow and it can burst the wall of the tube, threatening an internalbleeding which could be fatal for the mother. The pregnancy had to beterminated.Further work produced a second pregnancy, but it spontaneously abortedin the first few weeks. It was not until 1977 that tests confirmed thesuccessful transfer of an embryo to a patient named Lesley Brown” (ibid).The ten years of Edwards’ marathon commuting back and forth between OldhamHospital in the Midlands, where Steptoe had his surgical practice, and his researchlaboratory in Cambridge eventually paid off (Edwards 1990:43). The pair had their firstsuccess with IVF technology in a naturally occurring menstrual cycle with the birth in1978 of the world’s first 1VF baby. Louise Brown was delivered by caesarian section,following a medically, ifnot socially, uneventful pregnancy.The alleviation of infertility was merely one of many potential studies the paircould have pursued. Other possibilities existed, as Edwards points out “depending on theavailability of human eggs and embryos for research, including a study of the causes ofchromosomal imbalance, the pre-implantation diagnosis of inherited diseases, relationshipsbetween cancer and embryonic cells and many others” (ibid: 43-44). These research69domains are presently providing fertile research territory for current reproductiveresearchers.This miraculous birth was followed shortly after by one in Australia, where aMelbourne team had begun work in 1970. Carl Wood had tried unsuccessfully to developan artificial Fallopian tube for a patient with diseased tubes. Researchers, who had beeninfluenced by experiments in animal reproductive biology, discovered that the number ofoffspring from pedigree sheep and cattle could be dramatically increased by giving thefemale animal superovulatory drugs. This regime caused the production of multiple ova.After insemination and fertilization in vivo, the embryos could be flushed from the uterusand transferred into less valuable livestock, surrogates with no genetic connection, whocould gestate the “quality” embryo (Singer and Wells 1984:15-16).Wood had reported this research at a conference of the Australian Society ofReproductive Biology in Melbourne in 1979. He had suggested an application of animalhusbandry, which could be used in humans. The fallopian tubes could be by-passed inwomen with tubal damage by creating embryos in vitro (in glass) and then returning themto the woman. Unlike the selective breeding in animals, the woman would be both thebiological, gestational and social mother of her embryo/fetus/child. This was preciselywhat Steptoe and Edwards had afready achieved. Of course, “No one was, at that stage,suggesting the use of selective breeding or surrogate mothers for humans - although inview of the origins of the procedure, there were always possibilities, once IVF succeededin humans” (ibid: 16). Inadvertently or not, the specter of a eugenic policy in relation toTVF was on the way to materialization.70ifi A ChRONOLOGY OF IKFERTIL1TY AND GENETIC SCREENINGTECHNOLOGIESWhen Patrick Steptoe, often referred to as “the father of 1VF”, said “we’re at theend of the beginning - not the beginning of the end” (1978), following the first WF birth,his words were proved to be prophetic. At that time he was referring to that long historyof research, which had preceded this milestone. His prescience was timely, however, as inthe next fifteen years, an explosion in conceptive technologies and genetic screeningtechnologies were about to develop from on-going research.The Voluntary Licensing Authority (1991) in the United Kingdom has cataloguedmany of the more recent milestones in new and not so new reproductive technologies(such as artificial insemination). As noted earlier, in Britain in 1969, the first fertilizationin vitro of a human oocyte occurred, followed ten years later by the first IVF birth andwithin seven months another one by Steptoe and Edwards’s technique. In between an IVFbirth occurred in Calcutta, India. In this case the doctors had used a different technique;“after the mother’s egg had been fertilized in vitro, it had been frozen and stored for fifty-three days before implantation in her uterus” (Scott 1981:215). Shortly after a birth wasreported by the Australian team ofWood and Trounsen. The first 1VF birth in Canadaoccurred in 1983 as a result of 1VF treatment at the University of British Columbia IVFprogramme.These early successes were swiftly followed by multiple births using IVF; twinsand quadruplets in 1983 and triplets in 1984, all in the United Kingdom A technique thatallows for embryos to be fertilized in one woman, then “flushed” and implanted into aninfertile patient first took place in 1983 (OTA 1988:298). By that year, a deep freezehuman embryo storage programme had been developed and a year later, in theNetherlands, the first baby was born resulting from the transfer of a frozen, then thawed71human pre-embryo. In 1986, the birth of the second frozen embryo ‘time-warp twin” wasborn (Brinsden and Rainsbury 1992:23). It is believed that the first embryos to be frozenin North Ameiica occurred at the Mayo Clinic in 1982. Carolyn Coulam, with theassistance of an animal scientist, froze seventeen fertilized eggs, which were among twentyshe had retrieved from a patient, who did not wish them to be discarded. Due to theMayo Clinic’s disapproval and demand that the frozen embryos be destroyed and out ofrespect for her distraught patient, who had consented to the experiment, Coulam left herlong-standing appointment at the clinic and removed the seventeen embryos to Pittsburg.The patient who had a baby from the initial replacement of three of her embryos,subsequently had another child from one ofthe fateful frozen embryos.7Following the first wave of TVF successes, new technologies and practices weredeveloped to help those with other sorts of infertility problems, such as women, who wereanovulatory and men with oligospermia (see glossary), poor sperm motility orabnormalities. In 1984, the first birth from an “egg donation” occurred in Australia. Bythe early 1990s, amid considerable controversy, ova donation was extended to includepost-menopausal women, who could now gestate a fetus and become mothers fromoocytes donated from younger women.In 1990, the first birth occurred in Italy, following subzonal insemination (SUZI),which involves the micro-injection of several sperm into the perivitelline space of thehuman egg, in order to overcome male factor infertility, In 1993, the first baby was bornthrough a refinement of the SUZI technique, intra-cytoplasmic sperm injection (ICSI).This technique was pioneered in Belgium by Van Steirteghem, who reported to IVFCongresses in Brussels and Montreal in 1994 that data from 1300 ICSI treatment cyclesPersonal communication from Dr. C. Coulam of Genetics and IVF Institute, Fairfax,Virginia, May 1995.72showed that more than two-thirds of the 000ytes injected by the micro-technique hadfertilized. 439 children had been born by August 1994, and there had been a 3.6 per centmajor malformation rate, although it was too early to assess longterm consequences (11/FCongress Magazine 1994:4).The human genome project8has resulted in some early advances in isolating someof the genes responsible for inheritable diseases. 1VF technology is proving to be a usefuladjunct to the research into diagnosis and elimination of certain genetically diseasedembryos prior to a pregnancy being initiated. In what is call preimplantation diagnosis,pre-embryos created through 11/F have become valuable “commodities” in a newgeneration of pre-embryo screening technologies. These technologies are heralded as atriumph for families stricken with family histories of severe inheritable diseases, as theyoffer affected couples the opportunity of parenting children, who are unaffected by a“defective” gene, such as the cystic fibrosis gene. Pre-implantation diagnosis, the first inthe line of pre-embryo screening research technologies, is conducted at the eight cellstage, three days after fertilization, by removing one cell and using it for genetic testing. Ituses a hybridization technique to speed up the screening process, so that normal preembryos can be replaced in time to develop normally.9 Nothing is known yet about whatit means for future children to be born from pre-embryos, which have been invaded anddivested of one of their totipotential cells, then “kept on ice” awaiting the go ahead forimplantation or destruction.8 The human genome project involves mapping the 3,500 million base pairs that compriseie complete set of genes which humans possess. (See genome in glossary).Since extra-uterine embryos develop more slowly than in vivo embryos, their growthdoes not keep pace with developments in the uterine wall leading to problems inimplantation. It is critical, therefore, that in diagnosing a genetic disorder, that the preembryo’s viability is not compromised for its later gestation (Newell 1995).73In 1990, the first baby was born following pre-implantation genetic diagnosis (seeglossary), as a result of the work ofRobert Winston’s team at the Hammersmith Hospital,London, England. This centre uses tests for sex selecting X-linked recessive diseases,such as cystic fibrosis. With its combined research and treatment facilities it is on thecutting edge of several experimental techniques on humans, which includes the use ofdeliberately engineered patient-specific DNA probes to check the pre-embryos of awoman known to be a earner for a genetic defect which could cause the syndrome in amale child. Yet another newly pioneered technique aptly named FISH - fluorescent in situhybridization - is also being applied to humans, in order to sex early pre-embryos, as wellas genetic defects. Winston’s team is now working to develop better means ofinvestigating genetic illnesses such as fragile X syndrome, myotomc dystrophy, Kennedy’sdisease and Huntington’s disease. In the future new treatment options will include thedirect treatment of “diseased” pre-embryos or their indirect use in treating other lifethreatening critical human diseases, such as cancer or Parkinson’s disease (Newell1995:21). The new techniques on the horizon will probably involve embryonic surgery toreplace defective genes.Research clinicians are increasingly undertaking much of this primary research intheir dual roles as clinicians and research scientists. 10 One research clinician axiomaticallyjustified the union this way: “Today’s research is tomorrow’s medical practice, so it is10 A recent example of this is the disclosure by Bernard Hedon, president of theorganizing committee of the fifteenth International Federation of Fertility Societies’congress to be held in Montpelier, France in September 1995, that his work as head of thedepartment of reproductive medicine in Montpelier is “primarily that of a hospitalclinician, responsible for a team of clinicians. Teamwork is essential to achieve anything.I also head a small research group which is currently working on embryonal implantationand endometriosis.. Embryonic co-cultures and assisted hatching are among the mostpromising techniques in this area” (Hedon quoted in Dorozynski 1995:7-8).74important that we know the direction research is taking” (Dorozynski 1995:8). The ethicsof the close connection between pure scientific research and clinical application occurringwith these pioneer experiments is frequently treated in a cursory manner as exemplified byWinston, one of England’s foremost researcher/clinicians in the field of preimplantationgenetics. He is frequently in the media limelight. On the one hand he maintains that thereis considerable cross-fertilization of ideas between his research group and his treatmentgroup, and on the other hand he says he has deliberately kept them separate.I have conlirmed from my own experience that you don’t do good researchifyou practice medicine part-time and science part-time...The aim is to givethe scientists as much freedom as they want, not to structure theirexistence. They have to find what intrigues them rather than follow acollective goal (Winston quoted in Newell 1995:2 1).He maintains that in a democratic country such as Britain, that regulations caneffectively curtail any effects from the potential socially harmfiul nature ofpre-implantationtechnologies. IVF pioneer physician, Jacques Testart in France, is far less optimistic andsees the eugenic threat of pre-implantation technology as not one which can be entrustedto democratic governments (National Film Board ofCanada 1992 hereafter NFB).Since 1990, approximately eight clinical preimplantation diagnosis programmes havebeen set up worldwide. In June 1994, a global estimate assessed that from 149 completedtreatment cycles that twenty-nine children have been born from this technique. (Nisker1995:247). There is one in Canada, named EPICS (early pre-implantation cell screening),at the University of Western Ontario in London, which is affiliated with a researchcomponent, funded by the Ontario government. The treatment arm is directed byGeoffley Nisker and the research arm by Robert Gore-Langton (NFB: 1992) Theirapproach appears to be consistent with Winston’s justifications for collaborative scientificand treatment ventures.75lv THE MEDICAL DISCOURSE OF INFERTILITY AND SUCCESS:PROBLEMS OF DIAGNOSIS AN]) CUREIn the fifteen years since the inception and proliferation of 1VF services worldwide,there has been a two-pronged approach to creating pre-embryos. One relates to thediagnosis of causes of infertility and attempts to alleviate these problems by a variety ofmedical means; the other concerns the detection of genetic disorders and attempts to findsolutions to the bringing into existence babies predisposed to certain inheritable diseases.This study is primarily concerned with the former, although it is placed in the historicalcontext of a wider scientific interest in embryo research. This section examines theprevailing medical discourses that have been designed to establish a definition of infertilityand which have then been used to classify infertility as a disease. The prevalence ofinfertility in the Canadian population has been largely based on only three smalldemographic telephone surveys (CRCNRT 1993: 194-197). Once a population of peopleare established as infertile and in need of infertility services, such as IVF, the next problemis to define the criteria for what constitutes successful treatment.(i) The Discourse of Epidemiology (Population Studies)Defining infertility and looking for causal relationships is a fairly recentpreoccupation in biomedicine. As with other current health problems, such as AIDS,infertility has multifactorial causes, which are currently poorly understood. However, theepidemiological literature about infertility has begun recently to address social and medicalpractices which result in known risk factors (Mueller and Daling 1989).In the mid 1980s, population studies started to collect global data relating tohuman infertility. An extensive World Health Organization (WHO) study was conductedbetween 1979-1984 in thirty-three centres in twenty-five countries worldwide. This WHO76investigation represents the largest data base ever assembled on the characteristics, clinicalfindings and results of 5,800 couples seeking evaluation of their infertility. Among thefindings was the fact that bilateral obstructed fallopian tubes and other infections wererelated to a woman’s history of sexually transmitted disease (STDs), peMe inflammatorydisease (PIDs) and pregnancy complications (WHO 1987:964-965). Statistics compiledfor one of the WHO studies projected that approximately 30% of couples in parts ofAfrica may be infertile.It is estimated that infertility affects about 2.3 million couples in the United States(Mosher and Pratt 1990). In Britain, some 50,000 new cases of infertility are diagnosedeach year (Pfeffer and Wooflett 1983), an inevitable underestimation, as not all people willseek medical attention or they may present themselves with other symptoms.11Conversely, as one Canadian physician points out “nowadays many couples seek advice orwish treatment long before a reasonable “trial” has occurred - they have unreasonably highexpectations”. (interview with infertility specialist, September 1993).In Canada, infertility statistics still remain inadequately defined, despite theCanadian Royal Commission on New Reproductive Technologies (CRCNRT) conductingthree limited telephone surveys between December 1991 and March 1992. The results ofthese incredibly cursory studies, provided from commission contracts with Canada HealthMonitor and Decima Research, have been challenged by the Social Science Federation ofCanada (1992) and feminists (Basen, Eichler and Lippman 1993), who have criticized theirresearch practices. However, the results add to a growing public perception thatOne detailed study of a single District Health Authority in England concluded that atleast one in six couples needed specialist attention at some point because of an average oftwo and a half years of infertility (Hull et al. 1985, cited in Doyal 1987:177) This patchyinformation on the extent of infertility services was recognized in the Warnock Report(Wamock 1985:13).77procedures like IVF are a necessary and successfiul service for the 250,000 couples whoCRCNRT believe are experiencing prolonged infertility problems (CRCNRT 1993:194).The first of these Canadian surveys sought to determine the prevalence of infertility incouples in which the female partner was aged 18-44 years. Then CRCNRT assessed theprevalence of infertility in Canada in two ways: by conducting three national surveys andthen synthesizing their results and through secondary analysis by examining three othersurveys canied out in the 1980s for other purposes.’2 It concluded that 300,000Canadian couples (eight and one halfpercent), who had cohabited for at least one year, atthe time of the survey, were infertile. After two years of cohabitation, 250,000 (sevenpercent) remained infertile (ibid: 180). As long as forty-five years ago a study had placedthe permanent infertility rate of Canadian couples at ten percent (Wlielpton and Kiser(1948) cited in Bryant (1990)).Since most of the infertility studies have focused on female infertility, it has beenwell recognized that female fertility decreases with increasing age and in an inverserelationship to socioeconomic status (Henshaw and Orr 1987). Similarly, Strickler (1992)indicates that social factors such as sexually transmitted disease, general levels of healthand age patterns of child-bearing all have a part in determining these patterns.(ii) The Numbers GamesThe justification of therapeutic intervention has plagued the reproductive medicinefield during the 1980s. A major problem has been both in defining infertility withinpopulation studies and what constitutes a definition of “success” in infertility treatment.12 See Appendix 1: The Prevalence of Infertility in Canada - Surveys conducted for theCommission and Appendix 2: One-Year and Two-Year Calculations of the Infertility Ratein Proceed with Care (CRCNRT 1993:194-197).78Eiyant, in a study commissioned by the Canadian Advisory Council on the Status ofWomen, has identified this problem in thatthe numbers chosen to define “infertility” affect both the perceivedmagnitude of the problem, and the apparent cure rate. This must be bornein mind whenever infertility rates and therapeutic success rates arediscussed” (Bryant 1990:2).In its report, CRCNRT also acknowledged this common misperception and gaveassurances of its intention to use the estimates it collected in the Canadian population as abaseline for tracking infertility rates in Canada in the future, as well as for comparison withother countries.’3The CRCNRT in its approach based on medical evidence considered three factorsas to how it defined and measured infertility for population surveys (CRCNRT 1993:181-186). Firstly, it measured the endpoint, whether pregnancy had occurred, as opposed tofailure to carry a pregnancy or failure to give birth to a healthy child. Secondly, itaddressed the time period to define a couple as involuntarily infertile, which is arbitrary,and chose the World Health Organization (WHO) time frame of two years.’4 Thirdly,CRCNRT addressed the population who would be counted, and focused upon infertile13 Caution has been advised by several groups (e.g. National Action Committee on theStatus of Women (NAC) and the Social Science Federation of Canada in accepting theaccuracy of the data collected by the Commission. Intense criticism of its researchpractices throughout its turbulent four year research period has been presented in mediaand feminist publications, such as McTeer 1992, Social Science Federation of Canadaf92, 1993, Basen, Eicliler and Lippman 1993.This time period is based on the evidence that failure to conceive naturally after twoyears, generally indicates a low chance of conception without intervention. Researchsuggests that a normally fertile, sexually active couple not using contraception has anaverage monthly chance of conceiving of twenty to twenty-five percent, countingpregnancies that result in live births (Hull et a!. 1985).79couples who were cohabiting (married or common-law). It noted that unlike prevalence15research methods the United States, it was not possible to include in the survey the fortypercent ofwomen, between ages 18-44, who do not live with a male partner. Thus it alsoexcluded same sex couples from the population of the study.16 Implausibly, theCRCNRT justified this exclusion on the grounds that methods could be refined in futurestudies, but that infertility estimates in the United States did not differ significantly fromthose reached by the Commission. As feminists well know, exclusion by omission is nodefense.(iii) “A Take Rome Baby”: Measuring the Rhetoric of “Success”Problems about defining infertility not only relate to who is counted, but what iscounted. The categorization of the term “success” in IVF therapy has been both confusingand misrepresentative. For example, national indicators about the success of a treatmentsuch as 1VF is based on the individual reports of physicians and clinics providing theservices. Some reporters have termed an IVF cycle as “successfiul” when gametes fuse atfertilization (a technical success). Others register success when a chemical pregnancy hasoccurred, which is established through an immuno-assay test of maternal urine or blood.A positive human chorionic gonadotrophin (betaHCG) will occur approximately twoweeks after embryo transfer (an implantation success). In other cases a clinical pregnancy,established by a sonar scan to detect a gestational sac at about three and a halfweeks after15 An important distinction is made between “prevalence” and “incidence”. Prevalencerefers to the number of cases at a point in time, while incidence refers to the occurrenceijae over a period of time (Dorland’s Medical Dictionary 1957).A current response to the neglect of same sex couples’ desires for creating childrenthrough both donor insemination and IVF is being considered by the gay/lesbiancommunity in British Columbia (personal communication by lesbian feminist January1994).80embryo transfer (an established pregnancy) will be considered a “success”. (interview withJVF specialist March 1994) While these are meaningful in that they establish certainbenckmarks that fertilization and pregnancy have been reached, they do not necessarilytranslate into a healthy, full-term “take home baby”. ULtimately this is the only meaningfulmeasure of “success”.By the early 1990s the world leaders in NRTs were recognizing the importance ofofficial registration of clinical “success” rates. The registry devised by the Society forAssisted Reproductive Technology (SART),17 a section of the American FertilityAssociation and the Canadian IVF registry both encouraged voluntary registration tostandardize the reporting according to certain criteria. Although SART results arepublished annually, it still leaves clients at the mercy of those unregulated practitioners andclinics who choose not to submit their statistics to a voluntary body. The CRCNRTreport has called for immediate formation of a formal national regulatory commission,with greater powers than the existing informal Canadian TVF registry. Its mandate wouldprevent irregularities in statistical claims to “success” for certain treatments, as it wouldonly license bonajIde clinics.17 Both the Alberta Foothills Hospital IVF and the UBC WF programmes becameaffiliated with SART in 1991.81V TUE CAUSES OF INFERTILiTY: MERGING STANDARD MEDICAL,PUBLIC HEALTH AND ENVIRONMENTAL DISCOURSES(i) The Standard Medical DiscourseParadoxically, while medical practices are expanding into previously unchartedsocial domains of new family relationships, commerce and genetic research, the solutionsto identified medical problems are being sought after in areas of society which are notnormally associated with health issues. For example, deviant social practices resulting insexually communicable diseases and industrial and environmental practices affectinghuman sexual health also are being implicated as causal links with infertility problems.Most commonly, infertility problems presented in clinical practice are establishedwithin parameters of individualized mechanical or physiological failure, rather than a partof broader social factors. The causes of infertility are equally distributed between malefactors and female factors, with a third category labeled “unexplained” or idiopathic (seeglossary), with no identifiable causes. Unlike the African Ndembu, who like manytraditional societies view infertility as a collective probleni,18 in the West infertility isconstructed as individually created, experienced and solved. Infertility treatmentstherefore focus on individual therapies rather than looking for solutions to the causes inthe larger society. Increasingly, it has been left to experts other than health practitioners,with a few notable exceptions.’9 Instead these experts focus on the social indicators inthe public health and environmental domain, which need to be factored into the diagnosticstew of fertility problems.18 Victor Turner’s (1969) classic study of the rituals associated with infertilitymonstrate the significance of commurnty participation in resolving the probleniSee John Jarrell (1993) discussion of infertility in relation to toxins in the Great Lakes.82Established medical discourse proposes that male factors may affect from eighteento thirty percent of infertility problems (Collins et al. 1984). Numerous articles in Fertilityand Sterility,20the official journal ofthe American Fertility Society, point to causes, otherthan underlying physical factors such as varicoceles and undescended testicles, which mayinclude exposure to lead or dibromocliloropropane (a pesticide), the mumps virus afterpuberty, as well as smoking and marijuana use.However, most of the preventable factors that have been studied so far affectwomen’s fertility. This emphasis on treatment of the female partner may in part resultfrom a universal misperception that blame for infertility rests with the female partner.Factors such as past contraceptive history,21 the prevalence of sexually transmitteddiseases (STDs), specifically chiamydia trachomatis and neisseria gonorrheae;22 anddelayed childbirth for frivolous or career development reasons, all support non-compliancein expediting women’s “expected” role of procreation. Other equivocal risk factorsinclude inappropriate lifestyle habits, such as excessive exercise, heavy smoking, substanceabuse and caffeine intake (Mueller and Daling 1989).See articles by Wentz 1986, Smith and Asch 1987, Kursh 1987, Soules 1988.Bryant (1990: 18) cites several studies which have indicated that peMc inflammatorydisease (PID), which commonly affects fertility, has been associated with intrauterinedevice (JUD) use, excluding copper-containing IUDs. Conversely, use ofbamer methodsand oral contraceptives have been shown to protect from STDs and PID. An inverserelationship between risk and the number of sexual partners was also indicated. For amprehensive list of references see Bryant 1980:36-37.STDs cause twenty percent of the infertility in some populations in the United Statesaccording to the United States Congress, Office 1988. Rates in Canada have beendropping since they peaked in 1982 following a steady rise since the 1950s. Ratescontinue to rise for girls aged 1-4 years and 10-14 years, highlighting sexual abuse ofyoung girls. Girls aged 15-19 were the highest risk group since 1986, 5.43 per 1,000 girlswere reported to have acquired gonorrhea (see Bureau of Communicable DiseaseEpidemiology 1988; Parra and Cates 1985; Hockin 1985; Todd and Jessemine 1987, citedin Bryant 1990).83What is not voiced in the discourse is the potential effects of some drugs anddevices associated with reproduction, which may prove harmful to women’s health.Rarely are harmful toxic agents in the workplace and the environment mentioned. Lessevident in the medical discourse of infertility are the iatrogemc causes, whereby medicalprocedures may also render people infertile. Andrew Kimbrell (1993), in his radicalcritique of the technological and commercial controls in American society perpetratedthrough certain NRTs, cites a number of these causes that affect women’s reproductivecapacities. These have been identified by The Office of Technology Assessment of theUnited States Congress and include infections from surgical procedures, surgicalsterilizations, treatment for endometriosis, unnecessary hysterectomies, cancer treatmentsand damage done by contraceptive devices (Kimbrell 1993:69).(ii) The Environmental DiscourseAccording to Bryant’s Report for the Canadian Advisory Council on the Status ofWomen, in 1990 the Canadian Government spent $3.5 million on research in reproductivetechnology and yet only $400,000 on public health research into the causes of infertility.23 •In a recent position paper, Louise Vandelac, a member of The Canadian Women sAlliance on Reproductive Health,24 drew attention to these facts. She notes that in spiteof the evidence, public health issues such as the safety of the workplace, a clean23 Vandelac, a feminist sociologist, was one of four commissioners hired for theCRCNRT, who was fired along with lawyers Maureen McTeer and Martin Hebert andphysician Bruce Hatfield. On December 6th 1991 they had filed a suit against the Chair,Patricia Baird and the federal government in an unprecedented action. Ten days laterwhen Parliament had adjourned for Christmas they were fired, with no recourse forejuttal. See Eichler (1993:196-222) for in depth account of events.This affiance is an ad hoc group of feminists across Canada, who are affiliated withNAC and interested in NRTs. Their position papers were prepared for response to theCRCNRT’s Report, which was finally released November 1993.84environment and better programmes for control of STDs continue to be ignored. Forexample, questions are beginning to be raised about the fertility status of farm workers inBritish Columbia. These are mainly south Asian women, whose fertility is alleged to becompromised by pesticide spraying.Similarly, evidence is now being assembled, which suggests a link betweenpollution in the Great Lakes and human infertility. A recent Canadian BroadcastingCorporation documentary, Sex under Siege (1994), in the Witness series, providesfascinating coverage of original research being conducted in Canada and elsewhere, whichconnects infertility with toxic effluents in major waterways and with compounds found inplastics. Paradoxically, while industry is contaminating Canadian waters and renderingpeople infertile, other industries, are polluting other Canadian water sources in order toproduce a drug which treats menopause symptoms. For example, Ayerst Organics Ltd. ofBrandon, Manitoba, a division of the multinational pharmaceutical company, WyethAyerst has recently been implicated in pollution of the Assiniboine River. In order toproduce the drug, Premarin, which manages post-menopausal symptoms, the companydumps “a murky and deadly stew, {into} Brandon sewage lagoon four, abutting theAssiniboine River .. .the waste from a controversial plant that processes the estrogen richurine ofpregnant mares” (Regush 1994:72).25Industry has been accused by the International Joint Commission, amongst othergroups, of long-term neglect in cleaning up of dangerous industrial chemicals.26 The25 This pregnant mares’ urine (PMU), referred to locally as ‘superjuice’, is collected frommares under inhumane conditions, which has environmentalists, animal rights activists andfeminists rallying against its production, especially since synthetic forms of estrogen androgen substitutes are available on the market (Regush 1994).These chemicals include especially chlorine-based pollutants, such as DDT, PCBs andmany pesticides, as well as by-products of the chemical, pharmaceutical and plasticindustries, which are routinely dumped in the Lakes. Current research links some of these85CRCNRT report cited conflicting studies of effects of exposure of pregnant women toPCB bioaccumulation in the Great Lakes. One study associated lower birth weight andsmaller head size in the children of affected women, while the other study did not confirmit (CRCNRT 1993:290). A growing number of cases have been reported of defects inbabies born to women exposed to toxins in North America.27With the perceived increased prevalence of infertility has come the promotion ofscience and technology as the correct solution to cure infertility. With the complicity ofthe media has come the notion in the public perception that technical advances may assistin the management of infertility problems. While surgical correction can permanentlyrestore damaged tubes, technology such as 1VF in conjunction with superovulationtherapy offers only artificial solutions. It does not cure infertility. Firstly, it offers acircumventory solution to mechanical (anatomical) disorders, such as obstructed fallopiantubes. Secondly, it creates temporary mimicry of normalcy for physiological (hormonal)disorders of reproduction. As yet little attention is given to socio-environmental factorsleading to infertility, whose resolution lies in an entirely different social realm frombiomedical therapy. To date, the debate on NRTs has tended to focus on the technologiesthemselves, rather than the antecedents that are beyond the technical realm.chemicals, which act like synthetic sex hormones, to reproductive damage to the offspringof animal and humans exposed to them (Vancouver Sun, April 12th 1994: A7). See alsoWrell 1993.For example, a high incidence of anencephaly, a rare defect in wirich babies are bornwith an open skull and only the rudiments of a brain, was noted in 1992 in Brownsville,Texas and its sister city, Matamoros. Suspicion for the cause of this defect rests on theeffluents pumped from the industrial plants of these Mexican border towns along the RioGrande (Vancouver Sun, January 20th 1992). Tn Vietnam mass abortions have beenoccurring following ultrasound detection of abnormalities in fetuses of women, twogenerations after the wholesale spraying of dioxin-containing herbicides, such as AgentOrange (Manthorpe 1994).86VI AN 1YF PROGRAMME IN BRiTISH COLUMBIA(I) A Short IListoryDuring the 1980s in response to the rapid acceptance and institution of the 1VFtechnology, 1VF clinics opened worldwide. The British Columbia 1VF programme’sinception occurred in 1982, at the University ofBritish Columbia, four years after the first1VF baby, Louise Brown, was born in Oktham, England. It was established within theDivision of Reproductive Endocrinology, Department of Obstetrics and (3ynaecology.The inception of the programme was the collaborative work of Gomel, the DepartmentChairman at the time, Ho Yuen, the present medical director and divisional head, andinfertility specialists Rowe and McComb, laboratory director Moon and the first IVFmedical director, Poland. Dr. Moon, the gamete and embryo laboratory director,reminiscing on the difficulty ofgetting a successful programme started recalls:Dr. Gomel initiated it, but everyone chipped in to establish the lab. and ittook a long time to get our first success in 1983, because at that time theoperating room was situated in the basement, the laboratory was situatedon the third floor ofthe acute care unit at UBC. I had to jump around, youknow. I had to go up to the lab and go down again to pick up again.(interview with laboratory director November 1993)This experience was not dissimilar to that of the English pioneers in the field,Steptoe and Edwards, after their removal from Oldham Hospital, where Louise Brownwas born, to Cambridge’s Addenbrookes HospitaL Funding from the unlikely source ofthe Daily Mail newspaper eventually led to their relocation in the present site, BourneHall, a Jacobean mansion. In Edward’s historical account of those early days, when theycould not generate operational funding, because development of 1VF had ignited a fierydebate between science and ethics, he reminisced:87But instead of a large, filly-serviced clinic with operating theatres, patientbeds, and a supporting staff to cope with a heavy schedule of operations,we were offered two rooms in old Addenbrookes’ Hospital; an ancientoperating theatre up on the third floor, and a shed on the ground floor forour laboratory. Eggs collected from patients upstairs would have to betaken downstairs for fertilization, and embryos would have to be carriedupstairs for replacement in their mothers. Upstairs, downstairs with suchprecious cargo - seven or eight times a day (Edwards 1989:12).The neglect of the physical plant resulting in practical inconveniences in bothprogrammes is symptomatic of the early days of operating 1VF facilities with lack offunding, due to the common perception that infertility does not constitute an “essential”medical service, since it effects such a small percentage of the population. This perceptionhas persisted in the medico-political arena offunding. Apart from the province of Ontario,Canadian medical plans have never funded the total 1VF procedures. However, once 1VFbecame available in British Columbia, there has been no shortage of enrollment in theprogramme. It has registered routinely about forty patients each month and has a waitinglist of about one year.Up until 1988, some JVF related procedures in the Vancouver programme werecovered by the British Columbia Medical Services Plan (Newman 1992). Oocyteretrievals were performed by the relatively invasive and expensive surgical technique oflaparoscopy, which required a general anaesthetic. This procedure was paid for by themedical plan, as was the embryo replacement, which was billed at that time as artificialinsemination by husband, ATH. During 1988, less invasive and less costly oocyteretrievals using vaginal ultrasound gradually replaced laparoscopy. Gamete IntrafallopianTransfer (GIFT) also was offered to patients as a variant of 1VF. In this procedure theoocytes are retrieved either by laparoscopy or under ultrasound guidance and thenintroduced with sperm immediately into the fallopian tube ofthe woman. For some clientsthis procedure has been considered more acceptable for religious reasons than creating88embryos in vitro. The procedure was discontinued by the programme in 1988, except onrare occasions, because its success rates were not any better than 1VF and “the procedurewas more invasive and required a general anaesthetic. Also it did not answer the questionof fertilization potential for the couple. At least with TVF we knew what the fertilizationpotential was and GIFT never answered that question”.28 (one of many telephoneinterviews with the IVF nursing director to corroborate data. April 1995)As part of a policy to check escalating health costs, in July 1988, the BritishColumbia Medical Services Plan (MSP) decided to withdraw funding for the IVFprocedures.29 Provincial governments have always been responsible for health care, since1867. However, in 1988, the federal government decided to progressively withdraw itsfunding contribution through provincial transfer payments, which put greater pressure onprovincial government budgets. This has resulted in provincial governments paying morethan the approximately fifty percent that they have paid since the block fundingprogramme was introduced in the early 1970s.28 A departmental memorandum, covering the month August 16th - September 16th1987, reflects that the sample of GIFT cycles perfonned was very small. In that monthonly five GIFT procedures were performed and no pregnancies resulted. In contrast,twenty-five patients were induced for IVF, twenty-two ofwhich went to embryo transfer,seventeen after laparoscopy and five after ultrasound retrievaL In these cases fertilizationpotential had been proven. There were, however, only five positive pregnancy tests in thisoup oftwenty-two patients.Ontario is the only province that has ever covered P/F costs for all infertile couples.OHEP paid about $1,500 for each 1VF treatment cycle performed at one of the fivepublicly funded clinics and several private ones. Patients at the public clinics paid for theirown drugs, which cost $1,000-$3,000 per cycle. On February 17th 1994, IVF, except forwomen with tubal obstruction, was one of several treatments or procedures struck fromthe list of insured services in Ontario, along with routine circumcision of newborns andrepair of earlobes deformed by pierced ears. The Ministry of Health and the OntarioMedical Association drew up lists ofnonessential services to be considered for delisting, inorder to cut the province’s health insurance billings by $20 million. (Brooks 1994:970-971).89These budgetary changes affected IVF services in a piecemeal fashion. Whereasthe initial medical consultation and investigative procedures remained covered by theprovincial medical plan, the surgical procedures were not. The IVF laboratory procedureswere afready being paid for by the clients, as were the cost of the prescription drugs.However, the pharmaceutical costs were reimbursed to the patients at a rate of eighty toone hundred percent through provincial or private insurers. By 1989, there wereadditional costs for cryopreserving and storing pre-embryos. In consequence, whereas in1985 the partial user fee cost to the client was $1,200.00; in 1987 $1,500.00 and in 1988$1,800.00, as of July 1988, participants became responsible for the total cost. (Newman1992:5).30 By the end of the 1980s, the costs had tripled according to a Vancouver Sunnewspaper article:1VF now costs $3,500 per cycle, with success rates of 15-20%. The clinicperforms 300 procedures a year and 75 babies have been born by IVF sincethe program started in 1982. Cryopreservation has been available sincespring 1989. 50% ofthe embryos survive the process and 6-10% result inpregnancy following implantation (Stainsby 1989:A5).These increased costs were not reflected in noticeably improved outcome statisticsof the programme. Prior to 1989, the programme kept an informal, in-house accountingof 1VF statistics. The TVF success rates and the percentages of the indications for clinicaltreatment were made available in the 1VF video, at least to those prospective participants,who had afready enrolled in the programme and borrowed the video.Since 1985, the clinic has collected outcome statistics, which reflect incrementalincreases in success rates for each phase of the treatment cycle (see Table 1). But asnoted in earlier, “success rates” of IVF, both nationally and internationally, have frequently30 See Appendix B for a breakdown of schedule and fees as ofAugust 8th 1988.90been misleading. To create uniformity in reporting practices by clinics submitting theirstatistics to a voluntary registry, reporters were requested to break down the numbers foreach of the stages of lyE cycle outcome. These included statistics for the number of 1VFcycles initiated, the number of embryo transfers, the clinical pregnancy rates, as well as thenumber of live, full tenn birth, including multiple pregnancies and abnormalities. As of1991, following the policy of other countries, such as Britain, Australia and the US, theUniversity of British Columbia 1VF programme started to submit its statistics to theCanadian IVF Registry,31 as well as the United States SART Registry.32The Canadian Registry was set up by Dr. Arthur Leader ofthe University ofOttawa.SART, the Society of Assisted Reproductive Technology, is affiliated with theAmerican Fertility Association and is responsible for collecting statistics from all of the175 registered clinics. This figure includes four clinics in Canada, which joined in 1991, ofwhich the UBC 1VF programme is a participant.91Z6—.o—SCcrSSII.< -————a)O‘.0‘.0‘.0‘.0000000000000QVzu a..i 00000Q—‘.000i’.)V0)tr1-C)Hc)—I——100UiUi—.00Q...‘—00-O00‘.0-1I)Oi-?’C0Lo00Vi0IWI ,,000000JT1Izp --i’.)cL.)—CL) 0000a•-‘—‘0 00000Ui0’<-CDc’The pregnancies rates recorded in 1985 (20.6%) were high because treatment at thattime was restricted to women under thirty-five years old and with a diagnosis of “puretubal factor”. Those women with non-tubal factor problems used the GIFT procedure.Statistics collected since the late 1980s reflect a small but gradual improvement in successrates. Whereas in 1989 pregnancy per embryo transfer were 16.4%, in 1992 they hadimproved by 9% to 25.5% pregnancy per embryo transfer. As the following tableindicates, when these outcome statistics are viewed in terms of percentage of live birthsper transfer cycle the improvement over four years is less than 6%. Whereas in 1989 theywere 8.8%, by 1992 they had increased to only 14.1% deliveries per cycle.The medical indications for lyE are listed in table 3 and apply to women who areless than forty years old when they sign up for treatment. “Couples must be in a stablerelationship, IT[V-negative, and without evidence of unstable or untreated psychiatriciiiness or other conditions that would be contraindications for pregnancy. Since the use ofdonor gametes is not currently feasible in this program, couples must provide their ownoocytes and sperm, thus excluding men with azospermia and women with ovarian failure”(Fluker and Ho Yuen 1993:883).93Table 2. Indications for Treatment from 1989 to 1992Indication Number PercentTubal Disease 1282 57inoperable or 1 year post reconstructive surgeryEndometriosis 207 9unresponsive to medical or surgical treatmentUnexplained 178 83 years durationMale Factor 168 8should have 1 million total motile sperm recoverable perejaculateMultiple and Miscellaneous infertility factors 404 18Source: Fluker and Ho Yuen 1993:883Between 1985 and 1993, at the Shaughnessy Hospital site, there were 2239treatment cycles initiated, resulting in 242 deliveries from 330 pregnancies. In 1992, 25%of couples conceived following each completed transfer cycle, and 14% took home one ormore babies for each cycle started. By 1993, the total cost including medications (onaverage $1,400, but ranging from $800 - $4,000), 1VF programme/procedure fees of$3315 and hospital short stay admission $280, had risen to approximately $5,000 (Flukerand Ho Yuen 1993:883-884). By this time, lyE treatments were beginning to be offeredfor some male factor infertility and for women over forty years, who were already enrolledin the programme. No oocyte donor programme or gestational surrogacy arrangementshave been made available to clients.(ii) The Current Situation of IVF in VancouverDuring the period of the research project, the 1VF staffs offices were located indifferent parts of Shaughnessy Hospital For example, the IVF medical director, who was94also the university divisional head of endocrinology and infertility; a reproductiveendocrinologist, the laboratory director, scientific researchers and clinical research staffand support staff were all located in offices in the academic wing, close to Children’sHospitaL Here the two endocrinologists and the gamete laboratory director also fliliuiledtheir university research and co-ordinated their teaching commitments as geographical lulltime professors (GFT). Meanwhile the nurse co-ordinator, nursing staff socialworker/counselor and two support staff were situated in the Jean Matheson Wing, alongwith two other infertility specialists, who were also GFT professors in the Department ofObstetrics and Gynaecology. Three IVF biologists, with occasional assistance from adoctoral candidate, carrying out research on discarded oocytes, under the direction of thelaboratory director, worked in the gamete laboratories. These were located beside theoperating rooms.The 1VF ultrasound technologist worked part-time with the IVF programme, andpart-time in the adjacent maternity unit, Grace Hospital, as did one ofthe part-time nurses.One of the reproductive surgeons worked at the Women’s Health Centre (WEIC),specializing in recurrent pregnancy loss and ultrasound screening where the sophisticatedand expensive ultrasound machine was located. It was here that IVF clinic appointments,as well as routine blood tests and ultrasound scans were conducted. In addition to thecore staff, four reproductive surgeons, who conducted private Obstetric/Gynaecologypractices, specializing in infertility, in Vancouver were also associated with the programmeto assist with oocyte pickups and embryo replacements. This enabled the surgicalprocedures of 000yte pickup and embryo transfer to be conducted seven days a week.Thus one out of a total of seven surgeons was available on a daily roster.Despite the diffusion of the staff throughout the Shaughnessy site, they maintainedstrong ties with each other through the network of long Shaughnessy corridors. The95mission control for this amorphous body of people was managed from the nursing coordinator’s office, as she was responsible for the smooth daily running of the programme’sinterface with a continual rotation of clientele. The overall acinjinistration was directedfrom the medical director’s office, on the other side of the hospital. Apart from theirprofessional cohesiveness and weekly staff meetings, the staff came together foroccasional social events, such as an annual Christmas dinner.Operating room staff; which included a Shaugbnessy Hospital anaesthetist and twooperating room nurses were made available to the 1VF programme for mornings only.This permitted a maximum of three retrievals to be done on any given morning, as well asany embryo transfers scheduled. In part, this is the reason why the waiting lists for 1YFhave continued to be approximately one year. In part, it has been due to the ability of thereproductive endocrinologists to schedule time to see patients in clinics two or three timesa week for the necessary medical counseling and treatment arrangements. During thehospital fieldwork period, throughout the summer and fall of 1993, room 10 was the onlyoperating room in use and the hospital was in the final stages of its closure and largelydeserted. A few nurses still clustered for their breaks to chat and eat in the nurses loungeattached to the operating suite.In February 1993, the Provincial Government declared the closure of ShaughnessyHospital, in order to save $45 million a year. The wards, which had previously been fillofveterans, when the hospital was part of the Department ofVeteran Affairs, and later asUniversity Hospital, Shaughnessy site, were now full of hospital beds, equipment, filingcabinets and boxes, which could be seen through the open doorways. A sense ofabandonment and dejection permeated the long corridors and uninhabited rooms. Thehollow shell of a once vital hospital was reflected in the abnormally loud sound offootsteps periodically coming and going down far off corridors. Previously, having been96employed as a clinical physiotherapist for five years in the hospital, I experienced strangeflashbacks, as I looked into the well-known rooms. I saw instead the images of oldveterans, busy stafl an atmosphere ofwarmth and friendship, which had now receded intothis spectral shell of a once Important veterans’ hospitaLOn November 24th, the last ovum retrieval was performed and two days later, thefinal embryo replacement brought a final closure to the 1VF oocyte retrieval/embryotransfer part of the programme at Shaughnessy HospitaL By the end ofNovember 1993,the official closure of Shaughnessy Hospital had occurred, leaving behind theadministrative, patient intake and research part of the 1VF programme. They continued tofunction surrounded by construction workers, who had begun to reorganize the physicalaspects of the hospital shell that were to be inhabited by the adjacent Children’s• 33Hospital.Unlike the high profile media coverage of the closure of Shaughnessy Hospital, stafflay-offs and reduction of critical services, the fate of IVF in Vancouver was shrouded insilence. Over the winter, uncertainty among the staff prevailed about the fate of the IVFprogramme, as decisions about space allocation at the Vancouver Hospital and HealthSciences Centre remained unclear. The 11/F staff took their normal one month break fromtreatment services in December. Some staff reductions were made at this time. Asecretary was lent to another department part-time, one of the casual nurses was laid oflwhile another took maternity leave. The social worker/counselor and an 1YF technologistwere laid offwith severance packages.The spinal unit had afready moved to Vancouver General HospitaL This hospital hassince been renamed Vancouver Hospital and Health Sciences Centre (VH[ISC), inresponse to the consolidation plans for the major Vancouver hospitals. The Shaugbnessycancer clinic had relocated at Burnaby Hospital and the adult cystic fibrosis clinic at St.Paul’s Hospital.97(ffl) An Uneasy SeparationIn early March 1994, the 1VF program started up services again, this time based attwo hospital sites. The procedure room and JVF laboratories were relocated atVancouver Hospital. Only the IVF laboratory staffmoved to their new premises in the oldmaternity building, on the fifth floor of the Willow Pavilion, which after more than half acentury of birthing babies was to become the place of artificially creating them. Theadministration and patient services remained at the defunct Shaughnessy Hospital.The IVE laboratory was dismantled at Shaughnessy Hospital and equipment wasmoved to the new site. The microscopes, the incubators and the two big tanks in whichthe embryos were cryopreserved were transported by the company responsible for theirmaintenance. During the two months before IVF services commenced again, thelaboratory staff reorganized their equipment in the newly renovated space, which seemedlarger than the previous laboratories. Extra space also had been made available for thesperm micro manipulation equipment34 on a solid marble bench, which would be run bythe Ph.D. candidate in embryology, supervised by laboratory director, once she haddefended her thesis.During this time the chief tecimologist had run trials with mouse embryos to checkthat the cryopreservation tanks had not been effected by the move. She was completingfurther trials on the day before the first retrieval “Beautiflil embryos”, she said in delightof the mouse embryos she had frozen two days earlier as a final trial “I wish all the34 . . . .One of the latest innovative reproductive technologies is intracytoplasmic sperminjection (ICSI), which involves the injection of a single spermatozoon into an oocyte.1CSI was developed in Belgium by Dr. van Steirteghem. More then 130 births haveresulted from the procedure, which has been developed to overcome male factor infertility.IVF Canada, a private Toronto clinic, claimed credit for the first pregnancy in Canadausing ICSI (Murray 1994).98human embryos froze so well”. Over the winter after the IVF programme closed, whenthe tanks had remained at Shaughnessy, under lock and key.VU CONCLUSIONThere has been a long history ofmedical interest in understanding the beginnings ofhuman life. The scientific medical discourse is well represented in a chain of theoriesabout conception models which stretches back to classical times. IVF is just a modemlink, and one among a number of recent tecimo-medical applications on humans which hasarisen from this legacy of embryological research. However, there is a fundamentaldifference between research on dead embryos obtained in the past from abortions, embryoflushings and in teaching hospital based embryo collections, and a living pre-embryo that iscreated in the TVF laboratory. It is now possible to nurture, examine and manipulate thepre-embryo as an animated, growing entity, external and separate from its gestator.Although there is an accepted fourteen day limit on the preservation of the pre-embryo invitro, prior to the development of the primitive nervous streak, nevertheless it takes on alife-of-its-own, despite its dependency on laboratory support systems. There is asubliminal recognition at this stage of its potentiality for the vested interests of bothresearch and the marketplace.The effects of alienation and reification automatically place the pre-embryo in adependency relationship other than its biological symbiotic relationship to the woman,who produces the oocyte, gestates the resultant embryo and will in all likelihood be theprimary nurturer and caregiver of the child. This other dependency association madepossible by envisaging the pre-embryo as a separate entity, albeit with human potentiality,99brings it tinder the purview of scientists, who reason its value as a highly instructiveinformation-bearing piece ofhuman matter. Its relative moral or social valence beyond thelaboratory or to the biological parents is eclipsed. It is a piece of research tissue.It would appear that 1VF is part of a continuum, and provides the necessary gatewayinto future avenues of embryological research, which perhaps may offer the final solutionsto how life begins. However, a different view of the pre-embryo emerges when it isplaced in the simple 1VF model of human infertility therapy. Here the complex socialorganization around creating pre-embryos to provide babies for infertile couples masks thepotential for other research. As fast as IVF clinics open up around the world, so do thebanks of frozen embryos. The future of those embryos is of limited concern to the healthproviders in the IVF clinics, procedure rooms and laboratories. The salientepidemiological discourse is clearly directed towards an identified need of a delinedpopulation of infertile Canadians wishing to produce families. While frozen embryos havelimited used in the IVF treatment domain, the by-product of the therapy, large numbers ofsupernumerary pre-embryo is of greater significance in the research field. In general theclinical momentum is directed towards refining treatment protocols and trying to improvethe statistics, “the numbers game”, which legitimates and validates the provision of alargely unsuccessful and expensive service.Political and public interest in infertility is also a fairly recent phenomenon.Problems of adoption, the availability ofmedically corrective infertility procedures and theneed to regulate the variety of services are all part of a growing communal awareness.These are further compounded by a generalized fear that environmental and industrialtoxins are damaging human fertility. Thus infertility is no longer constructed as a privategrief it is a highly charged political matter. This is apparent in the public process andsubsequent report of the Canadian Royal Commission on New Reproductive100Technologies. Currently, the medical, public health and environmental discourses are allfocused on the causality of infertility problems and in linding medical cures. Meanwhilefrozen pre-embryos accumulate in cryopreservation banks in clinics that remainunregulated. So in a relatively short period of time, infertility has moved from privategrief and social stigma, to entrepreneurship and national politics; from individual needs tomoral discourse.101ChAPTER 4TIiJ MEDICAL-TEChNOLOGICALDISCOURSE:CREATING AND FREEZING PRE-EMBRYOSThe tecimical processes of 1VF are poorly understood by the general population,other than those who are directly involved with the practicalities of the procedure.Patients and the staff of 1VF clinics share a clinical sub-culture with the practices andvalues which are the subject of this study. The fieldwork experience for this research isthat represented by a broad overview of the treatment routines of the University ofBritishColumbin IVF programme, which provides an introduction to the medico-technicalactivities of creating, transferring and freezing pre-embryos. The narrative presents aparticular view of a social organization in a specific 1VF programme setting, based on theinterplay of science, technology and medical practice. It creates a descriptive context formore abstract discussion of the pre-embryo as an emerging social category. Theperspective examined is that presented to me by IVE service providers and my ownobservations. It does not reflect the view ofpatients undergoing the procedures, whom Idid not interview, but rather a view of the patients in relation to the provision of thetechnology.Firstly, the different phases of the 1VF procedures from the time of enrollmentthrough an 1VF treatment cycle are outlined. Then I describe the cryopreservationprocess of freezing pre-embryos, including the circumstances which led up to freezingbecoming one of a number of options for dealing with supernumerary embryos. A thickdescription gives an account of the standard oocyte retrieval, fertilization, embryo transfer102and embryo freezing processes, that to the observer are bewildering technical details andyet to the practitioner are a matter of routine fact. It exemplifies how personal andcultural experiences of specific technical knowledge are accepted as common practice.Often this makes the researcher’s task more challenging. “Social scientists interested inproblems oftechnical change rarely ponder how people make sense of the technologiesthey use or what their sense making may imply for patterns of social organization” (Barley1988:497). The medical discourse of pre-embryos requires an intimate knowledge of asequence of medical and technological interventions through which pre-embiyos arecreated, stored and replaced in women on a daily basis. As this research attempts to makeclear, the different knowledge bases of the health professionals involved in IVF means thatthey construct distinct understandings about the value ofpre-embryos.I PREPARING FOR TI[[ SuPEROVULATION PROCESS(i) “Ladies-in-Waiting”: Coming “on board”The decision to resort to the technology of IVF is the end stage of a cumulativebuild up of investigations, which couples undergo on the long path from initial concernswith inability to conceive, through to the final decision that all other treatments havefailed. This technology is often seen as the last chance of having a baby and beforeresorting to adoption or accepting a childless lifestyle. As Mathieson, a researcher for aBritish government Member ofParliament commentsWaiting is the most common experience for infertile people. Waiting to seetheir own doctor, waiting to be referred to a clinic, waiting for the outcomeof tests and waiting to see whether the treatment has worked (Mathieson1986:5 quoted inDoyal 1987: 179).103In British Columbia, couples are referred to the University of British ColumbiaIVF programme from all parts of the Province. Sometimes a local specialist in obstetricsand gynaecology has done the early investigations into possible causes of infertility. Whenthis has not occurred, which is becoming more common, the clinic infertility specialistsmust initiate or reorder the battery of diagnostic tests. These range from simple patientinitiated charting of the female ovulation cycle, to testing factors in the male partner’ssperm that affect fertilization, to x-rays of the female genital tract through hysterosalpingograms and diagnostic surgical laparoscopy. Sometimes the therapy is theregulation of ovulation with drugs, while at other times, surgical correction of obstructedfallopian tubes is the solution. At the point when all other appropriate forms of treatmenthave been ruled out, and 1VF appears to be the only hope, then the long wait for IVFtreatment begins over again.Initially, when clients inquire about enrolling in the WF programme, they areplaced on the waiting list. It is approximately one year before they will be eligible for anIVF consultation. This leads to some patients turning elsewhere for more prompttreatment, especially if advancing age is a critical factor. When they reach the top of thewaiting list, each couple attends a two and one half hour orientation session at thehospital, where they watch a video in vitro fertilization at University ofBritish Columbia.They meet with the medical, nursing and counseling staff and have a medical examination.Between 199 1/1992 an orientation evening was offered, at which the medical director,nursing co-ordinator and social worker would meet with the new intake group in theevenings. For various reasons it was not a successfid strategy. Within a few weeks of theorientation session, patients were required to show their intent to proceed with treatmentby submitting a $500 non-refundable deposit. When an 1VF treatment cycle was started,104the balance of the payment became due in the form of certified cheques or money orderson the first day oftreatment. At this time they were truly “on board”.(ii) Counseling the ClientsThe “counseling” of clients before, during and after an 1VF treatment cycle isundertaken by doctors, nurses and the social worker/counselor from their differentprofessional perspectives. Considerable value is placed on educating and reassuringpatients, as they have to absorb a lot of information about the treatment process, as well asto come to terms with the high incidence of failure. In this way the staff attempt toprepare patients to deal with the emotional aspects of a highly technical procedure withpoor success rates. However, differences of opinion about what constituted counselingexist among staff members. The social worker/counselor feels that preoccupation withthe treatment aspects sometimes replaces the counseling aspects for some patients, in thatsome may feel rushed into making premature decisions. IVF nurses feel that patientsnormally have ample time to consider their options, because “the year wait-list allowedcouples time to gather information - for the most part, they seemed well informed and hadafready decided to have treatment”.1 They still have ample time to reconsider, as it isoften another four months before they become eligible for treatment. After the counselingsession with the nurse, who tells them that they are now at the point where they can booka treatment month if they wish, they are asked to wait a further two to three weeks beforecalling back to enroll. They are assured that delaying a decision in no way influenceslosing a place on the programme. These differing perspectives reflect the differentThe nurse co-ordinator commented that the challenge to informed decision-making ismore likely to have be to faced when there is a short or no wait-list, as may soon occurwhen the private, Genesis clinic opens.105professional epistemologies about the relative values of educating and counseling, asexpressed by social workers, nurses and doctors, as well as differing expressions of thepatients’ best interests.Coping with the reality of the high failure rate of 1VF and making further decisionsabout whether to continue with another WF cycle is an integral part of the counseling.One IVF nurse described her duties this way:I do a lot of counseling. I do hands-on nursing, such as giving theinjections, drawing blood, but a good part of it is the counseling aspect.Not deep counseling like N. does, but just the general counseling that isassociated with giving positive and negative results, once their cycle iscompleted and dealing with their questions before and after they come fortreatments.The social worker/counselor, with fifteen years of experience in adoption andinfertility, as well as individual, couple and family counseling, sees each couple beforestarting the IVF treatment. Often this counseling takes place during the busy orientationsession. However, she is always available to them for further assistance by telephone or inher office. Her position in the programme is unique in Canada, although much morecommon in clinics in other countries. She explains:I think I’m the only counselor who works right in a programme. The rest(of the Canadian 1VF counselors) are on a referral basis for those peoplewho are in crisis. Some clinics have a social worker, who is in a hospital,who comes when needed.When I ask who does the counseling at these clinics, she replies that “most placesin Canada don’t have them”. The Canadian Royal Commission on New ReproductiveTechnologies (CRCNRT) recommendation #119 has stated that “{C}ounseling be anintegral part of assisted conception services and be offered either on-site or by referral toappropriate professionals” (CRCNRT 1993:551). However, the report notes that patientssurveyed by the Commission found this aspect of their experience at 1VF clinics the least106satisfactory, in that the majority of clinics used the term “counsel” and “educate”interchangeably. In some clinics, the role of ‘counselor’ is filled by doctors, nurses oradministrators and that it is unclear as to whether these staff members had specializedtraining (ibid: 550). While the Commission recommends that clients should have access toa social worker/counselor, it is not explicit about how this should be achieved. In thissense the very complicated area of counseling is glossed over and diminished by thereport.2 The University of British Columbia IVF programme is not alone therefore in itsemphasis on ensuring that patient’s are thoroughly educated about the complex IVFprotocols, sometimes to the detriment of providing the objective counseling that may benecessary for some people, who for a variety of reasons, may require considerable adviceon whether it is in their long term interests to proceed. Once the decision to enroll intreatment is made, the decision-making reverts to that of the endocrinologist, who thenmust individualize the treatment management.(ffl) “Calling the Pergonals”: Calling the ShotsThe complex realm of the first phase of the 1VF treatment, the ovulation inductionphase, exemplifies the fine-tuned protocols and critical decision-making patterns, whichare legitimated though the filter ofthe reproductive endocrinologist’s scientific knowledge.Endocrinology3is a relatively new field within the specialty of obstetrics and gynaecology,2 witnessed the avoidance of answering this question, when it was put to theChairperson of the Commission, Patricia Baird, when she presented the McCleery LecturegFebruarY 23rd 1994) to an academic audience at the University ofBritish Columbia.Endocrinology involved the clinical management ofhormonal problems. Early remediesin the field included treatment ofwomen for amenorrhea (absence or abnormal stoppageof the menses) with bromocriptine, and with galactorrhea to counter excessive orspontaneous flow of milk. More recently, the field of endocrinology has promoted thewidespread use of estrogen hormone replacement (EHR) therapy for pen- and postmenopausal women. Swiftly this was followed by the mandatory addition of a107and the drug therapies developed in this field are among many which demonstrate therapid changes in clinical and laboratory research which are translated into patientmanagement.In the case of IVF, the first phase of treatment that women undergo is ovulationinduction. A critical sequence of drugs replicates the normal hormonal pattern leading upto ovulation, but more powerfully, such that multiple ova develop in the fluid-filledfofficles of the ovaries, instead of just one as in natural ovulation. The medications areselected by the endocrinologist according to each individual patient. These includeclomiphene citrate (Serophene or Clomid), human menopausal gonadotrophin (Pergonal),GnRH Analog (Lupron, Suprefact or Synarel), human chorionic gonadotrophin!hCG(Profasi) and Progesterone. (see glossary of medical terms for action of these drugs).The increased clinical use of long-acting analogs of gonadotrophin releasing hormone(GuRu) are now becoming routine treatment for infertility, because they suppress normalendogenous pituitary action and replace it with a more controlled one.In the University of British Columbia 1VF programme ovulation induction usuallystarts between days three and five of each patient’s menstrual cycle and lasts for five to tendays. At this time, women are expected to visit the IVF clinic for daily blood tests,ovarian ultrasound scans and injections.4 For out of town patients, accommodation isprovided at the Easter Seal House or Heather House for the ten to sixteen days of the WEtreatment cycle.progestational agent to the 0estrogen because of fears of increasing risk of breast cancerSperoff 1984).This protocol has changed slightly since the time of the research, as about eighty percentofthe patients give their own injections at home.108Some patients, who live within reasonable commuting distance ofVancouver, maycontinue to work through this phase. However, the physical and emotional toll on staminais high and often women take sick leave or use disability insurance. A few may even giveup work entirely during an 1VF cycle. The morning coffee hour offered by the programmeacts as a support group for patients, who are going through the treatment cycle at thesame time. As noted in my earlier pilot study of the IVF waiting room, women coming infor their daily blood work and scans often socialized with one another. I witnessed therelaxed attitude of some women, who appeared to be familiar with the protocols andchatted familiarly with other women, in contrast to those women, or couples, whoappeared withdrawn and apprehensive. Some women knew the nurses by name and left ina casual maimer when their name was called, unlike the jumpy attitude of the perhaps,first-timers or those who had experienced “canceled cycles” previously.This part of the programme is one of the critical highly charged emotional timesfor the couple, particularly the woman (Newman and Zouves 1991; Daniluk 1988). In thepast, one in five treatment cycles might be canceled prior to oocyte pickup, for a numberof reasons. Now there are fewer cancellations with the new gonadotropliin releasinghormone protocol. Sometimes the drugs cause an irreversible premature ovulation tooccur, or there is a poor ovarian response or an ovarian cyst may be detected onultrasound on the first day of treatment and requires delaying the cycle for resolution ofthe cyst. After months ofwaiting this can be a devastating disappointment to participants,who must face making a whole series of decisions about further treatment.In what has been called the phenomenon of perpetuated dependency, frequentlycouples, who have been unable to conceive a child and eventually have sought medicalsolution, go through a transformation of sell saying “I am infertile” and become desperate109for treatment at any cost and will not cease, if ever, until they have tried hard and longenough for a solution (Williams 1989b; Modell 1989; Sandelowski 1991).In research on twenty Canadian women concerning their motivation to participatein 1VF therapy, some of the frustrations of the women are recounted by those who havehad their treatment cycles “canceled”, when they are afready advanced in the procedureand have invested more emotionally. Yet they continue trying:Marilyn - I was really disappointed. I was really upset. Andrew took meout to dinner, and I don’t drink, but I had a drink because I was reallyupset. And he didn’t know what to do for me. So it was very frustrating atthat point. And again, I felt like I had let him down, I’d let myself down. Ithink it was more of a rude awakening, because it had gone so well in Julyand I went through the whole program, how the hell did I get canceled?So you go through a lot of what did I do wrong? I didn’t do anything.Every period is different and your body reacts differently each time.Lois - . . .1 remember getting in the car and crying all the way home. Pmnever going back there! They’ve had enough! Pm not a guinea pig anymore (she laughs nervously) And I just.. .Pd had it. I thought - this is it.I’m not doing this again. But about two days afterwards it was, okay, let’sget back in (she laughs) (Williams 1989b: 130).The preoccupation with what clients call “100% genetic parenthood” and with “theproduct of a fill biological baby” (Modell 1989:133) leads them into treatment compliancewith the expectations of their doctors for controlling “the odds of success” for a “lastchance baby”. This ethnographic study of an American IVF programme demonstrates thatwhile the technology may seem innovative, in reality it is conceptually conservative inupholding traditional ideas ofheterosexual sex.“{T}he ‘obsessive’ desire of infertile people for a child of their own” (Stanworth1987:22) and the pervasive tendency to caricature the infertile as desperate people(Pfeffer 1987:84) has not been helped by the stigmatic description of the distress of an110infertile woman as “barren woman’s suffering”, a disparaging comment registered byBritish 1VF pioneers (Edwards and Steptoe 1980:47).Those women, who undergo repeated IVF cycles, run the risks of experiencing theside effects from the powerful, superovulatory medications. These may range from thosewhich are usually associated with a normal menstrual cycle, such as breast tenderness,mood swings, backache and some bleeding to occasionally, hot flushes or headaches, andcloser to the time of retrieval, lower abdominal twinges or cramps. Very rarely, in lessthan 1% of cases, ovarian hyperstimulation occurs, where the ovaries become veryenlarged and fluid accumulates in the abdominal cavity. Symptoms of vomiting, diarrheaand excessive weight gain may be experienced, or if very severe, shortness of breath andchest pain. In this event, hospitalization for bedrest and close observation are indicated.These drug management problems are clearly explained to patients in the University ofBritish Columbia IVFProgramme PatientManual.The close daily monitoring of the menstrual cycle of each patient by blood testsdetermines the hormone levels, such that when estrogen has reached a certain range andwhen ultrasound scans have detected that the appropriate size and number of fofficles hasbeen attained, the human menopausal gonadotrophin (hMG) injections are discontinued.Every morning one infertility specialist is responsible for “calling the pergonals”, whichrequires reviewing each patient’s chart and adjusting the individual medications. In thisway the attending physician does not have to actually see the patient, just check thechart.5 When the critical point is reached, then two nights or thirty-six hours before theoocyte pickup, the woman is given an intramuscular injection of Profasi (hCG), which5 ... . .One of the cnticisms of the University of Bntish Columbia IVF programme is thatpatients do not have their own infertility physician, who can give a sense of continuity andsecurity as each patient goes along the 1VF roller coaster. This attention to individualizedtreatment is one of the advertising hallmarks ofthe new Bellingham clinic.111recreates the natural luteinizing hormone (LH) surge that normally triggers ovulation.This induces the final maturation ofthe eggs, which are then ready for collection. The eggretrieval will then be scheduled for about thirty-six hours later.11 TILE OOCYTE RETRIEVAL OR TILE “EGG PICKUP”The description of the oocyte pickup procedure is riddled with metaphors ofconception, which express women as passive objects, awaiting active male control andpenetration within the private domain of coitus. These mysteries of the act ofinsemination and conception are conveyed by the tensions, dynamics and role playing thataccompany the relatively short oocyte retrieval procedure. The surgeon symbolizes thepower of the male partner to control the submissive female body, to repeatedly probe, toinflict pain and to intrude into and beyond the secret domain of her reproductive selfConversely, however, in the l\IF procedure, taking (of eggs) rather than giving (of sperm)is the nature of the act.(i) The Routinization of A lEigh DramaWhile each IVF oocyte retrieval procedure is a unique event, there arecommonalties to the routine sequences for each IVF retrieval and these give meaning towhat Koenig (1988) calls the social creation of a “routine” treatment.6 At Shaugbnessy6 According to Koenig “When a new procedure has evolved over the mysterious boundaryinto the territory of standard therapy, it cannot be denied... .As with TPE {therapeuticplasma exchange) a new treatment may or may not be efficacious; it might be risky. Themoral imperative for the treatment overrides these concerns. It becomes unthinkable forthe physicians not to perform the treatment. The social inevitability of therapy takes on amoral tone; the experience of the technological imperative becomes a moral imperative for112Hospital, the procedure takes place on a daily basis in the operating room, ORb, startingaround 8.00 a.m. and is performed by one of the reproductive surgeons, who is on call for1VF that day. In all probability the couple may never have met this surgeon before andthey may well be attended by another one for the embryo replacement two days later.7Not surprisingly, a feeling of both success and apprehension accompanies each couple,who has reached the point ofthe oocyte pickup.The woman is prepared for the retrieval, as if undergoing any other form ofdaycare surgery. She is gowned, draped and given a small amount of short-actingintravenous medication for relaxation and pain control if necessary. Meanwhile, herpartner is producing a semen specimen in a room across the hail from the gametelaboratory.8 This specimen will be prepared in the laboratory for mixing with the oocyteslater in the day. As soon as he is ready, the male partner is gowned in operating room“greens” and is brought into the procedure room to sit at his wife’s head, a position whichis reminiscent of a hospital birthing procedure. Ironically, if he is not ready, they startwithout him and he comes in later.There is a disjuncture between the private realm of the couple, who are finallyabout to obtain, if fortunate, some pre-embryos and the social realm of the surgical team.It is as though the heads of the couple, so close together reflect their personal experienceaction. Hence the creation of a moral imperative is a social process, the end result of theroutinization and consequent acceptance of a new medical technology” (KoenigJ,,988:486).The new Bellingliam clinic in Washington State, which is soliciting British Columbiaclients with their attention to personalized services, has capitalized on this inconsistency inthe Vancouver programme (promotional flyer mailed to British Columbia infertilitypecialists).If there is a problem for the male partner in producing a semen specimen, the couplemay obtain it at home and bring it with them.113alone,9while the surgical team is attending to that other medical world out of sight behindthe ultrasound monitor at the other end of the patient’s body. I was drawn by thesimilarity to a husband-attended caesarian section, where the lower half of the woman’sbody is screened from the couple’s view. An ultrasound momtor° is placed over theabdomen facing the surgeon, while another monitor faces the couple, so that they canlikewise view the retrieval. The woman has become very familiar with the ultrasoundmonitor during the ovarian scans, which she has received three or four times during thesuperovulation phase. However, this time it is combined with the ovum retrievalprocedure, which she will feel with varying degrees of discomfort or pain. In the case Idescribe here, this particular patient has refitsed anaesthesia and is alert, unlike aprocedure I witnessed the following day, where the patient was very sleepy.An anaesthetist is in attendance, as s/he may or may not need to give furtherassistance. With a transvaginal ultrasound retrieval, usually only some high vaginalfreezing is necessary, unlike in the past, when oocyte pickups were carried out undergeneral anaesthetic, through the 1aparoscope. There is an atmosphere of hush and theoverhead lights are dinimed.’2 This theatrical ritual is reminiscent of that outdated term.operating theatre.9 In the cases I observed the couples who had consented to my attendance, seemedlivious to the people surrounding them.Ultrasound imaging originated in sonar detection for submarine warfare, but was notincorporated into obstetrical practice until the early 1960s, some years after its acceptancein other medical diagnostic fields (Gold 1984 cited in Petchesky 1987:65). In the early1960s ultrasound was also used therapeutically as a physical therapy modality for swiftsolution ofinflamed tissues.This was the pioneer procedure developed by Patrick Steptoe, which made possible thegle ovum retrieval in a natural cycle, leading up to the first IVF birth.In order to diffuse some of this high drama, patients are invited to bring in some tapesthat they find relaxing, which can be played on a recently acquired portable cassetteplayer.114As I sit on the surgeon’s left side, the ultrasound monitor is directly in front ofme.It is connected to the ultrasound transducer, which is about one inch in diameter andsymbolically reminiscent of an engorged penis. High frequency sound waves sent from thetransducer rebound and are converted into electricity, so that a computer can plot theinformation and produce an image of the woman’s reproductive organs.(ii) The “Egg Pickup”The surgeon gently introduces the transducer into the woman’s vagina, as sheexplains to us what we are seeing on the monitors. In monochrome, the screen displaysthe shapes of the ovaries and the uterus, but at an angle. As one’s eyes becomeaccustomed to the created images of the reproductive organs, the clear shapes of theenlarged fofficles come in and out of view, as the transducer is moved. They appearsomewhat like spherical cysts of varying sizes; one is noticeably large. A large internaliliac artery is outlined and later the intestines.In OR 10 all eyes are focused on the two monitors, thereby directing attentionaway from the experiencing woman and towards the anatomy of the female reproductiveorgans. Petchesky notes in her study of maternallfetal ultrasound how fetal imageryreplicates the paradox ofphotography to give “the appearance of ‘objectivity’ of capturing‘literal reality” (Petchesky 1987:62). As a visual society, we have become adept atvoyeurism, at virtual reality, disassociating ourselves from the empathic response to painand “being there”. We do this all the time when we watch on television news footage ofsome horrific event. Similarly, Barthes (1982:62) has pointed out that photographicimages are always based in a context ofhistorical and cultural meanings.The surgeon demonstrates the frighteningly long aspiration needle, about 1-2 mm.in diameter, which is introduced through a small orifice in the base of the ultrasound115transducer. She advises the patient that she will feel an uncomfortable prick as she pierceseach ovarian fofficle. The first fofficle pops and quickly deflates as the follicular fluidcontaining the egg drains into the test-tube, which is attached to the aspirator, by a longrubber tube taped to the patient’s left leg. As the surgeon deftly pricks one fofficle afteranother, they miraculously deflate and disappear in the grey ovarian outline.Meanwhile the nurse, who is sitting by the patient’s left knee detaches each testtube, as it fills; gets up and hands it through the window between the operating room andthe gamete laboratory to the biologist. The biologist is sitting out ofthe couple’s view at asmall table monitoring and logging the test-tubes as they are passed to her. She calls backinto the OR a number, only when one or more ova are found in the contents from eachtest tube, which another biologist is viewing under a high powered microscope.Within ten minutes, the surgeon has punctured each of the fofficles, which she cansee in the left ovary. She then scans the whole organ, as some fofficles are less easy to seethan others. Sometimes the fofficular fluid is clear, at other times bloody or tinged withpink. In this instance, eight eggs have been found in the left ovary, although more thaneight test tubes have been passed into the adjacent laboratory. Halfan-hour has passed ina flash for me, ifnot for the stoical patient.Some ultrasound pictures, which have been taken before the retrieval started lie onthe console and one shows that only one enlarged fofficle is visible in the right ovary. Asthe surgeon moves to the right ovary, I am asked to switch over the monitor to that ovary.The follicle is resistant to puncture and the patient reacts with a loud “ow”, to whichresponse the surgeon apologizes, in a mechanical way, as she has done each time thewoman winces, as a fofficle is pricked. The patient feels everything without anaesthesia,which she has chosen to refuse. She looks awfully pale, as does her husband. They areboth withdrawn, but together, somehow unconnected from the efficient, swift activities116going on down our end of the table. Every so often, the surgeon swivels her stool to theside of the monitor, so that she can make eye contact and verbally reassure the couple,thereby bridging the artificial world of subject and object.Finally, the resistant large fofficle ruptures, the test tube fills with fluid andeveryone exclaims with pleasure, although in fact it does not contain an 000yte. In thiscase, bigger is not equated with better. There are no other fofficles to be found in thisovary. The surgeon removes the aspirator to check that it is not clogged. She introducesanother one and re-scans the ovary unsuccessfully searching for more foiiicles. She takessome fofficular fluid in a search for stray oocytes.By 8.40 a.m. the procedure is completed and the operating room team is mobilizedin a flash to clean up. The husband is sent outside. I stay and try to keep out of the way,as machines are moved swiftly to the side walls, a trolley is brought in and the patient isslipped on to it. The anaesthetist, who has had nothing to do, helps move the patient andwheels her outside into the hail, where the surgeon speaks reassuringly to the couple. Thenurse picks up the intercom and says “Room 10 is ready for cleaning”, the cue for thecleaner to enter the room and lethargically push a mop around in preparation for the nextpatient, who is waiting.ifi A WINDOW OF OPPORTUNiTY: INTO TILE lAB.(i) A Mecca of MachineryThe microscopic exercise of the egg hunt goes on in the adjacent laboratory. It isconnected to the operating room by a small corner window, through which follicular fluidand later pre-embryos are passed. This is a world completely off limits to the patients,117where two or three of the three busy biologists rotate daily through a myriad of technicalprocesses. They prepare medium and sperm, monitor ova and later pre-embryos not onlyfor replacement, but also for cryopreservation for use in later replacement cycles.The two IVF laboratories are considered as an extension of the operating room, sothat anyone entering must be correctly gowned. They are kept scrupulously clean, andequipment is handled wearing disposable gloves. When gametes are handled, thebiologists wear masks. In the laboratory attached to the operating room, there is amicroscope, housed within a laminar flow hood, which is used solely to observe andhandle the oocytes and embryos. An incubator for the oocytes sits beside it. On anothercounter a microscope is used for magnifying sperm samples and beside it an incubator forthe sperm samples, which are artificially capacitated13 before mixing with the oocytes.Under the counters are kept all the sterilized and packaged supplies. A counter forpaperwork is close to the table and chair beside the window linking the laboratory with theoperating room. It is from this site that the biologist can observe the procedure.Across the hail in the other laboratory, serum is prepared from new patientsundergoing the superovulation induction process. The serum is heat inactivated in a waterbath at 56°C. and sterilized through 0.22 urn ifiter unit This laboratory is crammed full ofequipment, consonant with what Reiser and Anbar describe as “(T)he landscape ofmodernhealth care is filled with machines” (1984:3). There is the sophisticated ultra pure water13 Capacitation under natural circumstances is a process whereby motile spermatozoamust undergo alteration during their time in the female reproductive tract in order todevelop the ability to fertilize eggs. After sperm have ‘escaped’ from the irihibitory factorswithin the liquefied seminal plasma in which it travels, capacitation involves severalchanges that alter the plasma membrane of the sperm to allow an acrosome reaction. Thisprocess is mimicked in vitro by separating the sperm from the plasma and capacitating it ina physiological saline solution supplemented by serum albumin and energy sources (Soules1989:191-192).118system along one wall, which provides pure water for the procedures. On the counter is afreezer, which has been programmed to freeze embryos loaded in slow cooling 0.25 mlstraws. It slowly steps down (slow cooling) the pre-embryos. Two largecryopreservation tanks and the liquid nitrogen relill tanks sit on the floor. A small deskprovides space for the technologists to do their paperwork and on the wall a fan playsincongruously above all the freezing equipment on a warm summer day, in an old hospitalbereft of air-conditioning.Very few people ever venture into these technological Aladdin’s caves. Requestsby some patients to view their embryos have been rejected by the laboratory director,because of the critical importance of keeping this area as sterile as possible. In manycentres a video monitor, attached to the laboratory microscope is placed in the operatingroom for patients to view their ova and embryos. The 1VF programme has not been ableto afford such equipment from its limited budget, despite it proving to be an indispensablepiece of equipment in the animal IVF laboratory in the Animal Science Department at theUniversity of British Columbia.’4 In some cases, the programme has given the patient aclean petri dish, as a memento of this elusive stage in the creation of their potential baby.This souvenir has similar symbolic resonance with the tiny casket, which some patients inthe United States, who expeñence recurrent pregnancy loss, use to mark the loss of a15potential baby.14 On one ofmy visits to the 1VF facilities in the University of British Columbia AnimalSciences Department, I was struck by the technology that was available to its researchers,in comparison with the human 1VF programme. It was much simpler for me to view theibryos magnified under the microscope on the adjacent television monitor.One of these caskets was displayed by Sherokee use, an expert in recurrent pregnancyloss at a lecture in Women’s Health Centre, Vancouver, on May 20th 1993. I was told ofanother symbolic marker of the loss of a fetus in the release of coloured helium balloonsup into the sky.119,,16(ii) Egg CareAs the test tubes are handed in rapid succession through the connecting windowbetween the laboratory and operating room, the biologist logs twenty-five aspirates fromone ovary and seventeen from the other. In all,, a total of twenty-five eggs are retrieved.The biologist calls back into the operating room as each oocyte is identified, not only forthe surgeon’s information, but also to boost the couples’ morale. The couple in this casehas withdrawn consent to my observing their retrieval procedure at the last minute. I amtold that the couple are overwhelmed by the ordeal, and in consequence unnecessarilytense about intruders into what they perceive as a very personal experience. I am invitedto remain in the laboratory to see what for me seems the even more personal experience ofthe fertilization oftheir gametes.While one biologist is logging the aspirates, the other is examining the samplesunder the microscope, which is housed in a flimehood. The procedures are performedswiftly and deftly, with silent concentration. First, the biologist draws up in a pipette abouta teaspoon of aspirate into a petri dish and examines it for oocytes. She sucks off theoocytes into another petri dish, mixes it with some medium mixed with the patient’s serumand then covers it with a lid. This serum has been prepared from the blood samples of thepatient, drawn during the superovulatory work-up the week before. The serum is used asa nutrient in the culture medium for preparing sperm and for the incubation of the oocytes.Incubation occurs prior to insemination, which takes place about three to five hours afterthe retrieval process. The granulosa cells in the remaining aspirate is put aside forgraduate student research projects.16 “Egg” is the colloquialism most often used by 1VF professionals, as well as patients,even though the more correct term, ovum or oocyte is used in operating room andlaboratory notes, conference papers, etc.120Once an oocyte is picked up from the fofficular fluid, it is placed in a culture dishand washed with PBS medium about two times Finally the oocyte is cultured with aspecial medium (JIF1O) containing seven point five percent of the patient’s heat inactivatedseruni Then the dish is placed in the incubator to await the insemination procedure. Eachdish is labeled with the female patient’s surname and colour coded from among six rotatingcolours. One shelf of the incubator is reserved for each patient undergoing a retrieval thatday. In this way safeguards are implemented to ensure that there is no chance of mixingup the embryos.The same intensity of silent concentration, as I witnessed in the operating room,occurs in the laboratory as each oocyte pickup procedure occurs. There may be up tothree oocyte retrievals, followed by as many embryo replacements, on any given morning,so there is pressure to keep moving along. The operating room and its nurses are onlyavailable until lunch time and anyway there is much else to be done by the surgeon and thebiologists. In between procedures, the surgeon does paperwork, and talks to the patients,the nurses prepare for the next case, and in the laboratory, the pertinent laboratoryequipment is swiftly cleaned in preparation the next case.(iii) Insemination and Syngamy: Technology versus NatureOnce the male partner has produced the semen sample’7in a room across the hall,one of the available biologists examines a specimen under the microscope. Undermagnification, the tiny drop of semen on the slide appears like a pond, full of activetadpoles, surrounded by bits of floating debris and intriguingly irregular shaped cells. This17 One half to one teaspoon of sperm is produced by a healthy, fertile man. Eachejaculate contains between 200 million and 500 million sperm. But only one sperm isrequired for fertilization to occur (CRCNRT 1993:147-148). See glossary.121semen will be kept in an incubator in the main laboratory in a test tube, supported at a 300angle and covered with some of the medium containing the female partner’s serum, inorder to enhance “swim up”. This process facilitates the “goo& or motile sperm to swimup to the top of the sample, which then appears clear as the dead sperm remain at thebottom. The clear portion or supernatant is drawn up with a pipette and introduced into aclean tube and centrifuged. The resultant sperm pellet is washed twice with the mediumcontaining maternal serum and the number of motile sperm in the final preparation arecounted. Finally, the concentration is adjusted to about 50,000 sperm per drop. Thebiologists also processes the blood samples of new patients, who are being “worked up”for retrievals later in the week, in order to produce the maternal seram.With the bustle of the morning over and after lunch, the business of inseminationfinally occurs, by placing a drop of the prepared semen sample on to the oocyte envelopedin its culture medium in the petri dish. This usually takes place about three to five hoursafter retrieval. Then the fertilized oocytes will be left overnight in their dishes andexamined the next morning when they have reached the pronuclear stage. At this time, thebest are reserved for embryo transfer the following day, while the rest, if there are any andif the couple so desires, are frozen for future use in a natural cycle.18 Within twenty-fourhours of the sperm penetrating the oocyte, the process of syngamy (see glossary) hasoccurred, when the nuclear membranes of the two pronuclei dissolve and thechromosomes unite. “Although the genetic constitution (the genome) of the zygote isestablished at syngamy, the genes do not begin to function until the zygote has eight cells.Until then, the zygote is operating under genetically programmed instructions from the18 A natural cycle is one in which a woman has not undergone superovulation, or onlyminimally, in order to replicate the optimum time for an embryo replacement. it is usedcommonly by women, who have excess preembryos stored in the freezer. A natural cyclereplacement is also substantially cheaper and less invasive than an 1VF cycle.122egg only” (CRCNRT 1993:153). A few hours after syngamy occurs, the process of celldivision, cleavage, causes the cells to split into two, then four, then eight, sixteen cells andso on.’9 Usually, the pre-embryo created through IVF is replaced at the two to four cellstage.(iv) Cleaving Embryos: Watching, Waiting and WastageThe period between the ova retrieval and the embryo transfer, when the cleavingcells are left to their own genetically programmed sequences, is a critical and liminal timefor both staff and patients. Human intervention is at a minimum. It is a period duringwhich the patients after leaving the hospital have to wait. The biologists can only watchover their charges and ensure that no outside factors interfere with the optimumconditions for cell division. In part the lack of knowledge about and thereforeengagement with this process for patients is a means of self-protection, because they havebeen primed to the poor fertilization success rates of IVF technology. One 1VF nurseexplained her view ofwhy patients use this distancing process:I have talked to couples about that period before implantation. They aretrying to keep it very clinical in their minds, because that’s their way ofprotecting themselves, if the treatment fails. They don’t want to think of it asthe death of this embryo or that they have failed the embryo. They want toput aside the grieving of that particular section of the technology.Because the laboratory is off-limits to patients, this is also an area of the 1VF technologyabout which patients have very little comprehension.19 . . . . . .In normal conception in vivo, this division occurs at about eighteen hour mtervals toform a clump ofblastomeres, each one ofwhich becomes successively smaller. However,the clump remains about the same size, about the size of a period at the end of thissentence, until implantation occurs.123According to the differing epistemologies of 1VF health professionals, such asmedical, nursing, laboratory, counseling, a variety of perceptions about the conceptus inits early stage are expressed. For example, the IVF nurses, who work most closely withinfertile couples through daily monitoring ofhormone levels and in counseling them abouttheir concerns about treatment, tend to define the pre-embryos in relation to the potentialparents. One nurse swiftly elides her definition of the embryo with the concerns of thepotential parents:The embryo is the joining of two cells. But it is more than that, to thesecouples, the embryo has such emotional significance, because many ofthese couples have never achieved a pregnancy before and to them, even ifthey don’t become pregnant from the treatment, I think that the realizationthey have created an embryo, even Wits in the lab., its meaningful to them.Pm talking generalizations here and obviously there is a difference from onecouple to another how they view their embryos.Another nurse followed the same type of reasoning:the human embryo is a living thing, something that a man and a womanform and its something pretty special and its just not possible to create ahuman embryo, due to external problems that the couple have. With thehelp of research and science they are able to accomplish that.In distinction, those scientists, 1VF technologists and 1VF physicians, whoseepistemology is based in embryology tend to focus on the pre-embryo as part of adevelopmental process, in which their skills are critically involved. A biologist describesthe arbitrariness with which cell division occurs and the potential failure ofpre-embryos todevelop.The embryo is like two cells that come together, but it could potentiallybecome something, but you don’t know because there are a lot of factorsthat will make it a human being.124In natural conception, each of the cells in the blastocyst cluster is totipotentiaLThis means that any of the cells has the ability to become the true embryo and subsequentfetus. Each cell has an independent, genetic constitution, a genome. But most of thesecells are not destined to become the embryo. By seven days after fertilization, the outerring of cells, called the trophoblasts, begin to invade the lining of the uterus, (theendometriurn) and eventually become part of the placenta. The plate of cells whichbecomes the embryonic disk separates two fluid-filled spaces, which become the amnioticcavity.It is from this disc that the embryo itself develops. By about 14 days afterfertilization, implantation is complete, and one or two days later the firstindicator of a body axis becomes visible. Called the primitive streak, itappears as a heaping up of cells at one end of the embryonic disk. Thus,the embryo proper develops fromjust a small fraction of cells that make upthe zygote before implantation. Only at this point, (15 or 16 days afterfertilization) can individual embryonic development truly be said to havebegun, because only with the development of the primitive streak is itpossible to tell whether one embryo, multiple embryos, (identical twins ortriplets) or no embryo at all is developing (CRCNRT 1993:158).In reality, more than ninety-nine percent of the zygote develops into the trophoblastand other supporting tissue, such as the placenta, chorionic viii, amnion etc. It is for thisreason that some people prefer to use the term pre-embryo for the zygote prior toimplantation.The long journey from two cells to complete human being “makes it open to therisks of errors and dysfunction. In fact, only half of all fertilized eggs survive embryo andfetal development and result in live births. The remainder are lost sometime betweenfertilization and the end ofpregnancy, many of them before implantation and many withinthe first few weeks ofimplantation” (ibidl6O). This knowledge ofthe common wastage ofgametes and embryos associated with natural intercourse and conception, in vivo, allows125many of the IVF staff to keep biological realities in perspective and therefore not to beconsumed by moral quandaries concerning discarding unneeded or damaged pre-embryos.In my mind, an embryo doesn’t have the right to be gestated. I guess Idon’t have problems with discarding embryos - no. I don’t lose sleep overdiscarding embryos because that is the choice the gamete providers havemade and have to live with. I don’t think anybody has a right to interferewith that kind of decision.The laboratory director perceives the pre-embryo objectively from a scientificstandpoint, unclouded by moral theology:Conception outside the body gives a lot of confusion. Most of us put toomuch emotion on the embryo and it’s unnecessary. They are just simply 1-2 cells.., anything can happen with this type of 1VF embryo. For example,even in (the) natural cycle, we don’t know how many embryos are fertilizedand disappear, aborted or rejected, by the body. Also, the 1VF embryo isonly at the two to eight cell stage, early embryos - less than 8 cells. Even ifwe transfer to the mother, what is the success rate? 20%.? Can you accuseme that I am murdering 80% of the embryos. Once the embryo is attachedto the mother’s womb, is growing and healthy, then I would call that thereal potential then.Likewise one of the IVF physicians, with expertise in endocrinology, situates the preembryo in terms of its critical dependency on human or artificial nurturers for its futuredevelopment.An embryo, a zygote is the structure that is formed following thefertilization of an egg; an egg that is fertilized by a sperm which as it startsto divide becomes a zygote and an embryo, which is human tissue -livingtissue; but incapable of living without tremendous support from the 1VF labor the mother and even in the IVF lab. only for a very limited period.Another 1VF physician and fetal ultrasound expert, involved in both the technicalaspects and patient care, also refines her definition in embryological terms, according toboth her specialized professional knowledge and her socialization to the practical situationofpatient care.126I have problems with calling it (the pre-embryo) an embryo when I amtalking to the couples, telling them about the embryo replacementprocedure, because for me it is an embryo when it has a form to it afterimplantation. I tend to call it a fertilized egg rather than embryo.In all the explanations posited by TVF stafl the reification of the pre-embryo isfocused clearly on its biological, extendible status as human tissue, which is sometimessubject to rejection. The ability to think both in terms of the social relationships aroundthe embryo and linearly about the pre-embryo as part of a biological developmentalprocess pervades the rhetoric of 1VF, whether or not there is formal knowledge ofhumanbiology. The experience of biological aging is a universal phenomenon, which Leachpoints out is associated with our odd concept of time passing as “a discontinuity ofrepeated contrasts” (Leach 1979:228). Likewise, we tend to take for granted theconnected sequencing of the biological progression from embryo, to fetus, to infant, tochild and so on.(v) The Embryo TransferWithin thirty-six hours of fertilization the pre-embryos, which will be somewherebetween the two to eight cells stage, will be ready to be replaced in the woman. Thisevent occurs in the same procedure room as the retrieval but in a far less tenseatmosphere. It is a relatively simple, speedy and low-tech procedure. Earlier, one of theother biologists loads each of the pre-embryos from their individual petri dishes into acatheter in such a way as to create the minimum of damage to the pre-enibryos. Thesurgeon, this time assisted by one of the 1VF biologists, introduces the pre-embryos in thecatheter, attached to a long, narrow tube, high into the woman’s uterus, usually withoutany local freezing. Emotions are often running high at this point for the couple, for whomit may be the first time that they have come so close to a pregnancy. While the woman127relaxes for a while after the procedure, the biologist remains in the procedure room,talking in an informal manner and trying to reassure the couple.In reality, what follows afterwards is another tense period ofwaiting. Firstly, thereis the fourteen day wait until the pregnancy test is performed, even if the patient starts tobleed in the meantime. Several weeks later ultrasonography will identify and confirm animplanted embryo. For some the long wait is over, to be replaced by the anticipation of anuneventful gestation and birth; for many others the decision-making process starts all overagain. For others the failure to conceive brings to a closure the attempt by a couple fortheir own biological child. Many more couples’ hopes rest on their pre-embryos, whichare frozen solid in the large cryopreservation tank in a laboratory, which they are neverpermitted to enter. Some 1VF centres allow visitation rights to the cryopreservation unit,in respect of the attempted bonding between pre-embryos and potential parents.IV FROZEN IN TIME AND SPACE: FREEZING PRE-EMBRYOSThe western cultural infatuation with technology20 clearly revealed by someanthropological studies (Koenig 1988; Bassett 1993) demonstrates that there areunexplained social processes, which occur when practices become accepted as routine. Inthe 1VF laboratory the equipment associated with the freezing procedures form a20 accept Bijker, Hughes and Pinch’s observation that technology is a slippery term and“it seems unfruitful and indeed unnecessary to devote much effort to working out precisedefinitions, at least at this stage of the research in progress” (1987:3). They distinguishthree layers ofmeaning of the word technology as described by MacKenzie and Wajcman(1985). The first layer is the level of physical objects and artifacts; the second refers toactivities or processes and the third refers to what people know as well as what they do -the know-how.128substantial part of this machinery, which is routinely utilized by the technologists.“Ordinariness”, “standard therapy”, this familiar pattern of routine make their workplacesocial life possible. “{H}abituation makes it unnecessary for each situation to be delinedanew, step by step” (Berger and Luckman 1966:53-54). For example, commonacceptance of routine practices makes it possible for the IVF laboratory director, who isnot even located on the same hospital site since the removal of the gamete laboratory tothe Vancouver Hospital and Health Sciences Centre (VHHSC), to rest assured of thesmooth running of the complex protocols. Even when the 1VF programme was based atShaughnessy Hospital, his office was located in another part of the hospitaL Onweekends, sometimes one biologists works alone. Thus there is an implicit reliance on andconfidence in the integrity and competence of the biologists to follow the acceptedprotocols and for the machines to do their job.(i) A Chffly ClimateA standard procedure, according to strict protocols, for selection and freezing ofembryos is followed by biologists at the IVF programme. The freezing of pre-embryostakes place on the morning after the oocyte pickup at the two pronuclear stage.21 Ifthereare five or more embryos, the best three are reserved for replacement the following dayand the remainder are frozen. Delaying the freezing until the day after retrieval allows forthe chance of delayed fertilization and in some instances for four embryos to be replaced.As with any highly practiced skill, the procedures look disarmingly simple to theobserver. The calm expertise of the doctors and biologists, born out of years ofexperience when applied to the oocyte pickup, insemination and embryo replacement21 See diagrams in CRCNRT report 1993:151-7.129procedures is also replicated in the freezing process. In the laboratory, where the storagetanks reside, the biologist prepares the cryoprotection solutions, which protect the preembryos for their freezing plunge. First, she clearly labels three centrifuge tubes and thenprepares three solutions in which the embryos are rinsed prior to freezing. The solutionsare of different concentrations,22which are then jilter-sterilized through double-stackedlilters in the correct order, using the same ifiter system.The biologist then labels and sets up three petri dishes (Falcon 3001), each ofwhich is filled with one of the filter-sterilized solutions. Each solution is mixed well, asthe propanediol (PD) tends to separate quickly. Then each pre-embryo is rinsed in the20% media for about three minutes, then placed in 1.5 M PD for fifteen minutes and thenfinally in 0.1 M sucrose plus 1.5 M PD for five minutes. At this stage the pre-embryos areready for loading into special cryopreservation straws.Each straw, called a French straw, is carefully labeled with the date, the patient’sname, laboratory number and straw number. The loading procedure involves a steadyhand to attach the coloured end ofthe straw to a mouthpiece adapter set. Using the otherend of the straw as a pipette, the straw is loaded first with a small volume of sucrosesolution, then air, then embryo plus sucrose solution, then air again and a small volume ofsucrose solution again, then air, then critoseal to hold all of the above in place. Oneembryo is loaded into one straw, until a maximum of five straws is used for each patient.Doubling may be required when a patient has more than five embryos for freezing. Thebiologist then places the straws in the cell freezer (Planer KRYO 10) in preparation for therequired slow cooling process, before the icy plunge into liquid nitrogen.22 Solution 1, labeled as 20% D-PBS (Dulbecco’s Phosphate Buffered Saline) contains 4ml. D-PBS + 1 ml. maternal serum. Solution 2, labeled as 1.5 M PD (propanediol)contains 8 ml. D-PBS + 2 ml. maternal serum + 1.25 ml PD. Solution 3, labeled as 0.1 Msucrose + PD, contains 5 ml. 1-5 M PD (solution 2) + 0,171 g. sucrose.130Prior to loading, the biologist, using a razor blade, makes a diamond shapedwindow in each of the goblets to be used. This window is for seeding.23 The goblet isfitted into the cane, which is lowered into the freezer. The cell freezer is manuallyactivated to begin the cool down process. When the cell freezer is ready for loading thestraws, it beeps. Then the straws are placed inside the goblets. Each straw is positionedso that the embryos gravitate away from the site offorceps’ contact during seeding.The cell freezer automatically decreases from room temperature to 70C at 20Cper minute. This temperature is then maintained for five minutes, during which period,seeding is performed. The samples are then further cooled at -0.3°C per minute until -400C temperature is reached. Freezing is then held at this temperature for one minute,then further cooling continues at -50°C per minute until -140°C is reached. At this pointthe biologist removes the canes with forceps and plunges them into the large liquidnitrogen tanks on the floor, into which they are placed in the rack, which is then loweredinto the tank and the lid replaced. Every so often the biologists 1111 up the big tank withliquid nitrogen from a smaller tank. This is performed by a method reminiscent of sciencefiction movies, whereby the liquid nitrogen is transferred through a makeshift paperfunnel, enveloped in clouds ofnitrogen steam and poured into the tank.(ii) More than Enough: Freezing ChoicesIn the early years of 1VF, before ovulation induction and the retrieval of multipleova became commonplace, there were no excess pre-embryos available for freezing.23The seeding procedure involves the forming of ice crystals on the straw. A thermalflask is filled with some liquid nitrogen and long forceps are plunged into the flask to cool.Then during the five minute holding period, each cane is lifted one at a time from thefreezer. The cold forceps are brought into contact with each straw and held for a fewseconds. If ice crystals do not form, the seeding procedure is repeated.131During the 1980s, three developments occurred to pave the way for freezing of humanembryos. Firstly, 1VF as a therapeutic modality became more enticing to potentialparticipants. This was due to the introduction in 1987 of routine use of the minimallyinvasive vaginal ultrasound-guided retrieval method. This replaced the surgically invasive,more complicated and less acceptable method of ovum retrieval by laparoscopy.Secondly, physicians routinely prepared their patients for the 1VF process withincreasingly sophisticated ovulation induction protocols. The rationale was to enhance thechances of greater ova production in the ovaries and better quality ova. More ooctyesfacilitated a greater number being retrieved and fertilized, over and above what a couplewould need for one replacement cycle. Thirdly, advances in the animal sciences andbovine industry showed that not only could embryos be successfully frozen, but qualitycontrol of embryos could be enhanced. Although of tangential interest for human IVF atthat time, immunity from diseases in some parts of the world, transportation andinternational marketing of embryos had improved dramatically the cattle industry in24Canada, which has become the world leader m the industry.Overtime the IVF programme has instituted several changes to the drug protocolsit had been using to stimulate oocyte production. In 1982, only pure IiMG (Pergonal) wasused, while by 1987, both clomiphene citrate and Pergonal were being administered. In1988, GnRH analogs (see glossary) were introduced for a select group of patients, whoeither tended to ovulate early or had a poor response to ovarian stimulation. Use ofanalogs had became standard practice to induce ovulation in the United States IVF clinics,241 am indebted to Dr. Rajamahendran, professor in the Faculty ofAnimal Sciences at theUniversity of British Columbia, for his assistance in explaining both the research andindustrial applications of bovine ovum retrieval, in vivo embryo flushing and embryofreezing and transportation. I appreciated his staff allowing me to observe the procedures.His own studies on cloning embryos were also of assistance.132with improved “success” rates. Therefore as of April 1994, despite some internaldissension among the endocrinologists, GnRH analogs are now routinely used in the25programme.In late 1989, the University of British Columbia IVF programme started to freezepre-embryos, in order to deal with the supernumerary pre-embryos. Cryopreservationwhen linked with superovulation, solved the problem of what to do with the excessembryos created from retrieval and fertilization of multiples ova. Since 1989 the numberof embryos in the freezer has increased to the point where on July 7th 1994, there were807 embryos in the freezer. As in other centres, little attention has been paid to theconsequences of stockpiles of unneeded pre-embryos or if a clinic decided to close itsoperation.Table 3. Number of Embryos Remaining in the Freezer Tanksper Year between 1989-19941989 691990 861991 1611992 2931993 1851994 106Although success rates with frozen embryos are poor, about eight percent clinicalpregnancy rate per embryo transfer, the procedure is now offered routinely as one of threeoptions of 1VF treatments. Despite the poor odds of success, the majority of IVFparticipants choose freezing. For example, in the last six months of 1993, seventy-five25 . .Although it is too early to predict, early results suggest that this may improve not onlythe likelihood of successfiul retrievals, but also better fertilization rates.133percent of couples elected to have their embryos frozen, although in reality only twenty-five percent had embryos available for freezing.The number of supernumerary pre-embryos possess important long-term personaleffort and legal issues for both the couples and the laboratory. Both partners must chooseand consent to one of the three options concerning disposition of surplus embryos, whichis explained in the general IVF Consent Form. The first option, (freezing) permits theretrieval and insemination of as many oocytes as possible and the replacement of three orfour pre-embryos26 in that retrieval cycle, while freezing the remainder for futurereplacement in a later cycle. With the second option (selection), couples reject freezing ofpre-embryos, but agree to retrieval of oocytes from all accessible ovarian follicles,followed by insemination. Then the best three and at most four pre-embryos are replacedin that retrieval cycle and the remainder are either technically fixed on slides for researchpurposes or discarded. The third option allows couples concerned by moral aspects toreject both freezing and selection of pre-embryos, because they may involve possibledestruction of extra pre-embryos. In this instance, a maximum of six mature oocytes areretrieved and inseminated and in the unlikely case that all six fertilize, they will all bereplaced. With this procedure there is a risk as high as 30% ofmultiple pregnancy. If thatrisk is unacceptable to the participants, then the number of oocytes inseminated may bereduced to four. For some patients the dilemma of wasting oocytes, which they haveconsented to not be fertilized, may also be a problem. All the participants are also made26 Transferring more than four embryos carries a significant risk of multiple pregnancy.The Voluntary Licensing Authority in the United Kingdom and the IVF Special InterestGroup in North America recommends that a maximum of three, and under specialcircumstances four embryos be replaced in one cycle. As of January 1995, the Universityof British Columbia programme changed its policy to transfer no more than threepreembryos in order to minimize risks ofmultiple pregnancies.134aware of the further option of selected termination or reduction,27 a technique wherebycertain post-implantation embryos are eliminated by one of a number of surgicaltechniques (1VF Consent Form revised October 1992).(iii) It’s Just a Matter of TimeUnintentionally, the cryopreservation procedure had created an unforeseenproblem as to what should be done with all the unneeded pre-embryos, which could not befrozen indelinitely. It has became standard procedure in the programme to store preembryos for only five years. After this time, with the permission ofthe contracting couple,they wiJi either be defrosted and discarded or used for research purposes. The time isshortly approaching when the five year limit will be reached and when a decision will haveto be made about those pre-embryos that have been in the freezer for five years.Evidence from Australia and New Zealand, where almost 10,000 pre-embryoswere stored by the end of 1990, have demonstrated some of the problems occurring withlarge banks of frozen pre-embryos. In both countries legal inhibitions had deterred bothinfertile couples from “adopting” a pre-embiyo for implanting and donors from donatingtheir suqlus pre-embryos. The latter would remain legally responsible for their preembryos, even if they donate them to another couple.28 Likewise the recipient couplewould not be the legal parents of children produced from the donated embryos” (MedicalPost 1992:21).27 . .Only one case of selective reduction has been documented by the UBC IVF climc,which occurred in the late 1980s. Currently, a participant has elected to use thistechniques to remove one of the three embryos/fetuses that have implanted, because shees not want to have triplets.In most Australian states, the father, usually the genetic one, is the legal parent. Yetthe woman, who carries the embryo of another couple, has no legal right to the resultantchild.135Recently, Dr. Armstrong, scientific founder of the 1VF programme at UniversityHospital, London, Ontario and professor of obstetrics and gynecology at University ofWestern Ontario and University ofAdelaide, warned that Canadians should take steps toavoid possible legal problems. He stated in an editorial article thatCouples should sign a legal document when they begin an 1VF programmeto choose between destroying, saving or donating the embryos to anothercouple or for research of early fetal development. That’s when the geneexpressions are formed, which can be helpfhl in researching the cause ofcancer, for one (quoted in Medical Post 1992:21).The 1VF nursing co-ordinator, who helped revise the University of BritishColumbia IVF cryopreservation consent form, while acknowledging that “the consentform is subject to judicial interpretation and any couple could take it to court”, feltrelatively secure that patients’ interests were being observed. However, in certaincircumstances patients’ frozen pre-embryos could revert to the programme’s control, withthe potential for litigation over ownership of pre-embryos, which has occurred with casesin the United States. (discussed in the next chapter).lam used to our scenario here, where the couple have the control, up to apoint, I guess, because there is a time limit imposed, the five year limit. Soif the embryos are not replaced within that five year time, the controlreverts to the clinic, who would then dispose of them. If the couple cannotbe reached, there are certain conditions imposed in the consent form andone is that if couples have embryos in the freezer, that couples mustmaintain contact with the programme, at least once a year, so that weknow of their intent. That is to avoid those situations where we loosetrack ofthem.She goes on to explain the expanded control of the 1VF programme, in the situation of amarital breakdown:A few times people have written to say that they want their embryosdisposed ofbecause the marriage has dissolved. That is a stipulation in theconsent form also, that if the relationship dissolves the programme gains136control of the embryos. It would then dispose of them. There is anotherthat couples are given a choice that in such an event that the program gainscontrol, that they have another choice of offering the embryos either fordonation or to dispose oftheniShe noted later, however, that the programme does not as yet have either apre-embryo or ova donation programme. However, they do have stored the preembryos of a couple, who did not want their pre-embryos frozen for themselves, butneither did they wish them to be destroyed. They chose to have their surplus preembryos frozen for donation at a later time. In the meantime, they had a baby andthe couple have not contacted the clinic again. The programme has received ethicalclearance from the University Ethical Review Committee, therefore it is probablethat donation ofpie-embryos may become an option in the future.The consent form also stipulates that if there is a death of one of thepartners, who have pre-embryos frozen, that the clinic gains control over those preembryos. The moral right of a clinic to make these kinds of stipulations hasapparently caused concern for some patients, because they feel the remaining partnermay wish to use those embryos in another relationship later or if the husband dies,perhaps the woman would want to gestate her posthumous husbands embryos atsome future time. Shore (1992) discusses some of the gendered inequitiessurrounding posthumous use of pie-embryos in relation to The WarnockCommission in Britain.The 1VF programme had decided that the consent form would remain in effect forfive years after the validation, but as the co-ordinator noted “it is too early to say how thefive year time frame will work, because we haven’t reached five years yet, since westarted at the end of 1989, and thee probably all been replaced. We probably have a137few left from ninety”.29 Although some effort is made to keep track of patients withembryos in the freezer, one 1VF staff member chaffed “some people totally forget theyhave frozen embryos”.V IDENTIFYING RISKS AN]) ACKNOWLEDGING TILECOMPLICATIONSIn the absence of national and international legislation on assisted procreation,each 1VF programme is responsible for developing its own individual treatment policieswithin ethical guidelines. While university operated IVF research programmes are morestringently monitored by ethics committees, private programmes, driven by both consumerand entrepreneurial interests are less scrutinized. However, in the wider domain ofinternational concerns about the quality of practice involving an increasingly complexarray of infertility treatments, recent events are shaking the medical and pharmaceuticalcommunities out of their complacency about ethical practices, causing them to close ranks.The catalyst for this strategy has been the publication of a longterm, thirty yearepidennological study in the United States into the relationship between the effects offertility drugs and ovarian cancer. The Whittemore et a! (1992) study3°proposed thatnuffigravid (never having borne children) women, who used fertility drugs were atincreased risk of 2:1 to develop ovarian cancer, in comparison with fertile women. TheA check on these number showed that a few frozen embryos stifi remain from 1989.The Wbittemore study was based on an analysis of twelve case-control studies ofovarian cancer between 1956-1986. It was conducted by the Collaborative OvarianCancer Group in the United States, which confirmed findings from many other studies,which concluded that oral contraceptives, pregnancy and lactation were substantialprotectants against ovarian cancer.138authors supported their contention that treatment with fertility drugs were implicated,rather than some underlying ovarian disorder, based on their evidence that there was ahigher risk associated with a diagnosis of infertility after 1970, the time at which fertilitydrugs were introduced to the United States, compared to those diagnosed between 196 1-1970 (Whittemore eta! 1992; 136:1184-1203).These lindings provoked an immediate and concerted response frompharmaceutical manufacturers of gonadotrophins, followed by the American FertilitySociety (AFS), National Cancer Institute and the United States Federal Drug Advisory, allofwhich found the study flawed. Experts immediately tried to reassure patients, pointingto various defects in the study. Arguments were made to refute evidence of a claim ofcausal effect in 1993, at a special session on ‘fertility drugs’ and ovarian cancer, to astanding room only crowd of delegates, at the annual meeting in Greece of The EuropeanSociety of Human Reproductive Endocrinologists and the International Fertility Society,The American Fertility Society criticized the small sub-division of the study, whenbalanced against the estimated 28-30% of all infertile women given ovulation inducingdrugs. The European Society of Human Reproductive Endocrinologists suggested thatthe increased risk of ovarian cancer might be related to the underlying defect rather thanthe therapy used to treat the disorder. It maintained that the risk was less than one in fivethousand, and that “this limited risk should be balanced against the benefit of achievingbirth” (Reported in IVFNews 1993:2, a newsletter published by Organon Canada Ltd.).The delegates argued that a few anecdotal reports in journals concerningborderline ovarian cancers associated with ovarian hyperstimulation syndrome wouldrequire investigation as to whether there is a true causal relationship or is merecoincidence. The Federal Drug Advisory estimates that since fertility drugs were licensedin the United States, chiomiphene citrate and IIMG in the late 1960s, there have been more139than twelve million cycles prescribed and yet no increase in cases of ovarian cancercommensurate with the rise in prescription. Likewise, the British National Institutes ofHealth’s surveillance of 3100 women, who had undergone 1VF, recorded no cases ofovarian cancer (ibid). The general consensus was that doctors should advice their patientsof the risks. A collaborative study, reported by Lunenfeld,3’who is credited with thedevelopment of human menopausal gonadotropliin, found no increase in cancer risk fromIiMG/liCG. He has been quoted as suggesting that the risks may be multifactorial:I think we have to tell patients about the Whittemore study, but alsoexplain its weaknesses. We must also tell them that nulliparity, infertilityand polycycstic ovarian disease have been consistently reported risk factorsfor carcinoma of the breast and endometrium. Hereditary factors,environmental factors - such as high galactose consumption - have all beenlinked to an increase in ovarian cancer risk (Lunenfeld quoted in InfertilityNews 1993:2).The strategy of presenting a unified front has not been one followed by allinfertility specialists in the international community. Schenker and Ezra (1994) in anextensive review of the potential complications of assisted procreative techniques haveacknowledged the iatrogenic effects of 1VF therapy and the importance of control ofcomplications before and during assisted pregnancies.32 While the authors agree thatassisted reproductive treatments should be allowed as a first choice, it should only be soin well controlled circumstances and preceded by thorough investigation of infertilityBruno Lunenfeld, American Journal ofEpidemiology 1987:780-790.These Israeli authors cover complications associated with ovulation induction, notablyassociated with ovarian hyperstimulation syndrome (OHSS) and the potential to developgenital cancers; problems associated with extra corporeal methods that are used for 1VF-ET, GIFT and ZIFT, in which problems associated with laparoscopy, anesthesia, oocyteretrieval and laboratory procedures are identified; and complications of assistedreproductive pregnancies, such as spontaneous abortions, ectopic and heterotopicpregnancies, congenital malformations and multifetal pregnancies and the course anddelivery of such assisted reproductive pregnancies (Schenker and Ezra 1994:411).140problems. They conclude with the caveat that while “{M}any of us consider cost as animportant factor of assisted reproductive practice. We believe the main problem is notcost but the complications of this mode of treatment, which may result in permanentdamage or even death to patients who otherwise are healthy” (Schenker and Ezra1994:411-422).VI CONCLUSIONIn less than twenty years the “science of the impossible” has become the “ART ofthe possible”. What appears to the untutored outsider as a world of science fiction madereality, for the 1VF staff creating extra-uterine life is a routine daily experience. Theregimented protocols embody specific interpretations about what constitutes clinicalexpertise and rational practice. The latter are envisaged as neither arbitrary norexperimental Yet Gordon’s (1988) analysis of the arbitrariness of medicine points outthat there is a commonly held belief that the scientific endeavour is to develop increasingand better clinical science for medical practice, which assists the art of making medicaljudgment “more rational, explicit, quantitative and formal” (1988:258). So applyingscientific principles to patient therapy with the goal of maximizing success rates is theunitary focus of 1VF staff. In this way they see themselves as providing a clinicalservices, rather than doing biomedical science. The focus on the IVF results is thatnumber count - more fertilizations mean more pre-embryos, which imply more chances atimplantations, which ultimately translate into more “take home babies”. The attention isdeflected away from concern with investigation of the biological processes of infertilityand conception, which distinguishes the epideniiological and clinical research.141The ethos of the University of British Columbia 1VF programme embodies agenerally cautious, conventional and conservative approach to 1VF patient treatment,which it views as morally correct. The staff are well aware of the experimental nature ofsome of the more controversial and risky applications in common use in other centres andthe new categories of clientele they serve, who were previously barred from treatment.However, while many staff do not resist morally some of these treatment options, neitherdo they envisage a ready acceptance of them in their programme. The nursing coordinator voiced the general satisfactory consensus with the ethical, conventional natureofthe IVF programme in this way:I feel really dedicated to it and I know that this programme is veryconservative. When I go to these (international fertility) meetings, I reallyfeel like the country cousin, as far as what we offer here to couples. But inmany ways, it makes it a lot easier.In contrast to the recently emerging international medical discourse about thepotential iatrogenic effects of superovulatory drugs and other 1VF applications, there wasat the time of my ethnographic research a remarkable confidence in the drugs, which itwas reasoned had surely been tested properly in animals trials before being marketed onhumans. There was also a general lack of interest with the long-term consequences ofunneeded pre-embryos, The ramifications of IVF were considered as beyond the purviewof daily practice and as belonging in the remote political and regulatory realms of law andgovernment to rule on in light of CRCNRT’s recommendations.The University ofBritish Columbia IVF programme is not market-driven, althoughit has legitimate concerns about cost recovery. The production of supernumerary preembryos and their cryopreservation are justified as a provision of additional services toconsenting patients and as methods for maximizing the chances of not only creating manypre-embryos, from which the best can be selected for transfer, but also as a cost-effective142mechanism for facilitating natural cycle transfers of frozen pre-embryos, despite theminimal success rates. It appeared to me that little thought has been given to the socialconsequences of donating andJor selling pre-embryos to third parties, nor to researchprojects involving pre-embryos as infonnation bearing entities or for preimplantationdiagnosis and genetic manipulation. These applications have little relevance in the practiceofthe simple model of IVF, which facilitates individual customer service.Both the patient oriented staff in the clinics and the laboratory staff work towardsthe common goal ofproviding a much desired baby for the contracting couple. However,beyond the social organization of the TVF programme is a less obvious facet of the IVFprocess, which has little to do with human interaction. Despite the highly technicalnature of the 1VF processes, the creation of pre-embryos is a combination of technologytrying to replicate nature as well as nature-in-action. The issue at hand is yet anothervariation of the old nature/culture controversy. No matter how culture - in this case themedico-technical culture of IVF - manipulates social environments, the facts of biology,the genetic blueprints and genetically programmed responses of the human organismdictate the final outcome ofthe technology. Scientists as yet do not know why ovaries offemale fetuses store more oocytes than could ever be needed in a reproductive lifetime.But they do know how to technologically override nature to suppress, mimic and createan ovarian environment to produce many, not just one mature oocyte per month, readyfor insemination. At present, scientists know little about exactly how nature triggers theaction of syngamy and cleavage of the developing pre-embryo. This is a miracle, whichoccurs unaided by human intervention in the quiet of the laboratory, free of humanobservation. If fertilization does not occur, no triumphs of technology can intercede inthe action. Likewise the technology of embryo transfer facilitates deposition in the uterusof the gestational woman, but it cannot control the subsequent implantation into the143receptive uterine wall. This remains at the discretion of natural factors, which are stillpoorly understood, as attempts at rectifying recurrent pregnancy loss in normally fertilewomen conlirm.In reality, IVF is still an experimental technology which attempts to replicatepiecemeal every aspect of natural conception and so far has only solved some parts of thepuzzle. Similarly, genetic engineering programmes are experimenting on pre-embryos asready-made sources of genetic information. It is to the advantage of genetic engineersthat 1VF provides a limitless supply of otherwise surplus discarded embryonic material,which has been artificially created in a controlled and hermetically sterile laboratoryenvironment.144ChAPTER 5‘1iLI LEGAL DISCOuRSE: ‘IHE CASE FOR THE PRE-EMBRYOIn Canada, assisted procreative technologies are developing swiftly in a largelyunregulated legal vacuum. However, a number of committees and commissions have beenmandated in the last two decades to provide a legal framework based on guiding principlesrather than laws. Last in this long line is the Canadian Royal Commission on NewReproductive Technologies (hereinafter referred to as CRCNRT), whoserecommendations were bypassed by the federal government in July 1995. Instead itpresented an interim measure, calling for a moratorium against nine technologies, andindicated that legislative and regulatory restriction would eventually follow (Bryden1995:A5). This fell far short of the anticipated outlawing of specific technologies and theimmediate formation of a National Regulatory Commission on NRTs, which would strictlyregulate all the technologies.There have not been any legal cases brought before the Canadian courts as yet aboutthe status of pre-embiyos, however, a number of interesting cases have occurred in otherjurisdictions, which have relevance for Canadian cultural values. These court battlesdemonstrate some of the potential problems that may arise when pre-embryos areorphaned, require custody, or their ownership is challenged. They represent the challengeto a construction of the pre-embryo as a new social and legal category which is neitherproperty, nor person; and how to consider its alienations and transfers as gift orcommodity. In terms of the matrix of social relations surrounding the pre-embryo, it145poses complex issues of who has vested interests in and rights to its versatile disposition.The present state of legal understanding demonstrates the confusion surrounding fertilityclinic responsibilities and enforceable state controls.I CANADIAN VALUES AND GUIDING LEGAL PRINCIPLESOne of the major controversies surrounding new reproductive technologies, ingeneral, is whether or not and how much they should be subject to legal regulation.Usually, legal aspects relating to regulation of the use of NRTs in Canada are analyzedwithin a discourse of ethics, which examines those values and objectives that would befurthered through such regulation.1 The law usually lags behind the social dimensions ofbiomedical issues. Political scientist, Blank notes this in relation to NRTs:The cultural and institutional frameworks of society largely define theboundaries within which technological development proceeds. Prevailingvalues although open to pressure for change by technology, are resistant tomajor and rapid alterations. Established institutions, too, resist change andattempt to minimize alterations. Although not always capable ofmaintaining stability, they moderate changes. Societal priorities thereforealways reflect existing social values and structures. (Blank 1984:4)The present Canadian constitutional and legal regime provides a useful frameworkwithin which regulation ofNRTs might be carried out. In the opinion of the Canadian BarAssociation (hereafter referred to as CBA), legal principles and accepted social policy,1 CRCNRT also used an eight point ethic of care framework for its medical evidencebased report. These ethical principles included individual autonomy, equality, respect forhuman life and dignity, protection of the vulnerable, non-commercialization ofreproduction, appropriate use of resources, accountability, and balancing of individual andcollective interests (CRCNRT 1993:52-5 8).146which have been developed from existing legislation and jurisprudence, have served toguide the processual attempts in Canada to promote, protect and preserve entrenchedsocio-legal values. However, it cautions that the proliferation of “the use of reproductivetechnologies should be subject to review when fundamental social and legal, as opposed tomedical issues, arise” (CBA 1990:14). In its submission in November 1990 to theCRCNRT hearings in Vancouver, the general legal issues that it broadly identified as thesubject matter for regulation at that time werethe status of the child, parentage and birth registration, artificialreproductive technologies, medical records, agreements for the gestationand delivery of a child and the surrender of custody (“surrogacy”), researchand experimentation on human genetic material, and judicial intervention ingestation and childbirth (CBA 1990:4).CBA argued in favour of a sociological view of the individual as opposed tobiological reductionism because “{T}he fact of biological reproduction, particularly theuse ofnon-natural means of conception, should not be separated from the social aspects ofchildbirth, child rearing, and family relationships” (ibid: 15). Thus legal concerns aboutNRTs continue to focus on socially accepted ideas about the salience of “the family”,while still allowing for new forms of family to be incorporated under its ample penumbra.2Therefore the impetus has been to develop NRTs within a framework ofcontemporary societal values so as to diminish conflicts between those people mostdirectly affected by them, such as parents, children and reproductive caregivers, as well asthe broader implications for society in general. Furthermore, since it is women who bear2 This strategy is currently being implemented with legal recognition of the desire to beconsidered family and share spousal benefits in the case of long-term same sexrelationships. As yet these principles have not been applied to NRTs. An impendingchallenge in British Columbia reported in the Vancouver Sun exists over the controversialissues of access by lesbians to artificial insemination by donor (AID) (Wigod 1993a:A1).Another case has been reported in England (Lightfoot 1994:1).147the greater risk of such technologies, it is their interests and opinions, in particular, whichshould be recognized.Historically, legal principles have evolved through instruments such as theCanadian Charter ofRights and Freedoms,3the Canada Health Act and provincial andterritorial legislation. Together they have embraced a consensus which asserts legalprinciples, which preserve values of individual autonomy and human dignity. TheCanadian Bar Association (1990) was of the opinion that these principles should prevail,unless good reason for change was found. These principles have been applied to suchaspects ofNRTs as informed consent, access to technologies, rights to knowledge aboutaffiliation, presumption of paternity provisions, regulation over areas such as adoption,child custody, maintenance and human tissue gifts.II PERSON OR PROPERTY: PRECEDENT SETTING CASES IN TILEUNITED STATESIn contrast to the non-litigious Canadian climate ofnew reproductive technologies,several cases have occurred in the United States, which are helpfiul in developing anunderstanding about how the pre-embryo may be socially constructed as potential personor as potential property of some party with vested interest. While decisions were made inThe Canadian Charter of Rights and Freedoms is contained in Part 1 of TheConstitution Act, 1982, which is Schedule B of The Canada Act 1982 (United Kingdom.)1982 c. 11. Rebecca Cook’s research paper published in advance of the CRCNRT reportnotes that Canada as a founding member of the United Nations and a participant in thedevelopment of international human rights covenants has used the language of theseinternational instruments to shape the Charter. In effect the Charter acts as a bridgebetween its international obligations and its domestic laws (Cook 1991:1).148each case eventually, the convoluted court processes demonstrated the uncertainties thatarose about how to categorize the pre-embryo.(i) ReosIn the early days of IVF, a wealthy American couple were killed in a plane crash inBrazil, in June 1984. The Reos had been attending an IVF clinic in Melbourne and hadleft two frozen pre-embryos there. Problems about the limits of decision-making aboutreproductive issues and the rights of the unborn arose from this event. While theAustralian Wailer Commission, which had been appointed to consider such issues,suggested that the “orphaned” Reos pre-embryos be thawed but not implanted, theProvincial government of Victoria later voted that they should be implanted into one ofthe many volunteers (Gallagher 1987: 197). This did not happen.Inheritance and succession are issues that all societies attempt to regulate to ensuresocial stability. The Reos case is a good example of the complications that can ensuewhen inhentance patterns become muddied by creating pre-embryos, particularly in atransnational context.4 Legal confusion occurred because the Reos couple did not leave awill. Questions arose as to whether the frozen pre-embryos should be considered aspersons and therefore have rights to the large Reos inheritance. If a gestational surrogatewas implanted with the pre-embryos, could she make a subsequent claim to the estate onbehalf of the child and herself? Other heirs also existed, who also had a claim to theestate. The legislation proved to be so complicated and difficult to interpret that no actionwas taken until 1987, when under relevant California law, the court decided that theThe Report of the Law Reform Commission of Canada (1992) warned about thecomplexities of “procreative tourism”, which can occur when NRTs service provision areutilized andJor gametes/preembryos are produced, stored and br transferred acrossnational boundaries.149hiorphanedu pre-embryos had no rights to the estate and Mrs. Reos’ mother was found tobe the sole inheritor ofthe estate (Kimbrell 1993:92).(ii) Davis v. Davis, Kass v Kass and Jones v. YorkA number of cases have occurred in the U.S., which demonstrate furtherdifficulties of decision-making surrounding the pre-embryo. Each case challenged thefundamental question about the nature ofthe pre-embryo as property. Two cases involveda quarrel between the biological parents of frozen embryos as to who had the ultimatecontrol over their destiny. The other case involved a dispute between a couple and andIVF clinic, where their frozen embryos were stored.“In no case, however, has the status of the embryo been presented more clearlyand confused more completely than in the trial court’s opinion in Davis v Davis (1989)”(Clayton 1991:102) In 1988, Mary Sue and Junior Lewis Davis, after six unsuccessfulattempts with IVF, decided to try the new freezing programme offered by the FertilityCentre ofEast Tennessee. In this attempt, nine pre-embryos were retrieved and two wereunsuccessfully implanted. The remaining seven pre-embryos were frozen; but before theDavises could use the pre-embryos, Mr. Davis filed for divorce. A bitter and protractedcustody battle for the frozen pre-embryos ensued over the next four years.It was the lirst United States case to decide on custody, ownership and the legalstatus of frozen pre-embryos. The trial court in the first instance ruled that life begins atconception and incorrectly held that pre-embryos were morally equivalent to children andthat it was in their best interests that they should be transferred back into Mary Sue Davis.In awarding custody of the pre-embryos to Mary Sue, Judge Dale Young concluded thatthe pre-embryos were “human beings existing as embryos” (quoted in Raymond 1993:61).However, Raymond points out that the judge reached the right conclusion for the wrong150reason, because using this logic, every pre-embryo created through 1VF would have to beimplanted in the egg donor, who would serve in Margaret Atwood’s (1985) term like a“uterine hostess”. In Mary Sue’s case then, she could be liable, although highly unlikely,to bear seven children from the seven available pre-embryos. Accepting the challenge thatwomen’s efforts to control their procreation and pregnancy behaviour would bejeopardized by this ruling, the Tennessee Appeals Court in 1990 overturned the ruling.The appellate court looked at the procreative liberties ofboth parents, and stated that thehusband had a “constitutional right not to beget a child where no pregnancy had takenplace” (Davis v Davis, No. 180 Tenn. Ct. App., Sept. 13 1990:4). It was reasoned thatMr. Davis thereby had the right not to procreate, even though he had consented to create5the pre-embryos m the first place with the intention ofbecoming a parent. Champion of“procreative liberties” lawyer and expert witness, John Robertson, argued in this case,that it would be a greater burden for Junior Davis to be encumbered with unwantedfatherhood, than for his ex-wife to undergo yet more invasive 1VF cycles. Raymondmakes a strong case that these allegedly equal rights to parenthood decisions are falseequivalents.The Supreme Court of Tennessee in June 1992, in criticizing the appeals court forviewing the pre-embryos as property, took the middle ground. “We conclude that preAn interesting reversal concerning a potential father’s procreative liberty occurred whena former boyfliend, Jean Guy Tremblay, of a Quebec woman Chantal Daigle, argued thathis self-interest in becoming a father should take precedence over Daigle’s right to have atherapeutic abortion. In the emergency session in August 1989, the Canadian SupremeCourt’s unanimous decision quashed the injunction a Quebec court had granted Tremblayto prevent Daigle having an abortion. To ensure that no woman ever had to endure asimilar ordeal to Daigle’s, the court said “We have been unable to find a single decision inQuebec or elsewhere which would support the allegations of “father’s rights” necessary tosupport this injunction... There is nothing in the Civil Code or in any legislation in Quebec,which could be used to support the argument. This lack of legal basis is fatal to theargument about “father’s rights” (Makin l989:A5).151embryos are not, strictly speaking either persons or property, but occupy an interimcategory that entitles them to special respect because of their potential for human life”(Davis v. Davis 1992:2 1 cited in Kimbrell 1993:97). The resolution in which the husbandwas awarded control of the frozen embryos resulted in the final destruction of the preembryos at Junior’s request. Mary Sue and Junior would have to start over again withnew partners using IVF if they wanted to have children. There was disappointment thatthe case failed to answer the question ofwhether to consider the pre-embryo as person orproperty (Crockin 1993:10). If they are property, then who owns them - clinics, donatingparents or recipient parents?In a current case in Nassau County, Kass v. Kass (1995), the New York SupremeCourt reached a different conclusion from Davis v. Davis. In Kass, the judge held that awoman had the right to control the future outcome of the pre-embryos she created withher husband. When she petitioned for divorce, the only contested issue in the divorce wasthe possession of the five frozen embryos, which she wished to gestate and her husbandwished to be donated for research (Jaeger 1995:16). So in this case, the wife wasentrusted with the right to control their destiny, thereby rejecting the rights of thedivorcing husband on the grounds that a man, whether manied or not, cannot control theconception nor continuance of a pregnancy. The judgment, in noting that a woman hasthe sole right to use contraceptives and to terminate a pregnancy, stated “The fact is thatin vivo husband’s rights and control over the procreative process ends with ejaculation.. .Itmatters little whether the ovum/sperm union takes place in the private darkness of afallopian tube or the public glare of a petri dish” (ibid). The court’s argument in this caseis consistent with feminist beliefs that women should have ultimate control over theirreproductive decisions.152Unlike the middle position decided in Davis, that embryos are neither persons norproperty, but nevertheless deserving of special respect, another United States’ case, ified inVirginia, York v Jones, decided in 1989, that pre-embryos should be treated ascommodities. This case was cited as an important precedent by the appeals court thatdecided Davis. The dispute concerned a conflict between a couple and a clinic over theownership and control of the couple’s frozen pre-embryos stored at the prestigious JonesInstitute in Norfolk, Virginia. The Institute had refused to allow Risa and Stephen York,who had contracted the clinic to freeze and store their pre-embryos, to transfer them to aCalifornia depository in Good Samaritan Hospital, Los Angeles. There Risa York wouldbe implanted with those pre-embryos under the supervision of Dr. Richard Mans, whochallenged his competitors in Norfolk with the taunt, “When a physician starts owningembryos and making decisions for his patients, there’ll be no stopping anyone who hasanything to do with pregnancy from getting involved” (quoted in Raymond 1993:6 1). Thefederal court ofVirginia ruled that the frozen pre-embryos, which they referred to as “prezygotes” were the “property” of the couple and the Jones clinic only held those preembryos in bailment (trust) for the couple pending their later use. Neither the welfare ofthe pre-embryos during their transportation across the continent, nor the interests of theclinic in ensuring their secure preservation were considered to have any legal relevance(Kimbrell 1993:97). Essentially they were considered the property of the gameteproducers to do with as they chose.These cases represent early attempts in the United States to define the legal statusof pre-embryos, and suggest that they may well join sperm and ova as full-fledgedcommodities. Lawyer and policy director of the Foundation on Economic Trends inWashington, D.C., Andrew Kimbrefi, has argued the analogy between commodi1ring fetalparts and pre-embryos. “(W)hile Congress has forbidden the sale of fetal parts, it is153unlikely that they will do the same for embryos, due in part to the view that so-called preembryos or pre-zygotes are merely “masses of cells” (Kimbrell 1988:98). However, heenvisages a time in the not distant future when “as reprotech advances, we will soon seeour first headlines announcing the first sale of an embryo and perhaps even the firstpatenting of a human embryo for research use” (ibid).(iii) Oocyte and Embryo DonationAs the case law and legislation develops, the destiny of gametes and embryos willprobably become subject to tighter legal controls as circulating commodities. UnitedStates legislation has recently been drafted concerning ova and embryo donation, whichpoint to a growing acceptance of and market in both gametes and fertilized ova. Thissuggests an elision of the two entities as similar in nature for legal definition. To date thefocus has been placed on using family law to protect the resultant progeny of suchrudimentary tissues, rather than a concern for research uses or the practice of marketinghuman tissue. For as long as the social and legal purview is on the consequences forfamily of assisted conceptions, there will be little concern about the pre-embryo as areified entity, which can be used to assist important medical research.Recently, two American states, Florida and Texas, have drafted and lobbied foregg and embryo donation. Oklahoma passed an egg donation law in 1990. Both stateshave given legal recognition to children born of egg and pre-embryo donation. In bothtest cases the recipient gestational woman and her husband are considered the legitimateparents of the child, in the same way as donor insemination (Crockin 1993:10). Tn thesecases the best interest of the child is the pre-eniinent consideration. Even in cases whereparental reality is more complicated than the one mother, one father biological model,courts have favored functional parent-child bonds, such as the Thomas S. v Robin Y., a154New York Family Court case, where a lesbian relationship overrode the request forunsupervised visitation with the child’s biological father (ibid: 11).(iv) Fetal Tissue Commerce and ResearchAlthough the sale of fetal parts in the United States has been prohibited, thissituation may be changing as a result of federal permission being granted to carry out aclinical trial to transplant fetal tissue for treatment of Parkinson’s disease. A $4.5 millionresearch project in the field of neural fetal tissue transplantation for treatment of fortyParkinson’s disease patients has recently been authorized. The American research grouphad already performed the first transplant in 1988, despite a national moratorium on thistype of research (Weber 1994:46). Likewise, in 1988, Canadian medical researchers atDaihousie University applied for ethical review to perform the first Canadian transplant ofneural fetal tissue for treatment of Parkinson’s disease. However, a similar ban as in theUnited States delayed this research trial until 1992 (ibid). Fetal transplants had alreadybeen tried in Mexico, the United Kingdom and Sweden.In Canada, considerable ethical debate has been raised by this innovation. Oneconcern is that perhaps pre-embryos in the future could be gestated in vitro beyond thepresent seventeen day restriction to a point where differentiated tissues would besufficiently advanced for use in research. If a culture medium can be perfected, it mayeven become possible to grow pre-embryos for the explicit purpose of providing tissueand organs for human transplantation purposes. The benefit here would be that anonymityof donor could be respected if pre-embryos came from a reserve pre-embryo bank. AbbyAnn Lynch, director of the Canadian Westminster Institute for Ethics, in calling for strictcriteria, has stated: “I think I would be concerned about the source (of the fetuses). Youmust absolutely guarantee that you are not growing embryos in vitro for the purpose of155being able to take its brain for transplant” (Povenko 1988:A5 and A8). In a recent studysurveying Canadian doctors’ attitudes towards transplantation of electively aborted humanfetal tissue, although they were not asked about use of pre-embryoaic tissue, they didconsider fetal tissue donation often to be analogous with organ donation (Mullen,Williams and Lowy 1994).ifi CREATING A CANADIAN LEGAL FRAMEWORK FOR REGuLATINGPRE-EMBRYOSUnlike the free enterprise, private health care system in the United States, as yetthere have not been any controversial law suits in Canada relating to pre-embryos. In thissense, the Canadian legal system has had more time to consider how pre-embryos, createdthrough IVF, should be socially and legally classified, although the outcome still remainsunclear. The Canadian process has evolved through a series of committees andcommissions, which attend to the problems that have arisen in other jurisdictions.Different types of law can be brought to bear in discussing regulation of the humanpre-embryo. These include property law, laws pertaining to persons, family law, patentlaw and contract law. There are also many forms of regulation and levels of decision-making about health related issues, which have relevance for NRTs in Canada. Varyingdegrees of control may be exerted by the different levels of government, by professionalmedical associations, hospital boards and health care professionals.(i) The Context of Canadian Health RegulationConstitutionally, health issues cannot be controlled by a single level ofgovernment. The federal government retains the ability to regulate, which is based both156on its interest in national health and welfare and within its national jurisdiction to enforcethe criminal law and control budgetary allocation of scarce health funds.The Canada Health Act behaves as the cornerstone of the health care system andits framework is intended to provide a broad social and health security net for allCanadians. The system is based on five criteria, comprehensiveness, accessibility,universality, portability and public administration.6 Unfortunately, despite the ideals ofthe Act, medical services are not implemented in a uniform manner across Canada, butaccording to provincial discretion.7 Provincial governments are responsible for regulatingthose matters related to health, such as control over hospitals and over health careworkers, hospital administrators and professional medical associations within theirjurisdictions. Provincial government funding of health is based on social and politicalrather than medical criteria. How this fits within the framework of the Canada Health Actor the Canadian Charter ofRights andFreedoms is as yet undefined.The power of provincial governments to regulate health services has beenidiosyncratic in defining what constitutes the practice of medicine. This has beendemonstrated in two instances in the area of reproductive issues where certainreproductive technologies have been considered not umedically required”. The CanadianBar Association (CBA 1990) argued in their brief to the CRCNRT that “(T)he new6 Comprehensiveness ensures a minimal level of insured health services, which aremandated at the national level and cannot be interfered with at the provincial level.Accessibility ensures reasonable access and uniform availability unimpeded by financial,geographic or regulatory barriers. Universality ensures that all Canadians have access toreasonable levels ofhealth services, regardless ofwho they are and where they live or theirfinancial status. For a comprehensive examination of the Canada Health Act, see SheilaIaftin (1989).In Canada, there is no uniform definition of the practice of medicine. Thereforeprovinces interpret differentially the Medical Practitioners Act of 1979, which broadlydefines the composition ofmedical practices and the Medical Act of 1989, which specifiesthe actual service and the profession ofthe person performing the service (CBA 1990:32).157artificial technologies constitute remedies and treatment for infertility, a human conditionwhich may result from disease and which may be regarded as a defect. Application ofthese technologies therefore probably constitutes the practice of medicine in law” (CBA1990:32).In both the cases cited by CBA, women’s reproductive autonomy has beencompromised. In 1985, the Alberta government unilaterally de-insured surgicalsterilizations, contraceptive counseling and the insertion of intra-uterine devices (IIJDs),except in specific circumstances. Funding was based on social and political agendas,rather than medical necessity (CBA 1990:33). In British Columbia, although IVF serviceswere not yet available in the province, they were automatically deemed as not “medicallyrequired” and therefore ineligible for insurance under the term of the Medical ServicesAct, R.S.B.C. 1979, c.255, s.1.CBA further points out that “such legislative action cannot, however, beconsidered conclusive since it ignores the link between infertility and disease or defect andthe invasiveness of the procedure” (CBA 1990:32). Technically IVF can only beperformed by an appropriately licensed surgeon in an appropriately licensed facility. Thesocio-economic effect has been to make those services available only to those who canafford it, in flagrant contravention ofthe principles ofthe Canada Health Act.(ii) Canadian Commissions and Committees for Regulating New ReproductiveTechnologies (NRTs)The mainstream legal discourse about NRTs in Canada has developed during the1980s from a plethora of influential commissions, reports and surveys. These precededthe piece de resistance, the recent report Proceed with Care, published in two volumes bythe Canadian Royal Commission on New Reproductive Technologies (1993). In general,158these documents have reiterated the importance of national standardization andmonitoring, national approval of research and accreditation and licensing of research andtreatment facilities. This legal discourse has attempted to co-ordinate andcompartmentalize thinking about an otherwise amorphous, uncoordinated series ofreproductive practices, which are developing largely unchallenged and uncontested.Beginning in the early 1980s, Canadian legal investigations have included thereport of the Advisory Committee on the Storage and Utilization ofHuman Sperm to theMinister of National Health and Welfare, Storage and Utilization of Human Sperm(1981), the Ontario Law Reform Commission (hereinafter referred to as OLRC) Reporton Human Artficial Reproduction andRelatedMatters in 1985; The Working Committeeof the Quebec Department of Health and Social Services, Rapport du comite du travailsur les nouvelles technologies de reproduction in 1988. In the same year the Bar ofQuebec published Rapport du comite sur les nouvelles technologies de reproduction. Ayear later, following the Quebec Department of Health and Social Service Report, asupervisory framework in Quebec for embryo research was proposed “that would requireofficial approval for current projects and prohibit trade in embryos or the creation ofhuman embryos solely for research” (CRCNRT 1993:657). However, to date nolegislation in Quebec has been presented to date.In 1987, the Medical Research Council of Canada in Ottawa published Guidelineson Research Involving Human Subjects, which upheld the fourteen to seventeen day limiton maintaining pre-embryos for “non-therapeutic” research in the in vitro state andrecommended that embryo research only be conducted to improve knowledge and thetreatment of infertility. It also reinforced the need for donor consent and for local ethicsboard approval for research on pre-embryos, and the unacceptability of transferring preembryos that had been subject to experiment, as well as limitations on certain kinds of159research, such as cloning. Two years later on the other side of the country, in BritishColumbia, in 1989, the Reproductive Task Force of the British Columbia Branch of theCanadian Bar Association released Reproductive Technologies in 1989.AJso in that year, the Law Reform Commission of Canada (hereafter referred to asLRCC), before it was disbanded, had published two working papers, Crimes against theFetus 8 and Biomedical Experimentation Involving Human Subjects. It had been called inan attempt to advance the public debate and to complete its trilogy studies in the area ofmedical law and procreation. The conceptual nature of gametes and embryos is an issuewith which Canadian legal scholars have also wrestled for nearly a decade. LRCC hadbeen established to examine issues of particular concern such as “delinition of the family;the filiation of children born as a result of medically assisted procreation, thecommercialization of procreation, the human body and its products and substances; andthe legal status of gametes and embryos” (LRCC 1992:1). It had been called in order todevelop a consistent national social policy on NRTs, because the reports of the OntarioLaw Reform Commission in 1985 and the Barreau du Quebec in 1988 had expresseddiametrically opposed views on a number of fundamental aspects of the issue. The LRCCrecognized that the ambiguity surrounding the status of the pre-embiyogives rise to moral and social objections that have appeared with the creationand freezing of surplus embryos. What is at issue here is one’s image of theembryo. Is it a thing, a person, a potential person, or something else?.. .Wemight ask ourselves in more general terms whether we wish to treat gametesand/or embryos differently from other parts of the body or alienable cells, or8 In Working Paper 58, Crimes against the Fetus, the Commission’s majorrecommendation is that the fetus merits criminal law protection, which the Criminal Codepresently does not achieve adequately. A new chapter would be included in the Code anda new offence of “foetal destruction or harm would be incorporated to make it a crime topurposely, recklessly or negligently cause death or serious harm to a foetus” (The LawyersWeekly. March 17 1989).160in other words, create a special regime suited to the specific nature ofgametes and embryos” (LRCC 1992;5 1).In general, all the preceding reports reflected the substance of the MedicalResearch Council guidelines concerning embryo research. Each recommended thatsystematic regulation and monitoring of research be carried out in order to ensure theguidelines were being applied consistently (CRCNRT 1993:658). Similarrecommendations have been made by the two Canadian Professional Associationsinvolved in embryo research, the Canadian Fertility and Andrology Society and the Societyof Obstetricians and Gynaecologists of Canada, in their Combined Ethics Committeereport Ethical Considerations of the New Reproductive Technologies (1990). In addition,three infertility surveys have also been conducted in Canada; the Canadian Fertility Survey(1984), The General Social Survey (1990) and the Ontario Health Survey (1990).Controversy had surrounded the delay in publication of the completed two volumeOLRC Project report, Human ArtfIcial Reproduction and Related Matters in 1985.Legal scholar, Bernard Dickens (1992), who had worked on the report, discusses theOLRC Project in terms of the three general orientations proposed to develop legalresponses to artificial reproduction and surrogate motherhood. One positionaccommodated individual’s private ordering of their reproductive behaviours. Thisincluded donation, selling and receipt of reproductive services. Another approachaccommodated several levels of regulation to enhance individual reproductive preference,while a third approach prohibited or frustrated these individual options. Finally, theCommission “rejected both extremes of the private ordering and the prohibitory approachin favour of a hybrid approach. Different techniques of assisted reproduction were foundto warrant different legal approaches” (Dickens 1992:62). Because it was released after161the British Warnock report,9 it led several critics to conclude that OLRC Commissionershad simply adopted the Warnock approach. According to Dickens (1992:47) this wasuntrue. However, there was congruence between Warnock and OLRC recommendationsin the areas of gamete and embryo donation, IVF and related techniques. The OLRC diddepart from Warnock and most other reports on NRTs in its recommendation onsurrogacy.Guided by the confiLsing developments that obfuscated the legal decision-makingconcerning the Scarborough, Ontario surrogate motherhood case in 1982, and the reportof a healthy baby being born by pre-embryo transplantation in California in January 1983,the OLRC Project set the following terms ofreference:to inquire into and to consider the legal issues’, including the ‘legal status’and ‘legal rights’ of children produced by artificial reproduction, the ‘legalrights’ and ‘legal duties’ of biological parents and their spouses and ofmedical practitioners and other personnel involved, the ‘legal procedures’for establishing and recognizing parentage of children, the applicability ofcustody and adoption laws and the bearing ofmedical and related evidenceon legal issues” (Dickens 1992:52-53).Not surprisingly in a Canadian political climate where children’s rights werebeginning to emerge, the focus of the Project was not on infertility per se or the concernsof those with fertility impairment, but on protecting “the best interests of children” bornthrough artificial means of reproduction. At this time the discourse of infertiJity promotedboth by the medical establishment and the newly emerging special interest groupsThe Wamock Commission, chaired by philosopher Dame Mary Warnock had beencalled by the British Government in 1984. Its recommendations were not translated intolaw until 1991 when the British Fertilization andEmbiyology Act was passed after muchcontroversial public and political debate. In February 1990, the House of Lords decided234 to 80 to allow research to continue on human embryos for 14 days after fertilizationunder the control of a new statutory licensing authority (Wintour 1990:3).162concerning infertility awareness about the plight of infertile people was still largelyunheard. The terms of reference thus restricted the Commissioners’ approaches.Otherwise, emphasis might equally well have been put on the best interest of couples, orprotection ofwomen’s interests, or the concerns of disabled people. What was noticeablyabsent at that time was the concerns that would be raised later, as occurred in Britain overthe political debacle about embryo research, about reconciling the emerging status of thepre-embryo. The novel ways in which pre-embryos could be used were only justbeginning to reach the media and public purview, and the problems associated with themwere still largely unenvisaged.The OLRC had recognized in 1984 the challenge of introducing a women’s orfeminist perspective in relation to reproductive technologies. However, while feministresearch at that time was just entering this area, a wealth of feminist writings wasundertaken later in response to the Report (Dickens 1992:57). This was the beginning ofa decade of feminist response to all aspects of NRTs and its related commigsions andreports.W TILE CANADIAN ROYAL COMMISSION ON NEW REPRODUCTiVETECHNOLOGIES (CRCNRT)Since the early 1990s there has been limited attention given to legal regulation ofpre-embryos and since the release of the Commission report in November 1993, there has163been a noticeable absence of interest. What is going on is happening behind closedgovernment doors and inaccessible to public comment)0In November 1990, the Canadian Bar Association submitted a report to theCanadian Royal Commission on New Reproductive Technologies (CRCNRT) at thepublic hearings in Vancouver. The impetus for this submission came from the findings ofthe Special Task Force Committee on Reproductive Technology, which had beenappointed by the British Columbia Branch of the Canadian Bar Association in May 1988.This task force was made up of Vancouver physicians and lawyers. The members werelawyers Janice Dillon (chair), Georges Goyer, Karen Nordlinger Q.C. and Professor LyonSmith, as well as paediatrician Dr. Sydney Segal and the medical director of the Universityof British Columbia TVF programme Dr. Christo Zouves. The Committees objective atthat time was to ascertain the scope of the practice of artificial reproduction and to reviewthe legal and ethical issues and problems arising from such techniques.More recently, Bernard Dickens has produced the research volume Legal Issues inEmbtyo and Fetal Tissue Research and Therapy for the CRCNRT. It was published in1991 in advance of the final report of the CRCNRT, in order to assist people working inthe field of reproductive health and NRTs, as well as to inform the public. It was anattempt to review some of the problems that might arise from the ability to producesupernumerary embryo. Dickens analysis is likely the most concise, comprehensive reviewin Canada of the probable difficulties and legal resolutions, which may result from use ofpre-embryos beyond its simple application for the gamete producers, who want tobiologically create their own children.10 A press release in July 1994 stated that the federal government was about to announcean interim management scheme on how to deal with NRTs, such as commercial and noncommercial surrogacy (Yeager 1995:A4).164He examines four legal issues in his report. Firstly, he considers issues of liability,including “wrongfiul life suits, in relation to research designed to render individual preembryos more easily implanted. Secondly, he examines the right of gamete donors toapprove research on pre-embryos. Thirdly and fourthly, he discusses the broadercirculatory issues related to the use ofhuman tissue from both pre-embryos and fetuses fordonation within families and as marketplace commodities, with monetary value.(i) Damaged Pre-embryos and Wrongful Life SuitsWhat would be the legal implications if wrongful life suits were brought overdamaged pre-embryos, which could result in a child being born with a serious impairment?Dickens infers that “it is improbable, however, that criminal liability would arise for grossnegligence resulting in the birth of an impaired child, unless that same child could havebeen born unimpaired” (1991:vii). Since genetic surgery on pre-embryos would onlyoccur in order to correct an already “at risk” pre-embryo of some identffied geneticdisorder, it is unlikely that genetic surgeons would be held accountable. But what wouldbe the situation if a couple, who had frozen embryos in good condition subsequently had achild with a disability that could be traced to the freezing process? Given this situation,what would the chances of IVF clinics absolving themselves of responsibility for freezingpre-embryos, when so little is known about the long-term consequences? As yet no suchlegal cases have been reported in any jurisdiction.The closest analogy might be a recent ‘wrongful life’ suit that has been broughtbefore the Supreme Court of British Columbia against a physician, who did not fullyinform her pregnant patient of all the possible dangers, when she contracted chicken poxin the twelfth week of her pregnancy. Subsequently a child, now seven years old, was165born with severe abnormalities, requiring twenty-four hour attention (StiJi 1994:B8). Theparents have sued for damages to offset the expenses of caring for this child.(ii) A Regulatory AgencySecondly, Dickens asks how regulation of research on pre-embryos could best beenacted. He maintains that the pre-embryo, embryo and fetal research and therapy wouldprobably be better accommodated legally not by legislative permissions and prohibitions,but by a regulatory agency. This is essentially the conclusion reached in the BritishFertilization and Embryology Act (1991). As English anthropologist Cris Shore pointsout in his analysis of the British debates, this Act resulted from “a bitter and protractedbattle over the legality of embryo research in Britain” (Shore 1992:295). Opponents ofthe bill had been quoted as saying “Parliament’s decision signaled the “collapse of moralconsensus” in Britain and a step towards “societys self-destruction” (ibid). In particular,Dr. Robert Winston’s Hammersmith Hospital team in London had been severely criticizedfor undertaking new research on screening pre-embryos for male genetic disease byidentil3’ing the sex of the embryo less than three days after fertilization (Hall 1990:11). Inthis case only female embryos would be transferred to the gestational woman, thuseliminating male carriers ofthe defective gene.Dickens advocates following the British precedent in Warnock, in calling for thelicensing of particular projects and research centres to be undertaken by a NationalRegulatory Commission. In this way the thorny issue of approval of research on preembryos could be uniformly addressed, with respect to their deliberate sacrifice for thesake of knowledge that would benefit future pre-embryos, which could develop intoembryos in utero and fetuses and be born unimpaired.166The report of the CRCNRT concurs with Dickens’ findings. Based on its ethicaland evidence-based medical review, it concludes that “decisively, timely, andcomprehensive national action is required with respect to the regulation of newreproductive technologies” (CRCNRT 1993:107). This would be achieved through anindependent national body, responsible for overseeing and controlling the developmentand application of technologies, both from research and practice perspectives. Six subcommittees would be established to assume each of the following functions in specificareas:setting and enforcing national standards and guidelines, standardizing datacollection and analysis, licensing clinics and practitioners, monitoringresearch and services, and providing information and advice togovernments regarding policy, legislation and regulation” (ibid: 110).In essence, these controls are similar to those recommended by the BritishWamock Commission report, published in 1984 and administered through a system oflicensing which replaced the Voluntary Licensing Authority)1 In Canada, the BairdCommission’s report, at a cost to the taxpayers of $28 million, also suggested that aNational Regulatory Commissioncould be established and put into operation within a relatively short timeframe given the urgency of action deal with these issues while there isstill time to contain and control current practices and future developments”(ibid: 112-113).Although the report noted a trend in recent federal policy away from thecommission model as a choice of the regulatory instrument, Commissioners felt the costswould be warranted (ibid:114). By early 1995, there was still no evidence of a National11 . . .Following the Warnock Report (1984), the Voluntary Licensmg Authonty changed itsname to the Interim Licensing Authority under the auspices of the medical profession(CRCNRT 1993:65 1-652).167Regulatory Commission being instituted and a generalized cynicism about the likelihood ofthere being any funding to undertake such an initiative has been expressed by peopleinterested in the Report, including Dr. Baird. Given the spirited debate in England, priorto the enactment of the British Fertilization andEmbryology Bill, it will not be surprisingif a better informed Canadian public does not lodge a similar debacle in the future.(m) Donating and SellingThe third and fourth legal issues examined by Dickens concerned the use ofhumantissue from pre-embryos and fetuses for subsequent use as a donation within a family or asa market commodity. How could the law come to terms with pre-embryo, as well asoocyte donation and their potential to become circulating commodities in an expandingreproductive tissue market?These issues could possibly apply to pre-embryos if, or more probably when, thetechnology becomes available to culture pre-embryos in vitro beyond fourteen days.Dickens raises concerns that women’s interests could be severely compromised bycoercion to either undergo superovulation and IVF or to accept the timing and techniquesof induced abortion, or to agree to terminate a wanted pregnancy, in order to best salvageembryonic or fetal tissue. As noted elsewhere there are more scenarios developing, wherewomen are specifically creating pre-embryos for the express purpose of checking theembryos for genetic problems. Preimplantation diagnosis (see glossary) of pre-embryos isan earlier and for some participants morally less odious version of prenatal tests, such asamniocentesis or chorionic villus sampling. These tests all in various ways determine if afetus has some identifiable genetic disorder. In each screening method, if the test is168upositiveU•l2 either the embryo can be discarded or the fetus can be aborted, puttingenormous pressure on women to make the bright” (or perhaps “wrong”) decision.Dickens notes that legislation might be warranted in some ethically objectionablecases where there would be a need to separate decisions to abort from decisions todesignate the human tissue for known recipients. For example, a woman agreeing toconceive, gestate, then abort an embryo or fetus for an elderly parent with Parkinson’sdisease or a dependent child in need of an organ transplant. Recently, a Canadian womanundertook a pregnancy, followed by a therapeutic abortion, in order to use the bonemarrow from her aborted fetus for a daughter who was in desperate need of a bonemarrow transplant to treat her leukemia. The report of the CRCNRT has absolved itseifof further comment on this complex subject by recommending Medical Research Councilfunding of fetal tissue research in order to relieve two concerns, supporting “potentiallylife-saving research, thile also providing, thorough accountability for the use of publicfunds, a mechanism to monitor and regulate the ethical use of fetal tissue” (CRCNRT1993:1005).V LEARNING FROM TILE PAST: GUARDING AGAINST TILE FUTURECanada has an unenviable record of laws whereby the state has exerted controlsover who and how Canadians should procreate. The genocidal underpinnings of theselaws was to ensure that future generations of certain categories of people should beeliminated. These regulations exist as a cautionary message of the most recent eugenic12 Rapp notes the paradox of the term used by genetic counselors to refer to a “positivefamily history”, which it is anything but that, because “it refers to presence of a serious,genetically transmissible condition” (Rapp 1994:7).169thrust which promises to eradicate certain categories of people from the gene poolforever. This initiative is associated with prenatal and genetic screening technologies. Atthe end of the twentieth century, which was heralded in with “germ theory” and “racialhygiene” cleansing programmes, the harbinger of the next century is “genetic theory” and anew form of quality control, “good/bad genes”. The pre-embryo serves as the “alreadymade” but unimplanted messenger of some of the sex-linked genetically transmissiblediseases that have been identified on the human genome. In cases where affected couplesdo not wish to abort an “affected” fetus, that is the fetus of the wrong sex, most usuallymale, the screening can be completed on the extra uterine embryo. It can then more easilybe discarded if necessary. In the future it may be possible to perform genetic surgery onpre-embryos to correct genes. More likely pre-embryos will serve as knowledge bearingsources about major diseases, like cancer, which have so far alluded scientific rectification.(i) The Eugenics HeritageThere was an active Canadian participation in the Eugenics Movement of the earlytwentieth century)3 which led to the legalized sterilization of many institutionalized,Metis and First Nations women. Eugenic policies had been initiated in New York by theEugenics Record Office, which resulted in two legislative outcomes; a compulsorysterilization law and the Immigration Restriction Act of 1924. By 1935, about 20,000people had been forcibly sterilized, more than half ofwhomwere Californians. Most oftenthese people were classified as “feeble minded, degenerates, sexual perverts, druggies anddrunkards” (Hubbard 1988:228).13 The Eugenics Movement of the early 1900s grew out of the assumptions of anEnglishman, Francis Galton concerning improving human stock through positive andnegative eugenics.170By 1937, twenty eight states had adopted Eugenic Sterilization laws aimed atpeople with epilepsy, mental retardation, mental illness and other kinds of disabilities(Saxton 1988:2 19). In Germany, the euphemistically labeled racial hygiene programmebecame seen as a public health initiative, so that by the beginning of the Second WorldWar between 300,000 and 400,000 people had been sterilized (Hubbard 1988:229). Thismovement was to reach its heinous culmination in the Nazi extermination of gypsies, thementally retarded and European Jews.A recent summary of early Canadian eugenic policies in Report 42: Genetics inCanadian Health Care (1991) notes that only two provinces in Canada passed The SexualSterilization Act. These provinces were Alberta in 1928 and British Columbia in 1933.Although Ontario did not pass legislation in spite of a bill (1912) and therecommendations of two royal commissions (1929 and 1938), sterilization on the mentallyretarded continued to be performed.Although both men and women were sterilized, the majority were likely women,who could be sterilized by a number of gynaecological procedures, which could alsoeliminate menses, which was an inconvenient hygienic problem for the institutionalmanagement of some retarded women. Mitchinson (1992) and McLaren and MeLaren(1986) record how gynaecological surgery was routinely performed on women admittedto mental asylums in Ontario and British Columbia, respectively, at the turn of century.Incredibly, this legislation was to remain in force for almost half a century, until 1972.During that time 2,822 cases of institutionalized mentally ill persons were approved forsterilization in Alberta. Twenty-five percent of these cases were Indians and Metis. Theoriginal act had required patient consent, but this restriction was removed in 1937. Thenumbers of persons sterilized in British Columbia who were “likely to beget or bear171children who would have a tendency to serious mental disease ofmental deficiency” werenot recorded, but were believed to be in the hundreds (quoted in Privacy Act 1992:35-36).(ii) Judicial Interventions: Maternal/Fetal DisjuncturesTo date judicial interventions have been restricted to either individual controls onaccess to workplaces or regulation of pregnancies. The increased incidence of judicialintervention into pregnancy and childbirth may be attributed partially to the recentdevelopment of technologies that enable visualization and monitoring of the fetus. Butmore seriously these interventions provide a window through which legal controls can beexerted over women’s reproductive behaviour during pregnancy and birth. In this way awoman may be forced to conform to socially accepted behaviours for the sake ofhe fetus,which sets up an uneasy disjuncture between a woman and her fetus.Since the 1980s, there have been a wave of legal cases focused specifically onregulating certain identified groups ofwomen during their pregnancies and births. In thename of promoting better reproductive health care, maternal health policies have focusedon ensuring healthy pregnancies and robust children. Some women, who have beenlabeled “deviant” because of their non-compliant health behaviours have been subject to avariety of legal sanctions.In May 1988, a special Task Force on Reproductive Technology, made up ofdoctors and lawyers, appointed by the British Columbia Branch of the Canadian BarAssociation, appended a study paper on Juridical Intervention in Gestation andChildbirth to their report on ethical and legal issues of the practice and problems ofartificial reproductive technologies and the problems arising therefrom. It made clearrecommendations regarding the oppositional nature of the fetus and the mother, whichhave arisen largely out of a growing societal concern with fetal rights. It sought a position172that mediates between a woman’s right to be secure from judicial intervention in herpregnancy and the right of the fetus to be protected from undue harm. This position wasbased on cases that had come before the courts in Canada and the United States. It dealtwith court-ordered interventions at the time ofbirth by Caesarian section, other cases thatregulated maternal behaviour and still others that dealt with incarceration or criminalcharges against pregnant women.’4Most of the judicial interventions in Canada have involved child welfare law. Thecase known as Baby R 15 is the lirst and only case of an apprehension of a fetus, whichhas come before the Canadian courts. An apprehension was permitted by theSuperintendent of Child Welfare prior to the mother’s agreement under coercion to aCaesarian Section. When the proactive legal feminist group, Legal Education and ActionFund’s (LEAF) sought intervenor status in the mother’s appeal of the resulting wardship,LEAF successfully argued that the relevant legislation concerned only born children. Sucha basic interference in the woman’s right to liberty and security could not be made wherethere was no legal authority to do so. In the United States legislative protection has beenless effective.16Canadian feminist lawyer, Patricia King (1989:395-399) has discussed what moralobligation, if any, a pregnant woman owes her fetus in relation to pregnancy behaviour.1714 . . . . .For a synopsis of Canadian cases of jundical mtervention see the Baird Reportf(RCNRT 1993:952-953). See Patricia Williams (1990:91-92).Family and Child Services Act and Baby Boy Roininen, no. 876215, 8 September 1987ov. Ct. B.C. unreported.A distressing case in the United States occurred in 1987, when the District of ColumbiaCourt of Appeal, Washington, D.C. ordered a C-section for a pregnant woman, dying ofterminal cancer, in which both mother and baby died after the surgery (RodgersJ 89: 181). Other United States cases are discussed in Rhoden (1986).In a recent United States case, a woman who shot herself in the stomach resulting inthe death ofher fetus, was charged with homicide and imprisoned.173A Canadian case, Re: Superintendent ofFamily and Child Services and McDonald wassubject to judicial review, when it found a neo-natal withdrawal syndrome infant D.J. “inneed ofprotection” from its mother. She had been considered “unfit”, because she was on18methadone treatment for heroin addiction. The decision was based on an earlier case,which dealt with a baby suffering from fetal alcohol syndrome. In another case, Re A (inutero), the Ontario court held that it parens patriae jurisdiction did not provide for judicialintervention on behalf of a fetus, only a child, in need ofprotection.Tn 1987, C.A.S. Belleville v. L. T. and G.K