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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 TIlE iN VITRO FERTILIZATION PRE-EMDRYO IN BRITISH COLUMBIA  by PATRICIA M. LEE B.A. , University of British Columbia, 1987  A THESIS SuBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR TIlE DEGREE OF DOCTOR OF PHELOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department of Anthropology and Sociology)  We accept this thesis as conforming the r  Signature(s) removed to protect privacy  uired stahdard  THE UNiVERSITY OF BRITISH COLUMBIA July 1995 © Patricia M. Lee, 1995  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  Signature(s) removed to protect privacy (Signature)  Department of The University of British Columbia Vancouver, Canada  Date  /ffrJ F/99  Signature(s) removed to protect privacy  DE-6 (2188)  ABSTRACT  The human pre-embryo is emerging as a new cultural category as a result of the processes of in vitro fertilization (IVF) technology.  The principle purpose of this  conceptive medical technology is to assist infertile couples produce their own biological children. I argue that three specific discourses, biomedicine, law and feminism, which have been selected for this research are generating conilicting and contested debates about the cultural values and meanings associated with the human pre- embryo. The physical separation of the pre- embryo as an independent entity created external 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 of infertility, preimplantation diagnosis and research into genetically related diseases. The versatility of the pre-embryo for use in both research and treatment has resulted in a growing controversy about its potential for altering the natural relations and sequencing of biological family organization and about its part in a larger social engineering project leading ultimately to change in social structure. A combination of anthropological methods demonstrate the centrality of the pre embryo in the enlarging controversial debates about new reproductive technologies. The biomedical-technical practices of creating, cryopreserving and replacing pre-embryos, which were observed in an ethnographic study of an in vitro fertilization programme provides foundational data for analysis of the three discourses.  A critical interpretive  approach in medical anthropology situates IVF technology in its cultural and historical context as part of a continuing scientific fascination with understanding the beginnings of life. IVF technology is a gateway into a modem exploration of human genetics, using pre embryos to probe the essential nature of human inheritance. The traditional debates in U  anthropology about the cultural nature of parenthood and the juro-political aspects of rules and rights in and over people and things have current relevance. They provide a cultural understanding about the ability of IVF to re-arrange the biological, putative and social relations of parenthood.  They reveal the methods whereby legal controls are  exerted by groups with different vested interests in children born from IVF and its adjunct therapies, such as surrogacy arrangements and ovum donation. A feminist anthropological perspective explores a recent approach in symbolic anthropology about the cultural meanings of procreation stories, as expressed by women, based on a particular cultural ideology. It reveals the means by which the technologies associated with TVF have the propensity to fragment and devalue women’s bodies, a strategy which is often endorsed by the culturally legitimated knowledge of medicine and law. Four overarching unmediated oppositions are identified in the analysis of the three discourses: 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 tension  between polarities highlights problems of meaning. These are expressed in the discourses as a struggle over values, which in turn are converted into struggles over power They represent the new cultural meanings and social consequences which are presently emerging in response to new conceptive technologies.  m  TABLE OF CONTENTS  ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES PREFACE: CONCEIVING THE RESEARCH PROJECT (i) Creating a Feminist Network (ii) Off to Foreign Fields at Home ACKNOWLEDGEMENTS CHAPTER 1. IN THE BEGINI1ING I INTRODUCTION (i) What is in vitro fertilization (JVF) technology? (ii) The Three Discourses: Medicine, Law and Femini (iii) The Context: Infertility and the Reign of Technology II A CONCEPTUAL CONFUSION: DEFINING INFERTILITY AN]) THE CONCEPTIJS (i) Infertility as a Terminological Confusion (ii) Mixing our Meanings: Redelining the “Embryo” ifi THEORETICAL PERSPECTiVES (1) Critical Interpretive Medical Anthropology (ii) From an “Anthropology of Women” to Feminist Anthropology (iii) A Feminist Approach to Discourse Analysis 1V THE BRITISH COLUMBIA WF PROGRAMME V CHAPTER OUTEINE  CHAPTER 2. MEANINGS OF CONCEPTION: FROM TRADITIONAL KINSHIP STUDIES TO NEW PROCREATION STORIES IN ANTHROPOLOGY I CONCEPTION THEORIES: TRADITIONAL DEBATES ABOUT PROCREATION IN ANTHROPOLOGY (i) Virgin Births and Concepts of Paternity II KINShIP AN]) BIOLOGY (1) Cultural Constructs ofBiological Processes (ii) (3enitor/Genetrix: :Pater/Mater: Problems of Parenthood (iii) Categorizing Parents: Some Cognitive Models ifi PROCREATION STORIES: RECONSTRUCTING KiNSHIP AN]) FAMILY  iv  Page ii iv viii ix x xii xiv xxii 1 1 1 4 6 8 8 12 15 16 21 23 27 30 33 34 34 36 36 37 39 41  IV THE POLITICO-JURAL APPROACH IN ANTHROPOLOGY (i) Rights in Rem, Rights in Personam (ii) Twin Universes: Persons and Things V GENDER STUDIES AND REPRODUCTION IN ANTHROPOLOGY (i) Moving Reproduction from “Off-Centre” (ii) Legal Anthropology and Relations ofPower VI CONCLUSION  .44 45 46 49 49 51 54  CHAPTER 3. THE MEDICAL DISCOURSE: THE HISTORY OF EMBRYO 56 RESEARCH AND THE BIRTH OF IVF TECHNOLOGY I FROM “FAILURE TO GENERATE” TO “CONCEPTION IN A 58 WATCH GLASS” 58 (i) Classical Greek Models of Procreation 60 (ii) Preformation Theories 61 (iii) Theories of Ovulation and Embryo Development (iv) The Egg Hunt: The Access to and Ethics ofEmbryology Research.. 63 II 1W AND EMBRYO TRANSFER: NEW WAYS OF MAKiNG 66 BABIES ifi A CHRONOLOGY OF INFERTILITY AND GENETIC 71 SCREENTNG TECHNOLOGIES 1V THE MEDICAL DISCOURSE OF INFERTILITY AND SUCCESS: 76 PROBLEMS OF DIAGNOSIS AND CURE 76 (i) The Discourse of Epidemiology ( Population Studies) 78 (ii) The Numbers Games 80 (iii) “A Take Home Baby”: Measuring the Rhetoric of”Success” V THE CAUSES OF INFERTILITY: MERGING STANDARD MEDICAL, PUBLIC HEALTH AND ENVIRONMENTAL 82 DISCOURSES 82 (i) The Standard Medical Discourse 84 (ii) The Environmental Discourse 87 VI AN 1W PROGRAMME IN BRITISH COLUIVIBIA 87 (i) A Short History 94 (ii) The Current Situation of 1VF in Vancouver 98 (iii) An Uneasy Separation 99 VII CONCLUSION CHAPTER 4. THE MEDICAL-TECHNOLOGICAL DISCOURSE: CREATING AND 102 FREEZING PRE-EMBRYOS 103 I PREPARING FOR THE SUPEROVULATION PROCESS 103 (i) “Ladies-in-Waiting”: Coming “on board” 105 (ii) Counseling the Clients 107 (iii) “Calling the Pergonals”: Calling the Shots V  II THE OOCYTE RETRIEVAL OR THE “EGG PICKUP” (i) The Routinization of A F[igh Drama (ii) The “Egg Pickup” ifi A WINDOW OF OPPORTUNITY: INTO THE LAB (i) A Mecca of Machinery (ii) “Egg” Care (iii) Insemination and Syngamy: Technology versus Nature (iv) Cleaving Embryos: Watching, Waiting and Wastage (v) The Embryo Transfer 1V FROZEN IN TIME AND SPACE: FREEZiNG PRE-EMBRYOS (i) A Chilly Climate (ii) More than Enough: Freezing Choices (ili) It’s Just a Matter of Time V IDENTIFYING RISKS AND ACKNOWLEDGING THE COMPLICATIONS VI CONCLUSION  .112 112 115 117 117 120 121 123 127 128 129 131 135  .  CHAPTER 5. THE LEGAL DISCOURSE: THE CASE FOR THE PRE-EMBRYO... I CANADIAN VALUES AN]) GUIDING LEGAL PRINCIPLES II PERSON OR PROPERTY: PRECEDENT SETTING CASES IN THE UNITED STATES (i) Reos (ii) Davis v. Davis, Kass v Kass and Jones v. York (ili) Oocyte and Embryo Donation (iv) Fetal Tissue Commerce and Research ifi CREATING A CANADIAN LEGAL FRAMEWORK FOR REGULATING PRE-EMBRYOS (i) The Context of Canadian Health Regulation (ii) Canadian Commissions and Committees for Regulating New Reproductive Technologies (NRTs) 1V THE CANADIAN ROYAL COMMISSION ON NEW REPRODUCTiVE TECHNOLOGIES (CRCNRT) (i) Damaged Pre-embryos and Wrongful Life Suits (ii) A Regulatory Agency (iii) Donating and Selling V LEARNING FROM THE PAST: GUARDING AGAINST THE FUTURE (i) The Eugenics Heritage (ii) Judicial Interventions: Maternal/Fetal Disjunctures (iii) Corporate Protectionism: A New Eugenics VI CONCLUSION  vi  138 141 145 146 148 149 150 154 155 156 156 158 163 165 166 168 169 170 172 176 177  CHAPTER 6. A NEW PROCREATION STORY:FEMINIST DISCOURSES FROM TFIE MARGiNS 1 NEW REPRODUCTiVE TECHNOLOGIES: AWOMEN S ISSUE 1 (i) In Whose Best Interests: Resisting Technology (ii) The Enterprise Culture: Fragmenting Women’s Bodies (iii) The Art of the Possible: A Modern Space/Time Warp (iv) “Granny Pregnancies”: A New Resource Management II REPRODUCTiVE RISKS (i) A History of Miracle Drugs and Devices and Reproductive Errors (ii) Risky Business: Superovulation and Fears of Ovarian Cancer ifi POSSESSION OR PERSONS? THE POLARIZED LANGUAGE OF RIGHTS DISCOURSE (i) Property for Personhood: Searching for the Middle Ground (ii) “Wrongful Life” and “Rights to Life” IV REPRODUCING DISABILITY: A FAULTY PARADIGM (i) Defective “genes”, women as “defective”: Choice and Coercion (ii) The Woman in the Body V CONCLUSION  ..  CHAPTER 7. THE PRE-EMBRYO AS SYMBOL:ON THE TE[RESHOLD OF NEW BEGINNINGS I SCIENTIFIC RESEARCH AN]) CLIKICAL PRACTICE II ROUTINE AN]) RISK ifi PROPERTY AN]) PERSON 1V REPRODUCTIVE TECHNOLOGY (CULTURE) AN]) NATURAL REPRODUCTION (NATURE) V CONCLUSION BIBLIOGRAPHY GLOSSARY OF MEDICAL TERMS COMMON ABBREVIATIONS APPENDIX A. THE HUMAN PRE-EMBRYO: VERSATILITY OF CREATING FAMILIES APPENDIX B. UNIVERSITY OF BRITISH COLUMBIA. P/F PROGRAM SCHEDULE OF FEES AN]) CHANGES  vu  180 185 185 191 193 198 202 204 208 210 212 217 220 220 222 227 229 233 237 242 248 254 256 287 291  292 295  LIST OF TABLES  Page  Table Table 1. University ofBritish Columbia IVF Programme Outcome Statistics 1985- 1994  92  Table 2. Indications for Treatment from 1989 to 1992  94  Table 3. Number of Embryos Remaining in the Freezer Tanks per year between 1989-1994  vi”  133  LIST OF HGIJRES  Figure. Page  Figure 1 Four Photographs of in vitro fertilization embryos  ix  xx  PREFACE CONCEiVING TIlE RESEARCH PROJECT  This research is the culmination of an on-going exploration, which has been in progress since the early days of the in  vitro fertilization  (1VF)  programme  in Vancouver,  British Columbia. It predates the establishment of the Canadian Royal Commission on New Reproductive Technologies (hereafter referred to as CRCNRT). 1 During this time, there has been a widespread transformation from use of simple 1VF procedures to treat infertile couples to an explosion of conceptive and genetic screening applications. While I have been most interested in the Canadian experience, biomedical research is international in scope and impact.  The dominant American developments and those of other  industrialized countries, notably Britain, European countries and Australia, have contributed to the Canadian experience. My interest in IVF has spanned the transition from a general Canadian lack of public awareness about reproductive technologies during the l980s, to the development of mass media explorations of them.  I have witnessed in press and in action a feminist  ground swell from a limited, timid, but sometimes radical response, to a concerted, educated and provocative intrusion into Canadian social and political policy. It is probable that, if it were not for the persistent feminist lobby concerning NRTs, public and political interest would not be provoked at all.  New Reproductive Technologies is often referred to by the acronym NRT. It is a term which covers the whole range of conceptive and contraceptive technologies, pre implantation and pre-natal screening technologies, embryo research, recombinant DNA and cloning. The medical community more often refers to the conceptive technologies by the acronym ART, assisted procreative technologies. x  In 1982, the fledgling field of reproductive surgery, which included the development of an 1VF programme, was being established in British Columbia, At the time, the developments in 1VF treatment appeared to be reminiscent of mysterious science fiction “hi-tech”.  The concept that the “disability of infertility” was being culturally  constructed to tie in with a new medical treatment, piqued my long-standing interest in various physical disabilities. Initially, I had intended to study infertile couples’ responses to a new therapy, and I was naively unaware that the field of 1VF was going to explode into a terrain fraught with so many social, cultural, legal and ethical implications. However, even at this time some of the early feminist critiques of NRTs (Holmes, Hoskins and Gross 1981, Arditti eta! 1984, Corea 1985) were being published. Members of the Feminist International Network for Resistance to Reproductive and Genetic Engineering (F]NRRAGE) 2 were warning of the dangers of these technologies for women’s health.  These criticisms went largely unheeded and unheard outside feminist  circles. In 1987, an international conference was organized by the Office of the Status of Women 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 on the Status of Women (NAC), are frequently portrayed as “fringy”, alarmist scare mongering in the face of continuing developments in well-funded techno-science.  2 In 1984 a feminist network of international resistance, critique and analysis of NRTs known under the acronym F1NNRET was formed and organized its first feminist conference against the technologies in 1985 in West Germany. The participants condemned much of the reproductive and genetic techniques as violating women’s dignity and challenged their racist and eugenic ideology. Two months later at an emergency conference in Sweden, women from twenty countries met to devise strategies to resist the technologies. At this time FINNRET became FINRRAGE. A series of feminist conferences followed in Belgium, Australia and Austria. (Arditti et al 1989:xix-xx). xi  Ironically, it was these social activist Canadian women, mainly academics, who in the first place fought for the formation of CRCNRT, in order to explore the complexities of these technologies for Canadian society. 3 This lobby did not include in its ranks any anthropologists, let alone feminist anthropologists.  However, one anthropologist was  included among the seven commissioners called to CRCNRT. 4  (i)  Creating a Feminist Network Tn 1989, when the Commission was formed, my nascent interest in feminism was  fanned into flames when I became an active member of West Coast LEAF, the British Columbia branch of the Legal Education and Action Fund (LEAF). 5 It was here that I was introduced to what seemed to me a revolutionary dynamic interaction between legal theories and practical action (Bayesky 1988). I discovered that law was not some remote field of knowledge for an intellectually brilliant few, but could be an action-oriented field of awareness about legal issues concerning women’s lives.  Attending LEAFs first  A nation-wide intensive lobby by women’s groups, the Canadian Coalition for a Royal Commission on New Reproductive Technologies, over a two year period, secured the creation of the Commission in October 1989. See notes 5 and 6 in Eicliler 1993:218 for a st of the organizations involved and the politicians who supported the lobby. A mixed blessing for anthropology has been that anthropologist, Suzanne Rozell Scorsone was selected. She is a spokesperson for the Archdiocese of Toronto on family and women’s issues, and is the Director, Office of Catholic Family Life. ‘While she contributed a perspective on the complexities of kinship and family, subjects which have been 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 to ie Commission Report (CRCNRT: 1053-1146). Legal Education and Action Fund (LEAF) is a national, non-profit, advocacy organization founded in 1985 to secure equal rights for Canadian women as guaranteed by the Canadian Charter of Rights and Freedoms (1981). Its two-fold mandate is to argue test cases before the Canadian courts, human rights commissions and government agencies on behalf of women, and to provide public education on the issue of gender equality (LEAFs Speakers Kit 1990:3). xli  Conference 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 come together to work on equality issues and to look for legal solutions by attempting to change laws that were gender discriminatory. It was through LEAF’s Speaker’s Bureau that I came to represent LEAFs views and resources with the newly formed Vancouver Women’s Coalition on Reproductive Technologies (VWCRT). This ad hoc group, representing a multitude of women’s groups in Vancouver, was concerned with educating themselves and others about NRTs. It was primarily a self-help group, with an outreach programme to help prepare women to write briefs to present to the Royal Commission on NRTs when it met in Vancouver for three days of public hearings in November 1990. Along with other VWCRT members I assisted in the preparation and presentation of a submission on feminist issues, which we considered vital for the Commission to address. This submission was more moderate than had been intended originally, because the National Action Committee on the Status of Women’s submission, presented in Ottawa ahead of the Vancouver hearings, had raised considerable public ire. It had called for a complete halt to 1VF. Fearing that a backlash against Canadian feminists might result, our submission attempted to raise the issues in a less 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 the disabled matured to the point where I considered that representation of all of these discourses was important to understanding a new medical technology.  I became  concerned with finding a way to combine the practice of feminist activism with critical anthropological theory. While I realized that there were discourses, as well as “discourses within discourses” (Cannell 1990) that were important to a filler understanding of all the  xm  issues, I could not do justice to all of them. Thus I felt secure in concentrating on those discourses about which I had already gained some insights. Over time and informally, I had established networks through a snowball effect with health care workers and academics in the field of IVF, with legal scholars, and in particular feminist legal scholars and feminist activists.  I also came to meet through  VWCRT, 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 of 1VF not only for the treatment of infertility as a disability, but for its potential iatrogenic effects. It seemed that on occasion certain aspects of the technology could cause further disabilities for women and their potential children. So disability, infertility and risk seemed inextricably linked, such that IVF treatment could become both the cure and cause of disability.  (ii)  Off to Foreign Fields at Rome The observation of medical procedures and most of the interviews with health care  workers for this study was conducted at the University of British Columbia in vitro Fertilization (IVF) Programme. During the majority of my research, the programme was based at University Hospital, Shaughnessy site, in Vancouver. Further observations were made later at the new facility in Willow Pavilion, Vancouver Hospital, which opened on April 29th 1994. My exposure to the practical world of hospitals and TVF procedures had been predated by my own training and practice in the field of rehabilitation medicine and my familial connections to the world of reproductive surgery. Through my maniage to an obstetricianlgynaecologist, whose clinical practice was focused on infertility problems and in whose office I worked on occasion, I came to the research with a detailed knowledge of xiv  the tests involved in the infertility “workup”.  I also had some background familiarity  about the IVF procedure and the formation of an 1VF programme in Vancouver. I knew personally a few of the 1VF staff and I had the opportunity to attend a number of Annual Conferences of both the Canadian Fertility Society and the American Fertility Society. I knew 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-spared junkets put on by the company at major conferences. My fascination with the marketing strategies of Serono, its wealth and power and tenacious iiiffltration into all parts of the North American infertility business had led me down a dead-end lane, when I naively attempted to study the company’s practices. The door slammed closed on what I thought was a realistic research project, when I attempted to obtain the Annual Reports of the company. Another problem with access was that contrary to my expectations that my personal connections would facilitate my entry into the medical aspects of the research project, I found the reverse to be true. In my initial orientations to the IVF programme, I was greeted with cautious ffiendliness and my research proposal was treated with skepticism. Despite all of the formal ethical clearances from both the University of British Columbia Social Science and Humanities Screening Committee and the University Hospitals Ethics Committees, there was an implicit sense of ambiguity among the staff about my role in my wanting to observe the IVF procedures and to interview them. A methodologically related problem of access was one familiar to feminist anthropologists. Early studies on the “anthropology of women” had shown how male bias is transferred to the field project, such that what men say is deemed important. I found from my research in a hospital setting, where men in senior positions of power were largely inaccessible to me, that it was the women who were more service oriented who xv  were more available to speak with me. Perhaps, the reason that it was easier for me to speak to female health providers rather than male physicians and administrators, reflects the 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 not want 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 and unequal nature of gender relations. 6 During my initial forays into the hospital, I experienced David Serber’s dilemma of doing research in a government bureaucracy in that “the process of gaining access was a continual activity” (1981:79). A university hospital treatment and research programme is a type of bureaucracy. Like Serber, I used an interview schedule composed of 15 general questions, which “served as guides to the issues and areas studied as well as a means of redirecting often rambling and personal discussion by informants” (ibid). These questions were 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 by interviews of the participants in order to obtain background knowledge and individual perceptions of what took place (Serber 1981:79).  While the exploratory interviews  technique was a successfiul strategy, the interview schedule proved to be methodologically more complex.  I had devised a generic questionnaire, which I had adapted so that  participants could address some of the topics, but not others, according to their specialized knowledge. Often I had to explain the reasons behind the questions, which on occasion led to illuminations for the participants about other points ofview.  6  Moore cites the work of Rogers 1975, Dwyer 1978 and Leacock 1978. xvi  The interviews with the other target groups, such as lawyers, feminist activists, disability rights activists and other interested health professionals, were all conducted in Vancouver. This fieldwork took place between June 1993 and May 1994. However, the documentary 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 from medical associations such as the Canadian Medical Association, the British Columbia Medical Association, Society of Obstetricians and Gynaecologists of Canada, and the American Fertility Society, in which I became an active member in 1990. I became an inveterate clipper of newspaper articles and a subscriber to feminist news sheets and journals, such as Kinesis, and the Journal of the National Association of Women and the Law (NAWL). As the publications proiiferated, so did my ifies. I attended every meeting held in Vancouver with “reproductive technology” in its title. So my network of contacts grew commensurate with my files. My original intention in the late 1980s had been to study patients’ experiences of infertility and their participation in an TVF programme. However, the difficulty of gaining access to the opinions of clients became insurmountable, because they are often perceived as emotionally vulnerable and in consequence their experiences have been poorly documented. The medical director of the IVF programme, who subsequently left to work at Pacific Fertility Services in San Francisco, had made it clear to me that he believed I was asking to study an over-researched and emotionally fragile population. This experience was reminiscent for me of studies in anthropology about getting past, the gatekeepers (Hammersley and Atkinson 1983, Berreman 1962) and the discussion of the vested interests that people in positions of power in institutions often hold over what constitutes valuable research (Daniels 1967). In reality, the intended project could have been significant because so few studies on experiences of infertility and 1VF xvii  procedures had been done to date, especially in Canada, with the exception of those by sociologists Williams (1988, 1989a, 1989b) and later Matthews and Matthews (1993), as well as Eicffler’s (1988, 1989) critique of NRTs focused on the sociology of the Canadian family.  Currently, a few studies are being published which have been conducted by  Canadian anthropologists, which in one way or another relate to the Report of the CRCNRT, now often referred to as the Baird Report, after its chairperson. Anthropologist commissioner Scorsone has produced six dissenting opinions which were appended to the Report. Feminist anthropological researcher, Tudiver’s (1993b) study on prenatal screening was commissioned by CRCNRT. The outline of a pioneer study on the effects of Norplant in Canada (Tucliver 1994), a study focused on procreation metaphors in CRCNRT briefs (McDonald 1994) and a combined anthropological and sociological collaborative study (Habib and Weir 1994) based on research for the Canadian Advisory Council on the Status of Women were all presented at a session of the 1994 Annual Meeting of the Canadian Anthropology Society in Vancouver. At the time of my frustrated effort to interview patients involved in the University of British Columbia 1VF programme, the clinic was preoccupied with establishing itself at a new site and with the new director. Although the medical director was unwilling to facilitate my research at this time, I did succeed in obtaining permission to conduct some exploratory observations. I spent time in the 1VF waiting room in Shaughnessy Hospital, where patients arrived daily to give blood samples in connection with the pharmacological superovulation protocols. These tests enabled both the critical timing of and conditions for the oocyte 7 retneval process for fertilization. At this time I had some informal .  ...  ..  I 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 a pejorative sense or in anecdotal quotes. I avoid jargon wherever possible. xvm  conversations with P/F staff and shortly after I was able through a personal contact to conduct an in depth interview with a couple, who had successfully completed the 1VF programme. Some ofthis preliminary ethnographic research informs this thesis. With the passage oftime and the swift changes in the institution of 1VF clinics and their adjunct therapies throughout Canada, this project has presented more challenge that I could ever have envisaged. It has revealed accounts which I would not have uncovered in a more circumscribed project. These have led me to question the power differentials which are constructed on the basis of certain forms ofintellectual property. I take the approach that anthropologists have always been interested in the perspectives and practices of marginalized peoples, and that a feminist anthropology is one critical way of addressing the gendered nature of inequalities, which percolate throughout all aspects of society. They have particular relevance to the gendered nature of IVF technology, which is played out on the controversial discursive terrain ofNRTs.  MX  Figure 1  Four Photographs of in vitro fertilization embryos  In vitro Fertilization and Embiyo Transfer by Don P. Wolf (editor) 1992. Blenum Press: New York and London. Pp. 224. xx  A. Two cell cumulus. Two cell embryo 16 hours post insemination (P1) with nucleated blastomeres and two polar bodies in fertilization droplet. B. Two cell embryo. Same embryo as in A, 19 hours P1, after removal of excess sperm and 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.  ACKNOWLEDGEMENTS  I owe a considerable debt of gratitude to my advisor, Dr. Elvi Wliittaker for assisting in the intellectual conception and growth of this thesis. Without her constant support this project could not have been accomplished.  I am grateful to Dr. Nancy  WaxIer 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 thesis developed. I thank Dr. Giffian Creese for introducing me to feminist theory and thereby altering the way in which I viewed the world.  I am indebted to the members of the  University of British Columbia IVF Programme, who took the time and interest to speak to me about their various endeavours, and for agreeing to be interviewed during their busy schedules. I thank the many lawyers, feminist scholars in several disciplines and feminist community 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 Nodwell and Daniel Holmburg for their willingness to discuss and read my work in progress and for their continued support in many diverse ways.  To Nic, ever my strongest critic and  supporter, I owe a debt of gratitude for introducing me into the unfamiliar terrain of medically assisted procreation and for his enduring patience and love.  My graduate  studies would not have been possible if my family had not been willing to reorganize their lives for my benefit.  To my children Dominic, Tim, Chris and Becky, I dedicate this  intellectual endeavour in token of my lifelong respect for learning and scholarship. The funding for this research was made possible by University Graduate Fellowships, for which I am most gratefuL xxil  CHAPTER 1 IN TUE BEGINNING... I  INTRODUCTION  (i)  What is in vitro fertilization (IVF) technology? This research examines the complex social and cultural understandings that are  emerging from the medical and technological ability to create human preimplantation embryos, pre-embryos,’ through in vitro fertilization (hereafter IVF) technology. In vitro fertilization involves fertilization of human gametes, that is sperm and oocyte (egg), by placing them together in a petri dish (in glass). This is performed artificially outside the female body, in the laboratory, in contrast to in vivo, inside the body, where normally conception occurs through sexual intercourse.  The term IVF treatment incorporates  several medico-technical phases. First, the medical procedure involves altering a woman’s hormonal system in order to produce multiple ova (eggs). Second, the surgical procedure entails retrieval of the ripe ova from her stimulated ovaries for the external fertilization procedure. Finally, the resultant embryo(s) are manually replaced into the uterus of the woman who plans to gestate the resultant fetus(es).  1 Throughout this thesis I use the term “pre-embryo” to describe the preimplantation embryo, 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’s uterus. The term “embryo” is commonly used when describing the 1VF embryo, so where this term occurs in the text, it is commensurate with the pre-embryo. 1  Initially, IVF was developed as a therapy to assist couples who were experiencing reproductive difficulties in producing their “own” biological child.  It is one among a  number of new reproductive technologies, often referred to as NRTs. 2 Many of these adjunct technologies have been developed as refinements and as other options to the traditional IVF procedure, thus expanding the enterprise into a variety of complex choices for patients and practitioners. These options for infertility treatments beyond the simple model include third party parenting, such as surrogacy arrangements and gamete donation, research on preimplantation embryos and commercialization of reproductive products and services.  These applications have developed far beyond that which could have been  envisaged when 1VF first became an option for infertility treatment.  They present  significant implications for the social realm and pose interesting questions for anthropological inquiry about the pre-embryo as an emerging social category and the complex social and cultural meanings surrounding its status. Analysis ofthe debates about artificial procreation offer a challenge for anthropological analysis. As Melhuus rightly points out: there is evidence that values are being contested, and a struggle over values can be legitimately contested as a struggle over power... .what is interesting in this struggle over values is the meanings given to the consequences of the new reproductive technologies (1992:306). I pose the question: What does it mean for women that medical technology has developed to the point where pre-embryos now can be created and manipulated outside of  2 Reproductive technologies (NRTs) are rife with acronyms, to which I will refer and explain throughout this text. The alphabet soup of drugs, ART (Assisted Reproductive Technologies) or APT (Assisted Procreative Technologies), and diagnostic and conceptive procedures include HCG, HMG, GnRH (drugs) and procedures such as IVF, DI (AID), SUZI, GIFT, ZIFT, POST, PROST, and ICSI (see Glossary of Medical Terms). 2  a woman’s body? Infertile couples 3 and their health care providers, lawyers, ethicists and theologians, feminists of various persuasions and disability rights activists are producing contesting and competing discourses, which view NRTs, such as IVF, as individually enabling, or conversely, individually and collectively disabling. Dialogical processes are proliferating and creating NRTs as complex polyvocal representations. 4 The cunent social bias towards the technological imperative and the therapeutic “quick fix” in medical care have tended to efface the real experiences of infertile couples participating in IVF therapy.  Sometimes, in their efforts to conform with social  expectations of parenthood and the socially perceived importance of the biological family unit, 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 IVF technology has been institutionalized so swiftly. While ostensibly claiming to help cure infertility, IVF is in reality an arbitrary procedure, which on occasion provides babies for some infertile couples.  TVF has another important function beyond the provision of children for those who can afford an expensive health service, which in Canada is not covered under provincial medical plans. By the late 1980s, there was evidence that surplus embryos were being created and stored routinely through IVF. This almost limitless supply ofpre-embryos can be used in an infinitely creative research environment for numerous projects.  These  3 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 to refer to people, who are unable to conceive a child as “the infertile”. I qualif,r infertility with a noun as it appears less discriminatory. 4 Clifford discusses the representation of the conilictive domain of discourse in modem society where “many voices clamour for expression” (Clifford 1986:15). In this he uses Bakhtin’s (1981) notion of dialogical processes proliferating at discursive sites such as ethnographies and novels. 3  projects seek to better understand how the processes of human fertilization and implantation occur, the generation of knowledge about the human genome, the possibility of eradicating some genetic disorders and finding treatments for diseases such as neurological disorders and cancer. A fascination with the potential problem of what is going to happen to all those unneeded pre-embryos has led me to focus my thesis on the complex social relations surrounding the 1VF pre-embryo itself Therefore I wish to explore and to comprehend the variety of ways in which the pre-embryo is being constructed as a new cultural category through its reification as a legal, medical and social entity. What does the pre embryo mean not only for the people who work most closely with it in providing IVF services, but to those people who engage with it or analyze it from varying degrees of abstraction?  (ii)  The Three Discourses: Medicine, Law and Feminism In this thesis I examine three selected discourses, biomedicine, law and feminism, 5  which I believe to be representative of the polyvocality about the cultural values associated with the creation of extra corporeal embryos.  These discourses are highly  specific in their themes and orientations. I fully appreciate, however, that none of the discourses represented in this thesis is monolithic; that each discourse is composed of a variety of points of view, embraced under a single epistemology. To begin with I explore  5 In this thesis I allude to other discourses, such as the experiences of infertile people and certain other theological debates, which are equally important, but which I have chosen not to discuss in depth. In particular I recognize the significance and range of intellectual reasoning 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. 4  the professional, authorized discourses of medicine and law, which dominate and are legitimated in social institutions. Then I readjust the anthropological lens to focus on the diverse representations of feminism, endorsed by feminist activists, feminist scholars, legal feminists.  I include that element of the disability rights’ movement, that espouses a  feminist approach, whose activities spurred the call for a Royal Commission on NTRs. Likewise I examine those discourses of IVF service providers, which are less often considered. While these may not be overtly aligned with feminist issues, they do represent a perspective which is particularly sensitive to women’s health and social issues. In this manner I believe these discourses to best represent the marginalized views about the implications for women of pre-embryo production.  The three discourses provide the  empirical evidence which is necessary to demonstrate how power is manifested at many different levels of society.  It reveals “the links between the competing discourses of  church, state, the medical profession and feminists of various persuasions as well as those who, for whatever reason, are ‘silent” (Melhuus 1992:3 07). The proliferation of artificial procreation techniques, of which IVF serves as a gateway technology to other applications, has raised uncertainty about the cultural values and meaning of these technologies.  The ambivalence experienced in relation to their  meanings calls into question our well-established notions of parenthood, the family, kinship relations, bodily integrity and the marketing of kinship through transmission of reproductive products and services.  5  (lii)  The Context: Infertility and the Reign of Technology 6  The social construction of infertility as a disease in the developed world and the subsequent ability to create human 1VF pre-embryos emerged at a historical moment that was ripe for the modem capitalist idea of “infertility-as-disease” control.  This concept  stands 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 its corollaries has led swiftly to routinization of this form of treatment for an increasing number of infertility problems. The demand for a Canadian Royal Commission on New Reproductive Technologies (CRCNL&T), specifically called to examine the social, political, economic and ethical challenges raised by a variety of new and not so new reproductive technologies in Canada, was a social indicator of a political and public awareness that the implications ofthese technologies were complex. It was evident that there were important ramifications for situating NRTs in the socio-economic context of Canadian health care  and society in general. Furthermore, the cultural construction of “infertility-as-disease” opened the door to medicalization of what was previously a personal and social problem of the inability to produce children, which had social ramifications about the importance of traditional family life. Paradoxically, a series of medical technologies such as the use of fibre optics in visualizing internal organs, the ability to capacitate sperm and provide a nutrient environment for in vitro embryos had all become possible in the 1970s. This enabled an innovative technical circumventory treatment to certain pathologies related to infertility, in particular, obstructed or absent fallopian tubes, to be surgically performed on women who  6 attribute this phrase to Reiser 1978. 6  were unable to conceive. 7 In an arbitrary manner 1VF quickly became the panacea for treatment of diverse pathological or unknown causes of infertility. During this time frame other social developments had occurred, which favoured a growing 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 control over their reproductive bodies and the birth rate continued to drop. Birth mothers were increasingly deciding to keep their babies. The difficulties of raising adopted children had become apparent and the problems of cross-cultural adoptions, in particular First Nations babies and international adoptions, were shown to be fraught with cultural, social and ethical dilemmas. The overall result was a diminishing availability of adoptable babies, and in particular white babies. These factors in conjunction with individualistic desires of infertile couples to produce their own biological children helped promote a technology which on occasion achieved this result, but which generated new unforeseen social issues. The consumerism, the individual enterprise that Strathem sees evident everywhere in the late twentieth century in the Enterprise Culture 8 (l992b: 10), is evinced in a new generation of would-be parents.  The individualistic desires of these couples to produce their ‘own children’ is  balanced by their intent to delay childbearing until careers and economic security are established (Crowe  1987).  However, for many women increases in sexually  communicable diseases (STDs and AIDS), unexplained, environmental and iatrogenic 7 The CRCNRT (1993) report has stressed that this diagnosis is the only one which it believes to be indicated for P/F treatment, which should then be funded by health provincial plans. 8 Strathem notes that the Enterprise Culture is a term used to describe the policies promoted by the Conservative Party in Britain in the 1980s, which was not only a political product tied to advertising but “it is as much constitutive of a cultural revolution as of the political will of an electorate” (1992b: 199-200). 7  factors of infertility have been confounded further by a “biological clock” that threatens to limit their customary expectations (Modell 1989).  The “try harder” (Phillips 1985),  “work longer”, “wish more” (Williams 1988) mentality has pushed infertile couples into demanding more medical services, even Wit means paying for them privately.  U  A CONCEPTUAL CONFUSION: DEFINING INFERTILITY AND TUE CONCEPTUS  A perennial research problem encountered is that work can only proceed when certain terminological confusions have been resolved. Early on in the research process it became apparent to me that WI was to make sense of the IVF technology and its ability to create 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 feminist contributions to this study.  (i)  Infertility as a Terminological Confusion Infertility is a universal concept, which has been the subject of not only much  personal anguish, but has on occasion changed the course of human history. Biblical and historical commentaries have chronicled myths, legends and accounts of infertile couples being blessed with children, then going on to found nations through God’s grace; monarchs falling from grace and major constitutional upheavals ensuing; and even whole cultures 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 to whether 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 cohabiting 8  couple to produce their own genetic children to form a social family. The nature of its classffication as disease, illness, disability, impairment or handicap is, however, more problematic. In North America, the commonly accepted medical delinition of infertility is one year 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 secondary infertility (having some condition which has reversed a proven ability to procreate) is an important one to make. Likewise, there is a difference between the inability to conceive and the inability to maintain a pregnancy, due to recurrent pregnancy loss . The overall 9 gloss of the term denotes the inability to produce live children and in modern Western society, there is incontrovertible evidence that there is an expectation by newly manied couples that they will have childrenJ 0 In the last forty years the term infertility has increasingly entered the Western lexicon.  It is what Lakoff (1987) would call a prototypic term,’ which can be  understood differently in different circumstances. Whether infertility can be classified as  9 I am grateful to Dr. Mary Stephenson, a gynaecologist experienced in the treatment of recurrent pregnancy loss, who advises the use of IVF in long-standing persistent cases, for pointing out this distinction for me. 10 A United States’ study (Glick 1977), for which no Canadian equivalent exists, demonstrates that 95% of newly married American couples expect to have children. Jane Gaskell’s study of British Columbia adolescents suggested similar responses (Gaskell 1988). 11 Lakoff ‘s (1987) theory of natural categorization, describes how the human mind creates human categories in terms of prototypic cores of meaning, which he calls “idealized cognitive models” (ICMs) or cluster models. These may have fuzzy boundaries as the prototypic features become more ambiguous the fhrther outwards the shared features extend. He examines the category “mother” in English as a prime example. 9  a disease, a disability, a handicap or an impairment depends both on the circumstances and on who is speaking. Medical anthropologists would agree that disease is culturally constructed and that belief systems in Western biomedicine, such as reproductive beliefs and practices, are situated within the power struggles of the broader society. Currently, Good (1994) has been examinmg the problems of the semantics of the term “belief’ in anthropology, from the late nineteenth century to the present. He argues that the analysis of culture as belief both reflects and helps to reproduce an underlying epistemology and a prevailing structure of power relations (1994:21). He explains how medical anthropologists have subscribed to this practice by using “beliefs” as a category in two contradictory ways in their cultural accounts. Most often they label as cultural beliefs those medical conditions for which biological theories have the most authority and least often for those where biological explanations are subject to challenge.  He points out how commonly medical  anthropologists have understood the cultural variation in beliefs about disease, that is “illness behaviour”, but have been counter-intuitive about disease itself as a cultural domain because: Disease is paradigmatically biological; it is what we mean by Nature and its impingement on our lives. Our anthropological research thus divides rather easily into two types, with medicine, public health, and human ecology providing models for the study of disease and its place in the biological system, and social and cultural studies investigating human adaptation and responses to disease. Its takes a strong act of consciousness to denaturalize disease and contemplate it as a cultural domain (ibid: 2). Kleinman has used the explanatory model (EM) construct as a means of making coherent sense of the cultural features that affect people’s health behaviours.  He has  explained the dichotomy between illness and disease and how medical treatment becomes rationalized in this way: 10  Disease refers to a malfunctioning of biological and/or psychological processes, while the term illness refers to the psychosocial experience and meaning of perceived disease. Illness includes secondary personal and social responses to a primary malfimctioning (disease) in the individual’s physiological of psychological status (or both)... Constructing illness from disease is a central function of health care systems, a coping function and the 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 as between social classes and ethnic groups within a single society.  The World Health  Organization 1980 (hereafter referred to as WHO) has made a classificatory distinction between impairment, disability and handicap and thereby has promoted “the growing tendency to view disablement as a social phenomenon which exists on a continuum” (Williams 1991:517).  Williams envisages this universalization of disablement as a  response to a number of health care changes, among which are an aging population and attendant chronic morbidity and a choice of technological fixes. According to data from a 1986 Canadian census, it is estimated that 4.2 million Canadians have a classified disability of some sort.’ 2 WHO (1980) defines an impairment as “any loss or abnormality of psychological, physiological or anatomical structure or function”. A disability then is “any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being”.  A third gradation, handicap, is “a  disadvantage for a given individual, resulting from an impairment or disability, that limits or 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 a  12 Census published by The Globe and Mail in a supplement New Attitudes: changing lives ofpeople with disabilities (December 3 1993 :C1). 11  The  phenomenon socially constructed from biological reality. For the purposes of this thesis, I refer to infertility as a disability. (ii)  Mixing our Meanings: Redefming the “Embryo” The cultural construct of the “embryo” also raises categorical problems. One of  the early issues that arose with the technological ability to create pre-embryos in vitro was the choice of term that should be used to describe this new entity. If it was to become possible to categorize the pre-embryo, then it had to be uniformly classified. Whereas one person might refer to an “embryo” as an early fetus, another person might be describing a just created zygote. It is important to be clear at the outset about the subtle distinctions that a term can make. The term “pre-embryo” is the one adopted by the Ethics Committee ofthe American Fertility Association (hereafter referred to as AFS) in a recent supplement on ethical considerations (AFS 1994).  The retired Chairperson of CRCNRT has  cautioned against inappropriate use of terms to describe early developing human tissue and advocates the use of the strictly biological term “zygote” to describe the preimplanted embyro (Baird 1994). 13 Any discussion of the pre-embryo must take place within the context of the social relations that surround it. For practical purposes, or at least without the aid of a high resolution microscope, the pre-embryo is non-existent. Only in relation to certain people and in certain circumstances does it take on a reified existence of its own.  It means  nothing to itself, but it evokes multiple meanings to those with an interest in it.  The  13 In a recent lecture in Applied Ethics at UBC, Baird explained the importance for ethical purposes 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 after fertilization has the potential to become the “true” embryo and subsequent fetus (Baird 1994). 12  perspective taken by different interest groups has ascribed this conglomeration of human tissue with or without certain vested interests and rights. Any conceptual analysis about the pre-embryo must identi1,’ the information conveyed by the word, whether in a scientific or non-scientific context (Regan 1980). A variety of terms have been used to categorize the cluster of human cells, whether created in normal conception or technically through 1VF.  These include the embryo, fertilized  egg, pre-embryo, pro-embryo, morula (a microscopic raspberry), conceptus, zygote, blastocyst, pre-implantation embryo and fetus. However, the term “embryo” has been commonly used to refer to all stages from the time of fertilization on, at least since the introduction of the teaching of practical embryology at the University of Cambridge in 1883. Authors of many 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 well as by contributors to Proceed with Care (1993), the report of the Canadian Royal Commission on New Reproductive Technologies. The words embryo and the closely related term fetus have been in use since the fourteenth century, 14 but it was not until 1986 that the compound words pre-embryo and pro-embryo were introduced independently to describe human cells, during the first fourteen days of development (Biggers 1990:1). Biggers argues from his archival research of relevant medical texts, that the definition of these terms alludes to phases in a  14 Biggers argues that the words embryo and fetus have been used in four ways; synonymously (1594 Oxford English Dictionary), categorically to identifS’ two successive disjoint phases of prenatal life (Webster 1828), to identify a subclass of embryo called fetus (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 time of conception or, since 1879, from the time offertilization (1990:1). 13  continuous process called the life cycle, which are arbitrary, and have been coined not on scientific grounds but for public policy reasons. The term pre-embryo was adopted simultaneously in 1986 by the Ethics Committee of the A]FS and the Voluntary Licensing Authority for Human in vitro Fertilization and Embryology (hereafter referred to as VLA) in Britain. In Australia, in 1985, the term pro-embryo was suggested to the Australian Senate Select Committee on the Human Embryo Experimentation Bill. Whereas the term pre-embryo was a new term, the term pro-embryo was an old botanical term. Both, however, referred to the phase prior to the development of the primitive nervous streak at fifteen days and the stage normally associated with implantation in the uterus. During this phase each cell in the cluster is totipotential, meaning that it can develop into either a “real” embryo on implantation, or part ofthe extra-corporeal support to the embryo, such as placenta. Only on implantation will the cells begin to differentiate. Both the terms pro-embryo and pre-embryo had been arrived at on a moral basis by 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 to ensure that no human pre-embryo created through IVF should be maintained beyond fourteen days, or used as a research subject beyond that point. This marks the time at which 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 days after fertilization, the human prenatal organism should be accorded a different order of moral value than at later stages, they did so for different reasons. The VLA’s reason was to enhance communication with non-scientists and to clear up the sloppy practices of using the word embryo for the entire product of the fertilized egg (McLaren 1986). The 14  AFS wanted to accord special moral status to the pre-embryo during “the special and unique 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 scientific inference, which asserts that the pre-embryo has reached a special place in biology and also in the scale of increasing moral status, that they believe is contiguous with human development.  Biggers (1990) rejects this assignation of moral values on arbitrary  terminology. He suggests preimplantation embryo as a less ambiguous term to recognize the phase prior to implantation. In this case the pre-embryo has only existed for about two days and will only be at the two to eight cell stage. It is smaller than a grain of sand or the period at the end of this sentence. I have chosen to use the term pre-embryo for the purposes of this thesis, not for any moral reason, but to make it clear that I am referring to the fertilized egg during the in vitro 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 pre embryo to imbue it with significance as a cultural as well as a biological construct.  UI  THEORETICAL PERSPECTIVES  This thesis integrates some aspects of the critical interpretive medical anthropological approach with discourse analysis viewed through the lens of a feminist anthropology, which reframes kinship theory in terms of new procreation stories. This strategy keeps women central to the analysis, while presenting the technology of IVF in a historical and cultural context. The contested debates surrounding the application of 1VF  15  technology and its adjuncts is represented by the analysis of the three specific and salient discourses of tecimo-medicine, law and feminism. Together the three theoretical approaches provide a framework from which to examine the complexities of IVF technology and its creation, the pre- embryo, as demonstrated by a Western Canadian IVF programme associated with the University of British Columbia. A critical medical anthropological approach focuses the debates on the politico-economic aspects of provision of a delisted medical service, which despite its  costs is becoming the treatment of choice for infertility problems. The description of the short and little understood physical world ofthe pre-embryo, during its extra uterine phase is presented through an ethnographic account of the Vancouver 1VF programme. As an example of an ethnography of science and technology, it situates the pre-embryo within a particular cultural and historical context. The discourse analyses expresses a variety of opposing interests about the cultural values of creating pre-embryos. It places the pre embryo within a network of social relations constituted of those people with a vested interest in its creation.  While the discourse analysis makes explicit the fimdamental  differences in relations of power and hierarchy, a feminist anthropological perspective examines 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 can be culturally constructed as a valued entity in its own right.  (i)  Critical Interpretive Medical Anthropology The critical interpretive approach which has been embraced by mainstream  anthropology is concerned with social life as “fundamentally conceived as the negotiation of meanings” (Marcus and Fischer 1986:26). This approach has been taken up by some medical anthropologists, who have begun to analyze beliefs and practices of medical 16  systems in terms of “the way in which all knowledge relating to the body, health and illness is culturally constructed, negotiated and renegotiated in a dynamic process through time  and space” (Lock and Scheper-Hughes 1990:49). This theoretical positioning provides a research framework which can incorporate elements of political economy, social constructionism and phenomenology. Health care has frequently been discussed within the framework of political economy (Navarro 1976; Doyal 1979). The latter according to Ortner llrst emerged in the United States in the l970s (1984:139).  Medical anthropologists have used political  economy to discuss class relations and the capitalist system in relation to studies of biomedicine’s effects on other cultures healing systems (Taussig 1980; Singer, Baer and Elling 1986).  Scheper-Hughes and Lock(l986) and Lock and Scheper-Hughes (1990)  have suggested the critical interpretive approach as a possible unifjing paradigm, because it reconciles the polemicism between culturological and political-economic perspectives within medical anthropology (Johnson and Sargent 1990). A critical as opposed to a clinical perspective is advantageous in order to understand 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 in  geographic, historical and cultural specificity, especially because the Western scientific endeavour 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 the hegemony ofpositivistic science and replaces it with a focus on negotiated meanings, in an attempt to explore the notion of what Turner (1986:2) refers to as “embodied 17  personhood”. This is the way in which the relationship of cultural beliefs connects with health 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 often uncovered as a result of the interaction between the researcher and the researched. The tendency for epistemological scrutiny to be suspended for Western social science and medicine has to be addressed (Young 1982:260). Therefore, in this research I have had to deal with my own cultural assumptions about family construction as being preeminently biological and the place of infertility in that scheme; as well as preconceived notions that medical interventions, however technological and experimental, will provide solutions to problems and lead to cures. This study incorporates the critical interpretive approach in order to make sense of a western health care phenomenon, the technological treatment of infertility and its by product the human pre-embryo.  It also enables the union of the otherwise disparate  threads of the personal experiences, economic, legal, biomedical and feminist issues about pre-embryos, which have been assembled through my ethnographic explorations and documentary research.  In other words, I contextualize the “local knowledges” I have  collected in this research within the historical context of national and international developments in NRTs.  The Euro-American cultural imperative to create biologically  connected 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 illogical in contrast to the majority of the world’s population which has hardly started to get to grips with fertility problems; a world that is full of children living in dire poverty, who appear by Western standards to be neglected.  But paradoxically, the point that is  sometimes missed by well-meaning aid agencies is that large families with many children, in the developing world are valued for other reasons 18  -  for example children’s contribution  to the family economy, their support for parents when elderly in societies without social welfare nets and for a variety of religious reasons. The motives behind promotion and provision of I\IF babies appear comprehensible when a “hi-tech” infertility therapy in located within the political economic framework of the self.serving complicity of the industrial medico-techno-pharmaceutical complex. Given the gendered, racial and classist aspects of NRTs, it becomes apparent why only the rich in the developed world have access to such technology, and conversely, why it is the poor and racially disadvantaged of the third and fourth worlds, who provide the raw materials (ova, sperm, embryos, organs etc.) and the services (experimental bodies for human contraceptive drugs and device trials, gestational surrogacy), which make these technologies possible. Corporate consumerism in the case of NRTs shifts from the retail trade sweat shops of Asia to the fragmented medicalized bodies, who happen to be predominantly women, especially poor women. Anthropologists have been noticeably absent until very recently from the critique about the paradox of “infertility-as-disease” control in the developed world and the more critical “fertility-as-disease” control in the developing world. In the 1980s some studies examined cultural adaptations to infertility problems in Affica (DelVecchio-Good 1980; Boddy 1988); and studies published in the economic and ecological development literature addressed issues concerned with women’s health and lifestyles (a few examples are Hill 1988; Mies et a! 1988; MoCormack 1988 and 1989, Raikes 1989).  Currently  anthropologists are beginning to focus on issues of overpopulation and “fertility-asdisease” control in global studies, noting that “infertility-as-disease” control is a particularly advanced capitalist concept (Inhorn 1994). Combining ethnography with epidemiology 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 of 19  infertility 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 as HFE), a number of anthropological responses (Wolfram 1987; Strathem 1992(a), 1992(b)) have been documented, which link the English kinship system with the recommendations of the Wamock Report and HFE Act. As yet little attention has been given to anthropological interpretations of the complex kinship dimensions, and in particular the gendered aspects of the new reproductive technologies. Finally, the critical interpretive approach in medical anthropology brings together not only the contributions of social constructionists and neo-Marxist political economists, but phenomenologists also. The bodily experiences of women through the life cycle, often seen as medical metaphors, have been the subject matter of studies by anthropologists and sociologists (Sontag 1978; Martin 1987; Beyene 1989).  The silent pain of infertility,  particularly for women, is projected through metaphor (Sandelowski 1986) and the symbolism of monthly grieving as a ritual process (Williams 1988). Often for infertile couples the negotiated meanings result from ambiguous responsibility in the doctor/patient relationship on couples undergoing infertility treatments (Becker and Nachtigall 1991). The lived experience of a physical and emotional roller coaster for women who undergo the 1VF procedures project the personal anguish of repeated desperate attempts to achieve a pregnancy (Modell 1989; Sandelowski 1991). The use of a critical interpretive medical anthropology in its fullest sense is limited in this thesis in that, as I explain in the preface, I was unable to gain access to those silenced voices so important to the negotiation of meaning, principally those people undergoing IVF technology. Firsthand, rich subjective accounts of personal experience not only would have helped overcome subjective/objective dichotomies, but would also have contributed to a fully rounded ethnographic account of a medical technology. In this 20  thesis, I have attempted to include other unauthorized voices those of women who, while -  not personal participants in the technology, have very real concerns about it for the health and welfare of women. This view acknowledges issues for women, based on race, class, disability and sexual orientation, which as yet have received little attention in the anthropological literature in relation to new reproductive technologies.  (ii)  From an “Anthropology of Women” to Feminist Anthropology The subject “woman” is largely ignored in the cultural fascination with IVF  technology and the production ofpre-embryos. This thesis attempts to give recognition to the ways in which reifjing pre-embryos often leads to the marginalization of women’s problems and to the disappearance of “the woman in the body” from the accepted symbiotic relationship between a woman and her pre- embryo/fetus. The development of a feminist anthropology has provided a method that ensures women are kept central to the analysis. Feminist anthropology emerged out of the “anthropology of women” in the early 1970s, in an attempt to give recognition to the problems whereby women were represented 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 had found that the initial solution to eradicating male bias in the discipline by simply adding women into the traditional equation simply did not solve the problem of women’s analytic invisibility. This bias would not go away, because antbropologists were themselves heirs to 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 rework 21  the universal category “woman” and thereby to construct women’s topics as essentially as interesting 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, not assumed, in the same way as categories such as “marriage’, “family” and “household”, all of which are culturally and historically specific. In this manner the theoretical trajectory of the “study of women” was shifted to the “study of gender”. 15 Anthropology and feminism have both had to cope with the concept of “difference”. As feminist anthropology developed, the problems of identifying the real differences between women’s situations, experiences and activities globally had to be faced. New theoretical constructs were required to recognize “otherness”, based on the differential experiences shaped by gender, class and race. Researchers, who are “women of colour”, are now challenging the western bias, the ethnocentrism of anthropology’s colonialist past and point to the racist assumptions of much anthropological theorizing and texts. All too often there is an assumption that the anthropologist is white, in the same way as in the past it was assumed that the anthropologist was male. 16 Thus, exclusion by omission is still exclusion. Moore (1988) advises that we need to reformulate the privileging of the female ethnographer and the power relations of the ethnographic encounter, because although women in all societies share similar problems and experiences, these are camouflaged by 15 A useful volume edited by M. Strathern, Dealing with Inequality: Analyzing gender relations 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 colour president of the National Action Committee (NAC) on the Status of Women, in that feminist assumptions about women’s inequality have reflected that of white, educated, middle-class feminists, thereby excluding by omission the variety of discriminations against women based on race, class and sexual orientation. These assumptions are beginning to be related to the differential use and access of NRTs. 22  different experiences worldwide with respect to race, the colonial experience, the rise of capitalism and the effects of international development projects. She maintains that the feminist anthropology of the future will therefore not only be involved in reformulating anthropological theory, but also in reformulating feminist theory. She advocates that the feminist critique in anthropology has been, and will continue to be, central to theoretical and methodological developments within the discipline as a whole. The basis of the feminist critique is not the study of women, but the analysis of gender relations, and of gender as a structuring principle in all human societies (Moore 1988:vii). In this research I make explicit the gendered dimensions of a critical interpretive medical anthropological approach in relation to the creation of the pre-embryo.  (iii)  A Feminist Approach to Discourse Analysis  A feminist approach to discourse analysis focuses on the mniner in which power is produced through processes of knowledge acquisition. This is accomplished through a plurality of discursive practices. These practices often make “scientific” claims to “truth”, which have the effect of excluding, marginalizing or constructing as deviant other discourses of human activity and thought (Boyd 1991). Therefore, dominant discourses always have the effect of silencing suppressed ones. Foucault’s scholarship on discourse analysis has been instrumental in revealing the link 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 and medicine, claim to speak the truth and thus exercise political power in a society that values that notion of truth. Smart claims that this is the case for law, because law does not, nor need not, make scientific claims to truth (Smart 1991:195-198). “subjugated knowledges”, such as women’s knowledge (ibid: 196). 23  It can disqualiFy Boyd explains how  discourse theorists stress that power is constructed in and through language because language as discourse always embodies a standpoint or claim to truth. In reality, we are always in the “process of absorbing and filtering the various discursive fields we encounter, 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 “a  hierarchy of discourses” (Soper 1990:241). Critical comparison of multiple sources of evidence provides a method for uncovering the common ground of events and experiences which are recognized and validated in disparate discourses. Therefore the collation of such discourses provides an ethnographic or “thick” description, regardless of the fact that the articulation of competing discourses may result from significantly different understandings of the cultural event, behaviour or category in question. Tyler has explained in his postmodem approach that contemporary ethnography can act as “a superorclinate discourse to which all other discourses are relativized and in which they find their meaning and justification” (Tyler 1986:122).  This study explores the knowledge claims of the three highly specific  discourses I have selected by means of giving voice to those complex and contested understandings which are being constructed about the pre-embryo as a newly emerging cultural category. Within each of discourses I examine there is no one monolithic discourse. Nurses use knowledge frames that are different from doctors, whose knowledge is different from biologists, social workers and so on. Lawyers who use critical legal theory may well construct the law in a different way from mainstream practicing lawyers. Feminist lawyers formulate their understanding from a critical approach that espouses feminism. Feminists may subscribe to a number of theoretical approaches, socialist, liberal, radical, humanistic, critical race theory. Some may be scholars, others social activists. Each view tints the 24  understanding of cultural issues in a slightly different hue. However, regardless of the subtle persuasions, each of the major discourses subscribes to a common epistemology, be it biomedicine, jurisprudence or concerns about gender inequalities. Each is bound by its epistemological umbilical cord to its major profession, discipline or view of the world. In this sense anthropologists are no less suspect, as Whittaker’s (1981) discussion of the nature of ethics and the clisjunctures of the collection and interpretation of fieldwork data suggested Perhaps it is enough to say at this stage that, to acquire knowledge and to interpret it with humanity seem to be ethical requirements of the human endeavour. A beginning answer may lie in developing further the anthropology 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 an epistemology sympathetic to the ethos and responsibility of anthropology. Perhaps, meanwhile, the only adequate answer lies, as it does for Kierkegaard, in indefinite and continual questing (Whittaker 1981:449450).  Foucault’s concept of discourse based on the knowledge/power nexus is being used by many feminist scholars as a means of opening up ways of thinking about power and privilege in society in terms of discourse analysis.  Recently, Canadian feminist legal  scholars, Gavigan (1988) and Boyd (1991) have adopted this approach in order to replace ideology with experience. In looking at some of the ways in which the law discriminates against women, they take up the postmodemist challenge to the assumption that ideology masks the variety of experiences in women’s lives, many of which are largely unrecognized. 17 17 Gavigan (1988) explains that the notion of ideology of motherhood hides the true experience of mothering, while Boyd (1991) examines this in relation to child custody and suggests that in thinking about multiple experiences and possibly multiple ideologies, we would do well to examine wider ranges of discourses. Their argument is that all the 25  Foucault’s work has also informed the work of feminist scholars such as sociologist, Dorothy Smith and philosopher, Nancy Fraser, who have developed novel ways of looking at dominant and oppositional discourses. They link feminist activism and analysis 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 potential means of empowering women. Perhaps there is no better way to view this strategy than in the proliferating feminist and feminist disability rights discourses which combine feminist theory with the gendered aspects of daily living.  In the context of NRTs, the power  struggles between dominant and subjugated discourses are made clearly apparent. Fraser has constructed a model of social discourse, which is designed to bring into relief the contested character of “needs talk” in social welfare societies (1989:160). She situates power in “the institutional fabrication and operation of expertise” (ibid: 11), using Foucault’s (1980) concept of knowledge/power.  Similarly, Smith envisages power as  embedded in the “ruling apparatus” (1987:160), such as government, law and professional organizations, as well as the discourses of texts, which interpenetrate multiple loci of power.  Thus power percolates “capillary-like”, to use Foucault’s term, through our  everyday experiences. She calls this strategy “institutional ethnography”, which explores the social relations that peoples create through their daily practices.  This research  subscribes to a feminist ethic (Whittaker 1994a) which explores the power relationships implicit in the authorized discourses of medicine and law.  Through their colonizing  intellectual knowledges and institutionalization of commonly accepted practices, they have  voices of parenting, beyond the legal model built on the nuclear, heterosexual, stable, middle-class, white model need to be heard. 26  the capacity to subsume and repress those other discourses, such as feminist and disability rights discourses, which struggle to be articulated and heard.  W  TILE BRiTISH COLUMBIA 1YF PROGRAMME 18  There is only one 1VF programme in British Columbia, the most western of the Canadian Provinces.’ 9 The mountainous terrain broken up by long valleys of rivers and lakes accommodates many remote communities with limited medical facilities. Therefore many British Columbians receive specialized medical care in Vancouver, the largest city, which is located in the most south-westerly corner of the Province, forty miles north of the Canadian/United States border. The majority of the tertiary referral services in British Columbia are based in the University of British Columbia teaching hospitals complex, which serves a provincial population of approximately four million people.  The IVF  programme is a unique infertility technology service within the Division of Endocrinology, and among a number of specialized tertiary referral services, 20 which are included within the University ofBritish Columbia Department of Obstetrics and Gynaecology.  18 The use of the term programme describes the protocols, the processes that a patient undergoes to produce multiple ova and that the gametes undergo to become pre-embryos and 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 to the Vancouver Hospital. Its medical director is a reproductive surgeon, who has run a successful Ontario programme. Some of the specialized staff presently working at the University programme have decided to work for the private clinic, which will offer more innovative infertility treatments. Artificial donor insemination (AID), a relatively low technology service, is also available 20 through one programme offered by a Vancouver obstetricianlgynaecologist working in conjunction with an andrology laboratory at the University of British Columbia. Other obstetricianlgynaecologists also provide the service with frozen sperm distributed by 27  ’ the 2 The Vancouver programme is among only fourteen in existence in Canada, same number of 1VF clinics that are available in the San Francisco area. Although the population base per facility may be similar, the Canadian reality is one of enormous geographic spread. For example, there are no programmes available in New Brunswick, Prince Edward Island, Newfoundland and Manitoba. The British Columbia facility was founded in 1982, in response to the growing interest in infertility technology, with the intent of provision of services under the auspices of the University of British Columbia as an experimental programme. It claimed the distinction of producing the first 1VF baby in Canada, a boy, who was born on Christmas Day, 1983. This was the only success during the early phase of the programme, as the programme closed for more than two years in 1983, while it reorganized and relocated. It commenced services again, in May 1985, in new premises at the University Hospital, Shaughnessy site, where its treatment facilities were spread out again in different locations within the hospitaL In its thirteen years of existence, the programme has never possessed a permanent integrated location; it has changed hospital facilities three times, has been administered by three medical directors and three nurse co-ordinators. However, throughout its uneasy  sperm banks outside of the province. The Department also provides sexual medicine and recurrent pregnancy loss programmes. 21 In Kyoto, Japan, in September 1993, the International Working Group for Registers on Assisted Reproduction reported that in 1991, 10 Canadian clinics reported to the Canadian IVF Registry, which is co-ordinated by Dr. Arthur Leader, professor of Obstetrics and Gynaecology at the University of Ottawa. 175 clinics reported to the United States IVF Registry (Fluker and Ho Yuen 1993:883). There are 50 registered programmes in the United Kingdom, according to the Interim Licensing Authority (1991). 28  existence, the composition of the medical staff and the laboratory director has remained 22 the same. The majority are university appointed geographic fill-time professors. The director of the gamete laboratory is also a full professor in charge of research and graduate students in embryology. He receives a retainer for his responsibilities in overseeing the laboratory and its staff Two women physicians were appointed later to the core of male physicians.  The remainder of the staff IVF and operating room nurses,  laboratory biologists, social worker/counselor are all female employees. In general, most of them have been with the programme for many years. The head biologist and the social worker were employed when the programme moved to the Shaugbnessy Hospital site in 1985. Interestingly, one of the main competitors for the growing number of British Columbians seeking infertility services is Christo Zouves, who was the first permanent medical 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 waiting list for the University of British Columbia IVF programme knew Zouves, he had no difficulty in luring them to his programme through a number of sophisticated marketing strategies.  Similarly, two new programmes in Washington State have adopted similar  marketing strategies. Despite these competitors, the University programme has remained faithfiul to its mandate of providing IVF in its most conservative form to heterosexual couples, living in stable relationships, using their own gametes, and with the resources to pay for a medical service, which is not provincially funded.  22 A geographic fill-time (GFT) professor is a designation given by the university to physicians whose primary responsibility is teaching students and conducting research. They are permitted to provide restricted services to patients, for which they are remunerated through the provincial Medical Services Plan. 29  V  ChAPTER OUTLI1{E  In Chapter 2, I discuss how anthropologists are no strangers to the ways in which cultures construct understanding about the meanings of the beginnings of human life. While comparative studies preoccupied earlier generations of scholars interested in traditional kinship patterns, since the sixties the focus has turned towards an examination of how Western, so called developed societies, understand their kinship arrangements. More recently, with the emergence of feminist anthropology, a methodological corrective has taken place to factor women’s experiences into the picture. This reappraisal in gender studies has produced accounts of procreation stories, which demonstrate how women make sense of their reproductive capacities; and how their cultural ideologies to a large extent direct their lives, including their procreative lives. The new procreation stories which are emerging from the use of new reproductive technologies, have profound implications for the category “woman”. In chapter 3, I show how the innovation of 1VF technology has not just suddenly become significant, but rather is a link in an ancient and tenacious chain of fascination with human fertilization and conception by generations of predominantly male scientists.  I  present a chronology of infertility treatments which have emerged from simple IVF technology, as well as some of the new genetic screening technologies which are on the research horizon. An account of the prevailing medical discourses about definitions of infertility and success rates in relation to problems of diagnosis and cure are followed by an historical overview of the only infertility programme in British Columbia.  I  contextualize the Vancouver IVF programme as I experienced it against a backdrop of provincial health care reforms and hospital disruptions.  30  In 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 to oocyte retrieval, to pre-embryo creation and often to the stage of deep freezing  As an  attempt at an ethnography of a medical scientific technology, the research conducted during 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 a close up view of medical procedures that are little understood and seldom observed. Grounding in the medical discourse forms the basis for the legal discourse that is discussed in Chapter 5. It focuses on the social and historical place that law has played in attempting to designate an appropriate status for the pre-embryo.  The socio-legal  construction of it as either potential person or property has resulted in interesting legal cases in the United States. In Canada, the status of the pre-embryo is emerging through decisions in other jurisdictions and the value that Canadians put on their health care system and the decisions ofnumerous committees and commissions that have attempted to regulate the use ofpre-embryos. The challenges to the mainstream legal rhetoric are presented in Chapter 6 by legal feminist commentaries which identit’ how the law often misrepresents the effects of assisted procreative technologies for women’s health and welfare.  A polyvocality of  opinions 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 of manipulation of women’s bodies and eugenic policies targeted at certain groups in society, feminist and feminist disability rights discourses are cautionary about the effects of reifying the pre-embryo at the expense of women’s autonomy. In Chapter 7, I conclude that that there are four overarching issues which link the three discourses. These issues are framed in terms of tensions between polarities, which is 31  a common tendency in Western thought.  The situation of the pre-embryo as a newly  emergent cultural category highlights these oppositions which have been previously bidden. When the status of the pre-embryo is viewed from the standpoint of a vacillation between opposing cultural constructs, it make evident the reason for cultural debate.  32  CHAPTER 2 MEANINGS OF CONCEPTION: FROM TRADiTIONAL KINSHTP STuDIES TO NEW PROCREATION STORIES IN ANTHROPOLOGY  The new procreation stories which are emerging around P/F technology may be examined along two axes of anthropological thought. One direction has demonstrated a change of interest from traditional kinship studies towards new inquiries into procreation beliefs. The other direction has illustrated a reorientation of structural studies emphasizing the juro-political aspects of society. Even today, the long-standing ideas and debates that anthropologists have argued under the rubric of kinship and family studies have relevance for modem studies concerning beliefs and practices about medically assisted procreation (Strathem 1992b).  They challenge us to rethink our preconceptions about kinship  relations and the structure of the family, which is “not a concrete institution designed to fulfill universal human needs, but an ideological construct associated with the modem state” (Coffier, Rosaldo and Yanagisako 1982:25).  If the state’s interest in family  formation relates to ensuring social stability, then it must be argued that it must also have an interest in regulating the complexities of family arrangements. The permutations of family relations produced by the expanded applications of 1VF are becoming increasingly more complicated and as such represent a challenge to government and law. Ideas about symbolism and procreation beliefs, concepts of parenthood, kinship relations, delinitions of family, the rights, obligations and duties vested in the property and personhood aspects of people, all represent cultural constructs that anthropologists traditionally have channeled into kinship studies. The value of studying these ideas has given kinship a privileged place in anthropology. It explains, in part, why anthropologists studied what they did and why sometimes they wore blinkers, which made them culturally 33  blind to their ethnocentric biases.  It also explains in part why until the 1960s  anthropologists’ approaches to biology and kinship have been predominantly juro-political, rather than focused on the cultural variations in procreation beliefs. A change in direction can be seen along two avenues, one stemming from Schneider’s work on the cultural meaning of kinship, which led to comparative studies of conceptualization theory and the other a re-assessment of the distinction between public, juro-political domains in which men are the dominant actors and the domestic sphere, traditionally treated as women’s sphere of activity.  I  CONCEPTION TREORIES: TRADiTIONAL DEBATES ABOuT PROCREATION IN AI TI[ROPOLOGY 4  Anthropological debates about the cultural understandings of the significance of how human life begins have littered the historical anthropological landscape since the nineteenth century debates on the nature of kinship and the possible evolution of social organization from matriarchy to patriarchy.  The early theorists (Bachofen; Morgan;  McLennan and Engels) in reaching a consensus that ignorance of paternity was a feature of primeval society, had brought a closure to any empirical conlirmation. In the early twentieth century, conjectural history began to be replaced by cultural relativity, and the debates re-emerged from the discoveries of some ethnographers (Sharp, Malinowski, Kaberry and Austin) of contemporary peoples, living in matrilineal societies, such as the Australian Aborigines and the Trobrianders, who appear not to recognize paternity. (i)  Virgin Births and Concepts of Paternity By the late 1960s another round of debates emerged about the significance of  kinship and the relationship between scientific biological knowledge and the cultural construction ofbiological processes. These controversial debates which raged through the 34  pages of Man between 1967 and 1969 were ignited by Leach’s provocative paper published in 1967 (reprinted Leach 1969), in which he discussed whether or not “primitive peoples” were ignorant of the facts of physiological paternity.  The spirited discussion  interchanged by Leach and Spiro, aided and abetted by Powell, Dixon, Burridge, Schneider, Douglas, Needham, Wilson and Schwimmer, attempted to resolve within their own ethnocentric frameworks some of the strange cultural practices and ideas of the people they studied. Leach (1969) claimed that rather than ‘primitive peoples’ being ignorant ofthe facts of physiological paternity, it is anthropological ignorance and not the Frazerian contention of “native’s childish ignorance” (Frazer 1914:5:102). Leach argued that (d)octrines about the possibility of conception taking place without male insemination do not stem from innocence or ignorance; on the contrary they are consistent with theological arguments of the greatest subtlety... they constitute a set of variations around a common structural theme, the metaphysical topography of the relationship between gods and men” (Leach 1969:86). He focused on Trobriand Islands’ society, as a cultural example of beliefs that disavow physical paternity. Here, a baloma, a matrilineal ancestor, who decides to return to the substantial world, impregnates a woman through her head. Both Malinowski and Powell had recorded confirmation by informants that matrilineal dogma asserted that male semen was a quickening agent and therefore the male contributes physically to the forming rather than the genesis of the wife’s offspring (ibid). In matrilineal societies, such as the Trobriands, formal dogma of kinship denies the father any status as genitor, therefore physiological paternity, whether it is understood or not is irrelevant (Powell 1968:651). This is in direct contrast to Judeo-Christian doctrines of genitor, as I shall explain shortly. Leach has pursued the argument that common-sense determines that it is improbable that genuine ignorance about physiological paternity should be a cultural fact anywhere. Furthermore he wonders why alleged “ignorance” of physiological paternity  35  should be deemed “primitiveness” in early ethnographic studies, while miraculous birth of divine or semi-divine heroes is a characteristic of “higher” civilizations. Dionysus, son of Zeus, 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 not amenable to anthropologists. The discussants in Man seemed to exhibit a similar inability to compare the limitations of their own ethnocentric Christian belief system.  11  KINSHIP AND BIOLOGY  (1)  Cultural Constructs of Biological Processes Anthropologists have had difficulty maintaining a theoretical distinction between  kinship and biology. Channeling folk beliefs into kinship studies to the exclusion of the biological facts of life may in part be explained by the discipline’s past domination by legal aspects of kinship. “Procreation was felt to be a fact of nature or biology and kinship was felt to be the social recognition and structuring of these ‘real’ true biological relations as they were known or knowable” (Delaney 1986:505). The theoretical position that the roots of kinship were located in the biology and psychobiology of reproduction were asserted by Goodenough (1970) and Spiro (1977). However, Schneider (1968(1980)) in his symbolic approach to kinship provided a cultural account of kinship as a system of symbols and meanings. He focused his concern on the definitions of the units and rules which make up the culture of American kinship, rather than the description of patterns of behaviour.  He identified sexual intercourse as  America’s central symbol of the culture, which can be seen both as a set of biological facts, as well as cultural notions and constructs about those biological facts. These constructs 36  include not only the cultural system of the formal life sciences which explicitly examine those biological facts, but also the informal ethnoscientific construction of beliefs about biological facts.  Both are models of the reality based on the biological facts.  But  Schneider makes the thrther distinction that certain cultural notions are expressed or symbolized by those cultural constructs which depict the biological facts. He states that “Sexual intercourse and the attendant {psycho biological} elements which are said to be biological 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 about kinship” (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 for commitment, which Schneider calls diffuse and enduring solidarity (ibid: 117). 1 Clearly there has been a lack of consensus by anthropologists in defining kinship, and it becomes even more problematic to juxtapose it with biology. Different societies define “consanguinity” in various ways. In modem Western societies there is a notion that certain relationships are biological as well as social, expressed through the sharing of common blood. In North America, Schneider found that kinship could not be discussed without the symbolic representations of “blood relations”.  (ii)  Genitor/Genetrix: :Pater/Mater: Problems of Parenthood A major contribution of kinship theory has been the illumination of the distinctions  made not only between descent and fihiation, but also between pater and genitor. Although the paternity controversy on a superficial examination seems to be about conception, it is not; rather it is about patrilateral filiation. This is a cultural strategy used 1  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 entirely different order” (1984:184). They define kinship as “a systematic body of categories, of rules expressed in terms of these categories, and of behaviour described in terms of these categories and assessed with reference to the rules” (ibid: 186). 37  as a means of keeping descent lines straight and ensuring that social rights and obligations are preserved. It defines how maniage recognizes the obvious biological association of the progeny of a woman with her aflines, her husband’s kin. offspring and legal paternity.  It is about legitimizing  It is about the cultural variety of ways that rights and  obligations are institutionalized across generations (descent) and between lineages (affiance). For example, in the case of Australian 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 the facts of cohabitation” (Leach 1969:87). Similarly the debates about the definition of family and marriage have centered on the legal recognition of children rather than on the procreation relations. Gough (1971) noted the limitations of the classic anthropological definition of maniage as “a union between a man and a woman such that children born to the woman are recognized legitimate offspring of both parents” (Notes and Queries 1951 quoted in Gough 1971). For example, the Nayar institutionalized the concepts of marriage and paternity, which were probably significant factors in political integration, by giving ritual and legal recognition 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, to establish legal paternity, because marriage rites were insufficient for this purpose (Prince Peter cited in Gough 1971). In the early years of anthropological fieldwork Rivers’ (1914) insights into studying the genealogies ofthe Murray Islanders led him to make the distinction between biological and social paternity. Later comparative kinship studies (Barnes 1964, 1977; Schneider 2  Gough (1971) uses the example of talirite and sambandham among the Nayar. The former, the ceremonial maniage of a pre-pubescent girl to a man, with whom she does not necessarily cohabit or engage in sexual relations links matrilineages through interpersonal relationships and affinity. The latter ensures legal recognition of paternity for a woman’s children regardless ofwhether or not their paternity is known. 38  1984) addressed this paradox of conceptualizing parenthood and how it related to kinship terminology. Barnes extended River’s classification, in order to make the triple distinction between pater, genitor and genital father. This strategy reveals how social ideology at the politico-jural level defines the status of “fatherhood” and “motherhood”. Whereas it is commonplace to distinguish between pater, the social father, and genitor, the putative physiological father, it is also necessary to distinguish genitor, the person who is believed to be the physical father of the child from the genital father, who actually “supplies the spermatozoon that impregnates the ovum (Barnes 1964:297). Also Barnes (1977) was the first to investigate this contrast between cultural interpretations of motherhood and fatherhood. He showed how the category motherhood is shaped by fatherhood, and not vice-versa, through clearly interpretable events in nature. Strangely, or perhaps not so surprisingly, this effect continues to be replicated in the value placed on fatherhood over motherhood in the confusion about parenthood with new reproductive technologies (Stolke 1986; 1988). Riviere’s axiom perhaps sums up the situation best “genealogies are social and cultural constructs, and not biological pedigrees” (1985).  Anthropological  understandings about parenthood and kinship as they relate to NRTs could have provided useflul insight for all the commissions and committees that have attempted to address these complex cultural constructs.  (lii)  Categorizing Parents: Some Cognitive Models Theoretical insights into human categorization, based in cognitive science,  4 as well as sociology are beginning to help clarify some of the paradoxes psychobiology,  The same distinction may be made for the category ‘mother’, in the case of a gestational surrogate. She is a woman, who gestates the child of another’s woman’s embryo and therefore has no genetic connection with her offspring. Socially, it is assumed that she is tie genetic mother because she is pregnant with the fetus. Studies in psychobiology discuss the primary bond between a child and its mother or mother-surrogate. Currently Fox’s (1993) study of surrogacy and the Baby M case argues 39  in Western thought.  Keesing’s cognitive psychology and cognitive science model  maintains that ‘what we have called kinship represents cultural glosses placed by different people on the bonding that they have recognized as fundamental to and constitutive of our nature 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”.  He  develops a convergent model of mother (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 by examples in modern science, as well as institutionalized adoption and fosterage (Keesing 1993:7). 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 of prototypy, 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 the prototypic term “brother” in Managalase society, in order “to account for the deviations from classical logic [which] will help us understand the ways individuals generalize and create images of others” (1994:26). The complexities of parental relations are drawn out by the redelinition of the people who perform different aspects of the roles of fathers and mother, which are now made possible by some ofthe new reproductive technologies (see Appendix A). They add to those complex arrangements already established through blended families, adoption and fosterage. When reproductive brokers and clinics also get involved in this venture, the  for the primary bonding of the mother-child relationship, expressed by gestation, birth and early nurturing. 40  legal and social situations become even more complicated, as can be seen in some of the Ameñcan legal cases about control of pre-embryos and children born from surrogacy 5 arrangements.  ifi PROCREATION STORIES: RECONSTRUCTING KINSHIP AND FAMILY  Recently, anthropologists have been examining the procreation beliefs of different cultures within the context of specific cultural world views. It has been argued that some of the earlier debates about virgin births and paternity by anthropologists, as we have already 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” (Delaney 1986:306). Nevertheless, earlier arguments do reveal some interesting ideas about the conceptual problems about social and biological parenthood. While Delaney (1986) does not contest Leach’s distinction between physical and metaphysical realities about paternity, she argues that he fails to see the consistency between them and thereby misses the fundamental issue that “(T)he anthropologist’s task is to try and understand what the concept of paterrnty is” (ibid:501, my emphasis). For her the significance is that paternity is about begetting, and maternity means bearing, and therefore paternity means that the male role in the production of children is understood as the generative and creative one (ibid). The case of Baby M is the best known example. A vicious and protracted legal battle raged over who were the nghtflul parents of a baby born from a contractual surrogacy arrangement between the Sterns, with Mr. Stern being the biological father, and Mary Beth Whitehead, the “surrogate”, who was both the biological and gestational mother. At birth she wished to become the social mother, which led to problems of breach of contract with the Sterns (Fox 1993). 41  Unlike the matrilineal societies discussed earlier, in Western and Middle Eastern societies that subscribe to a monogenetic meaning of paternity, a child is believed to be the result of Hone father, one blood”.  Coffier (1986) and Delaney (1986, 1991) have  demonstrated this in terms of the relation of rights and obligations to cultural ideology in modern Turkish and Andalusian societies.  The child is thought to originate from the  father’s seed planted in his wife, who is then symbolized as the nurturing field.  For  example, rural women’s folk ideas about procreation are essential for understanding every aspect 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 are  expressed through the communal and fundamental understanding of the distinctive differences between male and female roles in procreation: The important distinctions between inside and outside, open and closed, encompassed and encompassing, close and distant, are symbolically integrated in the conceptual model of the female body, which represents and expresses the lateral, spatial, and material dimensions of existence. The male role, conceptualized as generative, originating, essential, and linear, defines these various dimensions. Who you are is related to where you came from. Identity is a function of origin, and origin is the source of legitimacy. This is as true at the social level as at the personal, for the social 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 and Christianity, underpins a monogenetic theory ofprocreation. In this view men produce the divine spark of life, which is carried on from Adam through generations of fathers and sons.  Men are symbolized as flames, women as embers.  mission”  “Procreation is a “sacred  ,  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 modern  42  Turkish scholarship. 6 The monogenetic theory connects kinship and biology, whether Islamic or Christian, by symbolizing the persistent assumption in western thought of male control over the children of the women to whom they are married. It ignores the meaning of 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 pre embryos. It presents a clear symbolic message about who owns the conceptual moment of human life. 7 Studies by feminist anthropologists (Collier 1982, Delaney 1986, 1991, Luker 1984, Ginsburg 1987, 1989, Rapp 1989), which construct procreation beliefs based on specific 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 screening technology. 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 authors show how the dissonant moral views on abortion are constructed on certain ideas about sexuality, individuality, child care and family life.  Each faction in the abortion debate  draws on cultural discourses to engage popular support. Other new procreation stories about pregnancy loss, infertility and adoption are also beginning to appear in the anthropological literature.  Some of these accounts demonstrate how conventional and  conservative notions of parenthood and family continue to be reinforced. Modell’s studies 6  “The flesh, the bones, the muscles, the blood, the brain, and indeed all the faculties and the whole complicated and yet wonderfully coordinated machinery of the human body is all 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 of power and control are inscribed into language and images, such as when the pioneers of P/F, Steptoe and Edwards are called the “fathers” of the first F/F baby and are seen holding Louise Brown in the first moments of her life. The British Government filmed the birth on August 24th 1978. (National Film Board of Canada, 1992) 43  (1986; 1989) on adoption and infertility found little challenge to the accepted cultural interpretations of parenthood and family, despite the use of an advanced medical technology.  In the case of infertility treatments, she describes the interpretations of  parenthood by both patients and physicians, framed in terms of “odds” of a pregnancy when enrolling in an IVF programme in the United. States. She discovered that “(U)nlike other technological and social accommodations to infertility and involuntary childlessness, IVF upholds cultural values about the family, sexuality, and the proper relationship between parents and child” (Modell 1989:135).  While she reserves the conventional  meanings of IVF to the simple model of a technology assisting biological reproduction for married couples, she concludes, and I agree with her, that the “challenge of IVF to conventional meanings will come on other issues: the definition of a pregnancy and of a person” (ibid) in the context of its other expanded applications, such as surrogacy arrangements, ovum donation and genetic research.  1V  TUE POL1TICO-JURAL APPROACU IN MTIEROPOLOGY  In today’s political climate of controversial reproductive issues, it is impossible to discuss NRTs without contextualizing them in their political and legal regulatory framework. In general, the power of law reinforces powerful discourses such as medicine. Emerging critical legal, feminist legal and race theory scholarship is attempting to produce legal reforms which may correct some past injustices. Gendered inequities have exerted and continue to exert social and legal control over women’s reproductive bodies and practices. Likewise, critical legal and feminist anthropologists, interested in the politico jural aspects of cultures for the purpose of ensuring social stability, are attempting to refocus the vision of traditional anthropologists. The relevance of anthropologists’ past interests in thinking about categories of people as either persons in their own right or as 44  someone else’s property is significant in considering how the pre-embryo might be socially and legally categorized as more like person or more like property, or as something of an entirely different order. It may provide new illuminations for thinking about pre-embryos in relation to women’s bodies both in terms of bodily autonomy and the persistent genetic assumption that because “one-half of the biogenetic substance of which the child is made is contributed by the genetrix, and one-half by the genitor. .lEifty percent comes from his mother 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 legal rights and responsibilities to a man’s offspring.  (i)  Rights in Rem, Rights in Personam Since 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 rights of ownership, that is the interests that people place on what they own.  The idea that  status (j)ersonhood) is coiiflated in the social character ofproperty has been well examined in kinship studies.  A.R. Radcliffe-Brown (1952) early distinguished the relationship  between 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 such rights over his son, or a nation over its citizens. (b) Rights over a person ‘as against the world’, i.e. imposing duties on all other persons in respect of that particular person. This is jus in rem of Roman law in relation to persons. (c) Rights over a thing i.e. some object other than a person, as against the world, 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 a different kind from those classified under (a) (Radcliffe-Brown 1952:33).  45  Henrietta Moore puts a more modern slant on Radcliffe-Brown’s characterization of marriage as the acquisition of rights in women by the husband’s kin group.  “These  rights can be of two kind: in personam (rights in the wife’s labour and domestic duty) and in rem (rights of sexual access)” (Moore 1988:64-65).  In rem equates with total  ownership in a person or an object, which is Radcliffe-Brown’s (b) and (c). Thus men are presumed to have the right to ownership and control over their wives’ bodies. Through these  concepts Radcliffe-Brown  explained  succession  and the  transmission of property, with reference to the laws and customs of non-European peoples, in terms of transference of certain rights. Associated with rights are obligations and duties that descent group members exert over each other, towards the group as a whole, 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 and inheritance records straight, in the absence of coded laws. Historically, the Western legal system has made a clear distinction between what is considered “person” and what is considered “property”. Over time through a process of inclusion, certain groups of non-persons, who were considered someone’s property, have attained personhood status; for example, slaves, women, children and the mentally challenged.  (ii)  Twin Universes: Persons and Things  A fundamental problem which has arisen in discussion about the pre-embryo is the difficulty in categorizing it as “person” or “property”. Such attempts to categorize have led to varying degrees of cultural ambivalence. Not only are there misunderstandings about how to label the developing human entity through its different biological processes (as discussed in chapter 1), but also about the very nature of what it is and therefore about how it might be treated. Is it more like property or more like person, neither or should it fit some as yet undesignated in-between category? Is it an entity that may be given away, 46  or sold, or does it have some inalienable quality that makes either of the aforementioned irreconcilable.  These are some of the complex problems which have challenged legal  thinking and led to complicated court cases (see chapter 5). Fundamental notions about “person” and “property” have remained extremely tenuous in Western thought and in the intellectual pursuits of generations of anthropologists interested in law and society. The approach in social anthropology to maniage was heavily influenced by jurisprudence, as anthropologists made the connection between property and marriage (Bloch 1975, Goody 1976, Goody and Tambiah 1973 cited in Moore 1988:64). Levi-Strauss (1969) envisaged women as a form of property which members exchanged in marriage arrangements between descent groups, with the express purpose of forming ties of affiance through the practice of exogamy. Kopytoff (1986) is among a long distinguished lineage of anthropologists, who have explored notions of rights in and of people and rights in things. Their roots are based in the ancient past of Roman Law as disseminated by Sir Henry Maine in Ancient Law (1861). This text was widely read and influential in informing generations of anthropologists, and “even in the mid-twentieth century his formulations of social and legal evolution continued as a touchstone for new integrative theories” (Starr 1989:346).8 The twin concepts of “persons” and “property” are fundamental to our understanding of the radical disjunction between the “individual” and the “thing”, between the “subject” and the “object” in the western tradition.  The fact that these terms are  culturally and historically entrenched in this tradition and not universals has been pointed out by a number of anthropologists writing in the early 1980s about the place of women as objects in non-European societies (Hirschon 1984, Strathern 1984, Whitehead 1984). A  8  Starr cites Fried 1967; Gluckman 1965:113; Nader 1965:25, 1978; Colson 1974; Moore 1978:63. 47  re-examination of their assumptions led them to revise their views to see the women whom they studied as agents of their actions. Anthropologists (Appadurai 1986; Kopytoff 1986), who have examined the cultural perspective of the social biography of things, have also questioned the bipolar thought processes of what constitutes person or property, subject or object, in Western society as a cultural phenomenon, which is alien to much non-western thought. In contemporary Western thought, we take it more or less for granted that things physical objects and rights to them represent the natural universe of commodities. At the opposite pole we place people, who represent the natural universe of individuation and singularization. This conceptual polarity 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 a process of commoditization, and “people”, through a process of individuation or singularization. Anthropologists, of course, have realized that this conceptual dichotomy is by no means a universal. Kopytoff concurs with Durkheim in that what is individuated or singularized is sacred. And i1, as Durkheim (1915; original publication 1912) saw it, societies need to set apart a certain portion of their environment, marking it as “sacred”, singularization is one means to this end. Culture ensures that some things remain unambiguously singular, it resists the commoditization of others; and it sometimes resingularizes what has been commoditized (ibid 73). The most blatant example in the early modern European state was the neglect of this distinction in the practice of slavery. Only with the abolition of slavery in the West were slaves, in particular male slaves, resingularized to the status of persons. But it was to take until the early twentieth century through the struggles of the suffiage movement for women to be fully included into Canadian society as “persons” in 1929 with all the  48  contingent individual rights. Earlier they were considered, as were their children, the legal possessions of their husbands, without the right to control ownership of property, or retain custody of their children on divorce.  The legal status of children is even changing  nowadays as laws are recognizing certain children’s rights as separate from parental control However, for “(W)hatever the complex reasons, the conceptual division between the universe of people and the universe of objects had become culturally axiomatic in the West by the mid-twentieth century” (ibid 84). Kopytoff sees the abortion debate as the best example ofthis polarity between the universes ofpeople and things: It is best exemplified in the cultural clash over abortion, which has raged on throughout the twentieth century than it ever was in the nineteenth, and that this clash should be phrased by both sides in terms of the precise location 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” 9 The proliferation of gender studies in anthropology, since the 1970s, has served to  revitalize feminist scholarship on reproduction. Often considered as “a “woman’s topic”, the study of reproduction by anthropologists has never been central to the field” (Ginsburg and Rapp 1991:311).  Up to this time, previous research had addressed comparative  studies focused on the variety of beliefs surrounding a wealth of reproductive behaviours worldwide.  However, Ginsburg and Rapp (1991) point to the trend in anthropology  towards a political economic approach, which incorporates the central insight about “the  Off-centre is Franklin, Lury and Stacey’s (1991) term. 49  many ways that power is both structured and enacted in everyday activities  -  notably, in  relations 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 of  reproduction, including state and other powerful institutional controls, such as multinational corporations and international development agencies. The authors claim that by examining the multiple levels on which reproductive practices, policies, and politics so often depend... such a synthesis {of local and global} can reframe the way anthropologists study this subject, and move the investigation of reproduction to the centre of anthropological inquiry (ibid:3 13). Situating 1VF therapy within the global and local political economy of health provides an overarching framework for examining the current ‘local’ and ‘global’ struggles over delining the pie-embryo’s emerging status through the discursive practices of those with different vested interests. New versions of modern procreation stories are emerging from these discourses, which add to those other stories, which have been identified recently by anthropologists. They make explicit how issues surrounding 1VF and pre embryos often reinforce the old stereotypical ideas of male control over reproduction and how in privileging previously marginalized voices, that feminist cautions about the consequences 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 thought about kinship and family. In the past, because procreation beliefs were subsumed within kinship studies, which theories were given a privileged place in anthropology, procreation stories were poorly represented. Here exists an interesting analogy between the dominant legal-jural focus in the discipline as represented in kinship studies, and the underrepresented power dimensions of women’s interpretations in procreation stories. Currently, we are witnessing a similar pattern with male-dominated interest in the science 50  and technology of artificial procreation and embryo research. The research oriented focus rests on providing an ideal environment for creating embryos, which then can be manipulated in a variety of ways. This strategy has the facility to eclipse the gynaecentric story of women’s repeated attempts to reappropriate control over their reproductive capacities, which reinforces the symbiotic relationship between a woman and her embryo/fetus. Metaphorically, the male nurturer becomes “technology” (culture), while the female nurturer remains “woman” (nature), waiting to be tamed, or rather controlled, by culture. Thus paternity and maternity continue to be socio-legally constructed with NRTs in a particular form ofpower struggle in western society. As noted earlier, there has been a long tradition of debates in anthropology about the meanings ofpaternity and maternity. They have largely been constructed in terms of juro-political factors, rather than the historically and culturally situated meanings. After nearly a century of myths and misrepresentations about conception issues, gender studies in anthropology are now providing a corrective, which provides significant insights into the power relations within assisted procreative technologies.  (ii)  Legal Anthropology and Relations of Power A new generation of anthropologists (Starr and Coffier et a! 1989) interested in  legal studies have taken up that challenge and advocate treating “law as the symbolic representation of interests of particular groups, especially those groups in power” (Starr and Coffier 1989:24). society.  They do not subscribe to the claim that law maintains order in  They conceptualize “law as a historical product rather than as a universal  category” (ibid). Along with their colleagues in mainstream and medical anthropology, 10  These medical anthropologists include those who attended the symposium sponsored by the Wenner-Gren Foundation for Anthropological Research in Portugal in 1988. They reflected on the past and present historical developments in medical anthropology and collaborated on a volume edited by Lindenbaum and Lock (1993), in which they linked three previously unrelated domains of anthropological inquiry; human biology, the cultural 51  legal anthropologists are taking up the challenge to examine the circumstances, which according to Polier and Roseberry’s (1989) illuminations, have created a world that appears to be ahistorical and without structure. Over thirty years ago, J.A. Barnes’ argued that social anthropology should take the political struggle as given and examine how in that struggle various institutions including the law are used (Barnes 1961:194). Recently, legal anthropologists have breached sub disciplinary boundaries and have revitalized the field of legal anthropology by conceptualizing law and legal forms as historical products “embedded in and created both by particular historical circumstances and by interrelationships between local, national and international events” (contributors to Starr and Coffier 1989:24).  In recognizing the  asymmetry of power relationships and temporality, Starr and Collier (1989) no longer isolate the “legal” as a separate field of study. Instead, they refocus their analysis to wider  systems of social relations, which elucidate the relationship between social action, cultural ideology and economic conditions. June Starr argues that “{A}nthropologists should never have let the ancient Romans speak to us for so long in the accents of nineteenth century Europeans” (Starr 1989:365).  In her re-examination of Maine’s scholarship, she maintains that he  extrapolated often mistakenly from Gauis’ text Institutes to assume that Roman women had a considerable degree of control over their persons and their property in the second century A.D. Coveting a position in the Indian civil service, Maine seemed less aware of the continuing perpetual tutelage of women in his own countiy) 1  construction of knowledge and power relations. Some revisionary accounts were produced, which uncovered “the processes by which certain forms of knowledge achieve a ioral 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 form of a trust, so that male trustees and guardians had the true decision-making power concerning sale, investment, and so on. Thus in Great Britain in that period there were 52  {A}ncient law knows next to nothing of individuals... The Roman distinction between the Law of Persons and the Law of Things.. .though extremely convenient, is entirely artificial... The separation of the Law of Persons from that of Things has no meaning in the infancy of the law.. .it is more likely that joint ownership, and not separate ownership, is the really archaic 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 society has left a plain and broad mark in the life-long authority of the Father or other ancestor over the person and property of his descendants, an authority which we may conveniently call by its later Roman name of Patria Potestas (ibid). This thesis examines the part which is being played presently by law in building a legal understanding about the pre-embryo by privileging it as a new independent social category, divorced from its universally perceived symbiotic relationship with the gestational  “woman”.  I question how it is that law has unknowingly become the  accomplice to a set of circumstances which by raising the prolile of the pre-embryo as in need of regulation, has both submerged and polarized the previous symbiotic relationship with a gestational woman How has this affected the control that a woman had over her bodily integrity in relation to her conceptus? In rei1,ring the pre-embryo to give it a “life of its own”, how has this assisted the trend towards shifting the pre-embryo from potential person to circulating property?  certain parallels to times in classical Rome. Between 1881 and 1887 the Married Women’s Property Act became law in Britain, giving female British citizens the right to hold property directly in their own name and to make decisions concerning sale, alienation, purchases, and the like” (1977:35 8). 53  Vi  CONCLUSION  A variety of issues that anthropologists have studied throughout this century have relevance for a modern study of the pre-embryo as a new social category. Traditional  debates about concepts of paternity, which later led into symbolic studies about cultural constructs of biological processes have a particularly modern application in how to interpret the underlying cultural significance of paternity and NRTs. Kinship studies have revealed that juro-political statuses in societies without coded laws conflate personhood with 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. The social structure is maintained and the social relations are expressed as responsibilities among relatives  In complex modern, Western society built on individualistic and  nuclearized family ideals, there is a tendency for this cultural construct to become buried. But I argue that the fimdamental values have consonance with the continued preoccupation about the relevance of biological connections. In terms of some of the conceptive technologies, and moreover because of them, it is important to know who is responsible for whose children. Studies in symbolic anthropology undertaken by feminist anthropologists have taken an approach that shows how procreation stories told by women are an integral part of a culture’s cosmology. Procreation beliefs are constitutive of all aspects of a society. Similarly, reinterpretation of the juro-political by feminist legal anthropologists suggest that law be viewed as historically and culturally situated. The law is a symbolic representation ofthe vested interests ofparticular groups ofpeople, most notably those in power. Thus the maniage between the institutions of medicine and law is a particularly powerful and persuasive one. This study takes from the intellectual treasure troves of anthropologs past in order to discuss a very modern and perplexing problem in Canadian society. How should we interpret the pre-embryo created through a conceptive 54  technology, IVF, in terms of its status as person or property, its own rights or others’  rights over it?  55  ChAPTER 3 TILE MEDICAL DISCOURSE: TUE hISTORY OF EMBRYO RESEARCH AN]) TILE BIRTH OF 1VF TEChNOLOGY  The 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 1990:2 8). A fascination with understanding the begimiings of life has involved generations of researchers obtaining access to embryonic and fetal materials, which until very recently has been limited by their enclosure within women’s bodies, except on rare occasions of abortion and still births. In this thesis, I argue that experimental curiosity about embryos has led to a technological imperative to manipulate women’s reproductive capacities, often to the detriment of bodily autonomy. Increasingly, while embryos have become subjects, imbued with potential personhood, women’s bodies have become objects, reproductive research sites.  The old research goals live on in the new  technologies with an advancing level of technological sophistication and finesse.  The  medical construction of infertility as a disease has provided an avenue to the use of an array of new technological innovations, and has created not only “last chance babies” (Modell 1989), but more importantly an endless supply of supernumerary pre-embryos for new research programmes aimed at solving the ultimate questions of DNA structure and gene expression. Medical commentaries about the mysteries of conception reiterate a theme that has been well documented since classical times. Indeed there has been a long tradition of theoretical and empirical medical discourse about human embryological development. This discourse is thousands of years old. According to encyclopedic sources  56  magical beliefs about fetuses in many primitive cultures also appear in the European aichemical tradition and in cabalistic writings, and the extensive discussion of embryology in early Chinese and Indian natural philosophy and medical theory, before describing the ideas of Greek biologists like Aristotle and Galen, which retained their influence until at least the sixteenth century (Needham 1934 cited in Yoxen 1990:30). The next wave of medical interest in embryos were the conception models, which occurred with the preformation theories of the late seventeenth and eighteenth centuries. By the early nineteenth century these were giving way to empirical scientific research on female ovulation and embryo development, based largely on animal studies. This led into the most recent explorations into the origins of life, heralded by the new way of making babies with TVF and embryo transfer. It has proceeded in short order to a chronology of infertility 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 concern for providing treatment for people with a number of medical problems resulting in inability to produce children. The medicalization of infertility and the availability of technological treatments has resulted in the escalating use of conceptive technologies, some with very poor success rates.  However, fascination with embryological research has continued,  while little attention has been paid to environmental or social causes of infertility, let alone a thorough scientific evaluation of the potential iatrogenic effects of those infertility treatments presently available. The current medical discourse about pre-embryos can be seen most clearly in the practices of an 1VF programme. In this research an ethnographic component is presented of one such programme, offered by the University of British Columbia, in Western Canada. It is located at the tertiary referral centre in the University Hospital, Shaughnessy site in central Vancouver. It is the only 1VF programme available in the province and  57  provides a unique example of a stable programme, which has been in effect since 1982.1 It represents the most traditional model of 1VF therapy, offering only standard IVF procedures to couples living in stable heterosexual relationships. It has continued to exist despite a crumbling health economy, represented by hospital closures, health personnel layoffs and the rebuilding of a community based health model. The description of the 1VF programme’s structure and service delivery, as it existed in 1993 at the time of this research, forms the basis for later discussions ofmore innovative technologies.  I  FROM “FAILURE TO GENERATE” TO “CONCEPTION IN A WATCH GLASS”  (i)  Classical Greek Models of Procreation Aristotle’s largely unknown and recently translated treaty On Failure to Generate  was devoted to the subject of human fertility. Aristotle has been considered one of the world’s lirst students of human fertility. number of conception theories.  However, he subscribed inconsistently to a  He refuted the prevalent view held by most Greek  scholars, such as Plato, Hippocrates and Anaxagoras, that women were merely the nutritive receptacle for the developing fetus, which was created entirely from the male seed (Temple 1994). This belief reinforced the lineage structure that there could be no descent from the mother.  Aristotle also refuted the prevailing theory on “pangenesis” proposed by Hippocrates that sperm derived from all parts of the body.  Instead he believed that  women as well as men were responsible for conception and also “contribute seed”.  1  In July 1995 a private clinic, Genesis, opened in Vancouver. 58  Aristotle’s logical, yet unsubstantiated beliefs had been preceded by the eccentric views of the mystic poet-philosopher Empedocles and by Democritus. Empedocles believed that while each parent contributed to the heritage of the child, the two portions had been torn apart and the bits reunited in the womb. Demo critus compared sexual intercourse to an epileptic 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 of his time, such as the notion of parthenogenesis (see glossary). This idea was imparted to him by midwives 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 less seriously than the later Christian ideas that arose from the same Egyptian source. These ideas have been much discussed by anthropologists (Leach 1969, Delaney 1986, 1991). Aristotle also theorized that the retroverted uterus impeded conception. Although he did not subscribe to Plato and Hippocrates’ beliefs in a wandering uterus, which “gets discontented and angry and wandering in every direction closes up the passages of the breath and obstructing respiration drives them (women) to extremity” (Timaeus quoted in Temple 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 Renaissance was a theory of simultaneous development of all parts of a new human life, labeled epigenesis. It was subscribed to by Aristotle, Hippocrates and Galen, but refuted by Plato and Aeschylus. The weakness of the theory was that it did not satisfactorily explain how such a complicated process as the creation of life took place. A rival theory to that of epigenesis was that of preformation. Some early writers like Plato and Aeschylus argued that a miniature embryonic life was afready in place within the parent like an egg and embryological development only consisted of growth, not creation” (McLaren 1984:22). -  -  59  (ii)  Preformation Theories By the late sixteenth century the model of epigenesis was being challenged by  preformation theories. McLaren (1984), in his study of the perceptions of fertility in England from the sixteenth to the nineteenth century, recounts how these theories imagined a single parent, a homunculus, afready in existence.  It was not created, but  rather started to enlarge on conception. However, it was to take more than a century for this paradigm shift to occur. Firstly, Wiffiam Harvey, physician to Charles I, sought in vain to discover the human egg.  He has often been called the founder of embryology with his work De  generatione animalium (1651). A coninñtted Aristotelian, Harvey subscribed to the view that 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 finding the homunculus or semen in the uterus, Harvey returned to epigenetic theory, resolving that the egg was the product and not the cause of conception. He rationalized “that the formation of embryos occurred through some sort of non-material influence of the male semen that eventually caused the appearance of a fertilized egg in the uterus” (Yoxen 1990:31). This belief was to persist in Albertus Hailer’s later claim that the ovum became modified 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 and eighteenth centuries, emerged on the Continent in the light of new empirical medical evidence. The human reproductive system, particularly the female system, was coming under intense scrutiny with the growing interest in the study of human anatomy and dissection.  The breakthroughs came in the mammalian research.  Marcello Malpighi  developed a more sophisticated view of conception based on his work on chick 60  embryological development.  Remer de Graaf discovered the fofficles, later known as  Graafian follicles, which he erroneously identified as mammalian eggs.  However, the  mammalian egg was not to be found for another one hundred and fifty years, until discovered in 1827 by Karl von Baer. During all this time there was a growing scientific consensus 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 the discovery by Anton van Leeuweithoek in 1677 of microscopic beings in semen (McLaren 1984:23). Thus Ovists held that the miniature was contained in the female egg, while the animalculists argued it existed in the spermatozoa. 2 The historical variations on the ovist theory are numerous: Thus in John Case’s The Angelical Guide (1697) are references to the human egg being shaken by the sperm into the fallopian tubes; John Blondel 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 ovaries and the act of generation was ‘only the means intended by providence to supply it with life’; and William Cullen’s edition of Albertus Hailer while reviewing conflicting theories on generation held that the foetus was only excited into life by the ‘seminal worms’ (ibid). (iii)  Theories of Ovulation and Embryo Development The birth of modem embryology began in the second decade of the nineteenth  century. 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 into the man and then into the woman and then were born” (1984:159). There is a marked similarity in belief here with the Trobriand Islanders belief in the air or water born child spirits, baloma, described by Maiinowski (1932). 61  results in a mature egg in a fluid-filled sac on the ovarys surface. But it was to take nearly another century until American physician, E. Allen and colleagues in 1919 linked ovulation with the menstrual cycle, when they recovered a human ovum. Meanwhile during the mid-nineteenth century, an interest in how embryos developed and continually reorganized their structure had led to experimental research on mammalian embryos, particularly rabbits.  In 1880 Walter Heape, a Cambridge  physiologist 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 breeding and proved the function of the uterus to be a nurturing structure, unrelated to “hereditary impressions”. At this time research on agricultural animals and medical research on human reproduction were making similar connections, particularly in understanding the action of hormones on reproductive physiological processes. The growing collections of embryos, both mammalian and increasingly human at various stages of development, provided an inexhaustible supply of research materiaL These collections were stored in hospitals in both Europe and the United States in the latter half of the nineteenth and early twentieth centuries.  They aided researchers in  understanding fetal development and tissue differentiation.  These research collections  have parallels in the present proliferation of banks of cryopreserved pre-embryos, which are not needed for embryo transfer. They present tempting sources of undifferentiated human pre-embryonic tissue, which may provide researchers with less complex access than that recounted by Yoxen: However, the important point at this stage is to note that, although experimental embryology expanded significantly in the second half of the nineteenth century with dissections and investigations of animal and amphibian embryos, and although slightly later work in reproductive physiology threw light on ovulation and gestation, work on human embryos was necessarily limited to the dissection of dead or dying 62  It was in effect an extension of specimens obtained in hospital. comparative anatomy (Yoxen 1990:33). By the beginning of World War 1, the strategy of embryo collections funded by endowments had the effect of both systematizing and centralizing the sub-specialty of  embryology through access to post-implantation embryonic specimens.  A modern  research institute was established in Baltimore based on Franklin Mall’s embryo collections and funded by the Carnegie Institution. In Mall’s (1913) plea for an Institute of Human Embryology, he argued that a large collection of embryos, competent staff and the best equipment would help solve problems in many areas, including physical anthropology (Mall 1913 cited in Yoxen 1990:34). Later this collection was transferred to the Medical School at the University of California at Davis. Within half a century, researchers such as Corner, the first director “could draw upon unrivaled archival and technical resources in human embryology to develop his interests in the interactions between the physiology of reproductive hormone secretion, uterine function and human development” (Yoxen 1990:3 5). These discoveries provided the background knowledge that would be preparatory to the development of the technological intervention, which was to become IVF.  (iv)  The Egg Hunt: The Access to and Ethics of Embryology Research  It has been conjectured (McLaughlin 1982; Corea 1985; Yoxen 1990) that access to embryonic material was assisted by the loose guidelines about informed consent from patients and ethical research practices. Morals of the new systematic embryonic research appeared 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 the research practices of gynecologist, John Rock and pathologist, Arthur T. Hertig were 63  suspect. In the late 1930s, they retrieved fertilized ova from women, upon whom Rock operated 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 would ovulate, in the hope of retrieving an embryo from the fallopian tubes or uterus. In some cases surgery was “delayed for several months whilst the women returned to the hospital as charity patients bearing temperature charts, from which the date for surgery was computed” (Yoxen 1990:36). Procuring embryos from “volunteer” poor women, who were receiving charity medical care at the Free Hospital for Women in Brookline, Massachusetts, occurred under dubious circumstances (Corea 1985:101). Although they had consented to surgery, it is doubtful whether they were aware of the destined use of their unfertilized or fertilized ova 3 by researchers whom Corea refers to as “pharmacrats”. At the time, a journalist, Loretta McLaughlin revealed the reason why prestigious doctors were given admitting privileges at the charity hospital and did not charge their patients any operating fees. A hospital appointment “provided almost absolute research freedom, far less interference than at the larger, Harvard-affiliated hospital in Boston proper” (McLaughlin 1982 quoted in Corea 1985: 101). Tn this way researchers obtained carte blanche to experiment on human ova, which they hoped might be fertilized, as patients were asked to keep a record of when they had engaged in sexual intercourse prior to surgery. This surge of experimental research activity reached its zenith in the late 193 Os with an interest in extra-uterine fertilization, known as in vitro (in glass) fertilization. In Corea catalogues a long list of scientific articles, which report on attempts to retrieve and experiment on women’s ova. She comments that in these studies there is little evidence that women consented to the retrieval of their eggs, or even knew they had been removed (Corea 1985:135). 64  an article in the New England Journal of Medicine (1937), by Anon, “Conception in a watch glass”, there was an implication that Rock and Pincus’s research might lead to a cure for infertility caused by obstructed fallopian tubes. It was believed that Rock was the author ofthe article (Yoxen 1990:36). In the early 1940s, Rock and his assistant Miriam Menkin were “attempting to fertilize human ova, obtained from Rock’s hysterectomy patients, using semen from Rock’s junior doctors” (ibid). Rock, a devout Roman Catholic met with criticism from Boston society, leading him to abandon his research in favour of work on the development of oral contraceptives, which proved to be equally controversial research.  65  II.  1YF AND EMBRYO TRANSFER: NEW WAYS OF MAKING BABIES  In 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 capacitating sperm was a necessary prelude to extra-uterine fertilization. While Hertig investigated uterine and embryonic abnormalities, physiologist Gregory Pincus, who had worked in England on animal studies, was involved in hormonal regulation and the maturation of ova prior to ovulation (ibid:35).  Along with other researchers, Hertig went on with the  research, reporting that success had occurred in fertilizing thirty-four human ova, retrieved from two hundred and ten women (Hertig 1959:202-211). In the same year, 1959, Chang described an experiment in which he fertilized mammalian ova in vitro (Adams 1982). Also in the fifties, successful freezing of sperm, retaining fertilization ability, had become possible in the United States. Access to inexpensive, anonymously donated sperm provided both a source of sperm for studies of cap acitation in in vitro fertilization research, 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, whereas in the United States they soon reverted to a profit motive. Increasingly it became a means of economic subsistence for impecunious male students and welfare recipients (Titmuss 1971). Chang’s success at fertilizing ova was not replicated for another decade. The ova extracted from female mammals, namely rabbits, mice and rats were frequently immature  Capacitation of sperm usually occurs in the female genital tract, where the sperms surface acquires the ability to penetrate the zona pellucida, the outer layer ofthe ovum. 66  and research into various culture mediums was necessary to mature the ova prior to fertilization (Adams 1982). Edwards, a British physiologist, who later worked with Steptoe to produce the first 1VF baby, conducted research in the mid-1960s in the United States. He did this in response to his frustrated search for research ova in England (Edwards and Steptoe 1980). Feminist critic, Corea (1985) exposes what she maintains was Edwards’ true preoccupation with maturing human ova and how he used women in his unquenchable thirst for developing new fertility procedures.  She narrates how this concern is often  revealed 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 about the way eggs ripen. Later, while researching in another field, “the eggs were 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 they might have ovarian tissue to “bequeath” him. He would go to the hospitaL While the physician cut into the woman’s body, he would stand, masked and gowned, holding his sterile glass pot “the receptacle for the precious bit of superfluous ovarian tissue”. Dr. Edwards needed more eggs. He never had enough. He “scouted around” for them and tried to rally more doctors to his cause.” He “came away empty handed”. His sources “dried up”. Human eggs were slow coming my way, he wrote “despite the fact that I had struck up ffiendly relations with some of the gynecologists at Cambridge’s Addenbrookes Hospital” (Corea 1985:105). Between 1960 and 1965, Edwards worked on a time sequence for human ova maturation, linally reporting that early fertilization of human ova in vitro had been achieved, with all the necessary tests for procedural safety against chromosomal abnormalities (Edwards eta! 1969). Between 1966-1967, he worked in the United States 67  on two occasions conducting a number of experiments on capacitating sperm. On the first trip he used husband sperm collected post-coitally to place in culture with human ova. On the second visit he persuaded female patients to volunteer for further bizarre experiments in cap acitation, this time using donated sperm.  Thus in collaborating with American  gynecologists (he) collected bits of ovarian tissue, extracted eggs from the tissue, ripened the eggs, collected sperm (from whom he does not say, but in other experiments, he had used his own), put them into porous chambers, and found women volunteers who would allow the chamber to be inserted in them at night and removed in the morning” (Corea 1985:106-107). All this experimental research on cap acitation and nutrient media paved the way for a breakthrough to provide him with a reliable source of ovarian material to test his methods of in vitro fertilization with human ova. A new surgical procedure provided him with unfertilized ova directly retrieved from ovaries removed from female patients during routine gynaecological operations.  No longer would he have to hunt for sources of  ovarian tissue or fertilized donated ova. Afier reading an article by Steptoe, a British gynecologist, who had pioneered the use of the laparoscope to visualize the female reproductive 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 success with fertilizing human eggs in vitro was claimed. 6 Edwards 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 would When Edwards had spent sleepless nights over this experiment, his wife had questioned im 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. An American, Pierre Soupart, working with fertility specialist Howard Jones in Baltimore {wiiere coincidentally Edwards had worked in 1966} has also been credited with having been the first to fertilize a human ovum (1985:138). 68  continue 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 the experiments being condemned by the Archbishop of Liverpool (Singer and Wells 1984:15).  Ethicists Singer and Wells describe the early problems encountered as the  technology was applied to women, who were prepared to undergo 1VF treatment. It took four years of fiddling around with hormones, before the first pregnancy occurred and then this turned out to be an ectopic pregnancy; that is, the foetus was not growing in the womb but rather in what remained of the patient’s Fallopian tube. In this situation, the foetus has no room to grow and it can burst the wall of the tube, threatening an internal bleeding which could be fatal for the mother. The pregnancy had to be terminated. -  Further work produced a second pregnancy, but it spontaneously aborted in the first few weeks. It was not until 1977 that tests confirmed the successful transfer of an embryo to a patient named Lesley Brown” (ibid). The ten years of Edwards’ marathon commuting back and forth between Oldham Hospital in the Midlands, where Steptoe had his surgical practice, and his research laboratory in Cambridge eventually paid off (Edwards 1990:43). The pair had their first success with IVF technology in a naturally occurring menstrual cycle with the birth in 1978 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 pair could have pursued. Other possibilities existed, as Edwards points out “depending on the availability of human eggs and embryos for research, including a study of the causes of chromosomal imbalance, the pre-implantation diagnosis of inherited diseases, relationships between cancer and embryonic cells and many others” (ibid: 43-44).  69  These research  domains are presently providing fertile research territory for current reproductive researchers. This miraculous birth was followed shortly after by one in Australia, where a Melbourne team had begun work in 1970. Carl Wood had tried unsuccessfully to develop an artificial Fallopian tube for a patient with diseased tubes. Researchers, who had been influenced by experiments in animal reproductive biology, discovered that the number of offspring from pedigree sheep and cattle could be dramatically increased by giving the female animal sup erovulatory drugs. This regime caused the production of multiple ova. After insemination and fertilization in vivo, the embryos could be flushed from the uterus  and transferred into less valuable livestock, surrogates with no genetic connection, who could gestate the “quality” embryo (Singer and Wells 1984:15-16). Wood had reported this research at a conference of the Australian Society of Reproductive Biology in Melbourne in 1979. He had suggested an application of animal husbandry, which could be used in humans. The fallopian tubes could be by-passed in women with tubal damage by creating embryos in vitro (in glass) and then returning them to the woman. Unlike the selective breeding in animals, the woman would be both the biological, gestational and social mother of her embryo/fetus/child. This was precisely what 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 in  view of the origins of the procedure, there were always possibilities, once IVF succeeded in humans” (ibid: 16). Inadvertently or not, the specter of a eugenic policy in relation to TVF was on the way to materialization.  70  ifi  A ChRONOLOGY OF IKFERTIL1TY AND GENETIC SCREENING TECHNOLOGIES  When Patrick Steptoe, often referred to as “the father of 1VF”, said “we’re at the end 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 history of research, which had preceded this milestone. His prescience was timely, however, as in the next fifteen years, an explosion in conceptive technologies and genetic screening technologies were about to develop from on-going research. The Voluntary Licensing Authority (1991) in the United Kingdom has catalogued many 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 fertilization in vitro of a human oocyte occurred, followed ten years later by the first IVF birth and  within seven months another one by Steptoe and Edwards’s technique. In between an IVF birth 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 fiftythree days before implantation in her uterus” (Scott 1981:215). Shortly after a birth was reported by the Australian team of Wood and Trounsen. The first 1VF birth in Canada occurred in 1983 as a result of 1VF treatment at the University of British Columbia IVF programme. These early successes were swiftly followed by multiple births using IVF; twins and quadruplets in 1983 and triplets in 1984, all in the United Kingdom  A technique that  allows for embryos to be fertilized in one woman, then “flushed” and implanted into an infertile patient first took place in 1983 (OTA 1988:298). By that year, a deep freeze human embryo storage programme had been developed and a year later, in the Netherlands, the first baby was born resulting from the transfer of a frozen, then thawed 71  human pre-embryo. In 1986, the birth of the second frozen embryo ‘time-warp twin” was born (Brinsden and Rainsbury 1992:23). It is believed that the first embryos to be frozen in North Ameiica occurred at the Mayo Clinic in 1982.  Carolyn Coulam, with the  assistance of an animal scientist, froze seventeen fertilized eggs, which were among twenty she had retrieved from a patient, who did not wish them to be discarded. Due to the Mayo Clinic’s disapproval and demand that the frozen embryos be destroyed and out of respect for her distraught patient, who had consented to the experiment, Coulam left her long-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. 7 Following the first wave of TVF successes, new technologies and practices were developed to help those with other sorts of infertility problems, such as women, who were anovulatory and men with oligospermia (see glossary), poor sperm motility or abnormalities. In 1984, the first birth from an “egg donation” occurred in Australia. By the early 1990s, amid considerable controversy, ova donation was extended to include post-menopausal women, who could now gestate a fetus and become mothers from oocytes 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 the human egg, in order to overcome male factor infertility, In 1993, the first baby was born through a refinement of the SUZI technique, intra-cytoplasmic sperm injection (ICSI). This technique was pioneered in Belgium by Van Steirteghem, who reported to IVF Congresses in Brussels and Montreal in 1994 that data from 1300 ICSI treatment cycles  Personal communication from Dr. C. Coulam of Genetics and IVF Institute, Fairfax, Virginia, May 1995. 72  showed that more than two-thirds of the 000ytes injected by the micro-technique had fertilized. 439 children had been born by August 1994, and there had been a 3.6 per cent major malformation rate, although it was too early to assess longterm consequences (11/F Congress Magazine 1994:4). The human genome project 8 has resulted in some early advances in isolating some of the genes responsible for inheritable diseases. 1VF technology is proving to be a useful adjunct to the research into diagnosis and elimination of certain genetically diseased embryos prior to a pregnancy being initiated. In what is call preimplantation diagnosis, pre-embryos created through 11/F have become valuable “commodities” in a new generation of pre-embryo screening technologies. These technologies are heralded as a triumph for families stricken with family histories of severe inheritable diseases, as they offer 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 in the line of pre-embryo screening research technologies, is conducted at the eight cell stage, three days after fertilization, by removing one cell and using it for genetic testing. It uses a hybridization technique to speed up the screening process, so that normal pre embryos can be replaced in time to develop normally. 9 Nothing is known yet about what it means for future children to be born from pre-embryos, which have been invaded and divested of one of their totipotential cells, then “kept on ice” awaiting the go ahead for implantation or destruction.  8  The human genome project involves mapping the 3,500 million base pairs that comprise ie complete set of genes which humans possess. (See genome in glossary). Since extra-uterine embryos develop more slowly than in vivo embryos, their growth does not keep pace with developments in the uterine wall leading to problems in implantation. It is critical, therefore, that in diagnosing a genetic disorder, that the pre embryo’s viability is not compromised for its later gestation (Newell 1995). 73  In 1990, the first baby was born following pre-implantation genetic diagnosis (see glossary), as a result of the work of Robert 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 the cutting edge of several experimental techniques on humans, which includes the use of deliberately engineered patient-specific DNA probes to check the pre- embryos of a woman known to be a earner for a genetic defect which could cause the syndrome in a male child. Yet another newly pioneered technique aptly named FISH fluorescent in situ -  hybridization is also being applied to humans, in order to sex early pre-embryos, as well -  as genetic defects.  Winston’s team is now working to develop better means of  investigating genetic illnesses such as fragile X syndrome, myotomc dystrophy, Kennedy’s disease and Huntington’s disease. In the future new treatment options will include the direct treatment of “diseased” pre-embryos or their indirect use in treating other life threatening critical human diseases, such as cancer or Parkinson’s disease (Newell 1995:21). The new techniques on the horizon will probably involve embryonic surgery to  replace defective genes. Research clinicians are increasingly undertaking much of this primary research in 10 One research clinician axiomatically their dual roles as clinicians and research scientists. justified the union this way: “Today’s research is tomorrow’s medical practice, so it is  10  A recent example of this is the disclosure by Bernard Hedon, president of the organizing 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 the department of reproductive medicine in Montpelier is “primarily that of a hospital clinician, 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 implantation and endometriosis.. Embryonic co-cultures and assisted hatching are among the most promising techniques in this area” (Hedon quoted in Dorozynski 1995:7-8). 74  important that we know the direction research is taking” (Dorozynski 1995:8). The ethics of the close connection between pure scientific research and clinical application occurring with these pioneer experiments is frequently treated in a cursory manner as exemplified by Winston, one of England’s foremost researcher/clinicians in the field of preimplantation genetics. He is frequently in the media limelight. On the one hand he maintains that there is considerable cross-fertilization of ideas between his research group and his treatment group, 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 research if you practice medicine part-time and science part-time... The aim is to give the scientists as much freedom as they want, not to structure their existence. They have to find what intrigues them rather than follow a collective goal (Winston quoted in Newell 1995:2 1). He maintains that in a democratic country such as Britain, that regulations can effectively curtail any effects from the potential socially harmfiul nature ofpre-implantation technologies. IVF pioneer physician, Jacques Testart in France, is far less optimistic and sees the eugenic threat of pre-implantation technology as not one which can be entrusted to democratic governments (National Film Board of Canada 1992 hereafter NFB). Since 1990, approximately eight clinical preimplantation diagnosis programmes have been set up worldwide. In June 1994, a global estimate assessed that from 149 completed treatment cycles that twenty-nine children have been born from this technique. (Nisker 1995:247). 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 research component, funded by the Ontario government.  The treatment arm is directed by  Geoffley Nisker and the research arm by Robert Gore-Langton (NFB: 1992)  Their  approach appears to be consistent with Winston’s justifications for collaborative scientific and treatment ventures. 75  lv  THE MEDICAL DISCOURSE OF INFERTILITY AND SUCCESS: PROBLEMS OF DIAGNOSIS AN]) CURE In 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 the  diagnosis of causes of infertility and attempts to alleviate these problems by a variety of medical means; the other concerns the detection of genetic disorders and attempts to find solutions 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 historical context of a wider scientific interest in embryo research.  This section examines the  prevailing medical discourses that have been designed to establish a definition of infertility and which have then been used to classify infertility as a disease.  The prevalence of  infertility in the Canadian population has been largely based on only three small demographic telephone surveys (CRCNRT 1993: 194-197). Once a population of people are established as infertile and in need of infertility services, such as IVF, the next problem is 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 recent  preoccupation in biomedicine. As with other current health problems, such as AIDS, infertility has multifactorial causes, which are currently poorly understood. However, the epidemiological literature about infertility has begun recently to address social and medical practices which result in known risk factors (Mueller and Daling 1989). In the mid 1980s, population studies started to collect global data relating to human infertility. An extensive World Health Organization (WHO) study was conducted between 1979-1984 in thirty-three centres in twenty-five countries worldwide. This WHO 76  investigation represents the largest data base ever assembled on the characteristics, clinical findings and results of 5,800 couples seeking evaluation of their infertility. Among the findings was the fact that bilateral obstructed fallopian tubes and other infections were related to a woman’s history of sexually transmitted disease (STDs), peMe inflammatory disease (PIDs) and pregnancy complications (WHO 1987:964-965). Statistics compiled for one of the WHO studies projected that approximately 30% of couples in parts of Africa 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 diagnosed each year (Pfeffer and Wooflett 1983), an inevitable underestimation, as not all people will seek medical attention or they may present themselves with other symptoms. 11 Conversely, as one Canadian physician points out “nowadays many couples seek advice or wish treatment long before a reasonable “trial” has occurred they have unreasonably high -  expectations”. (interview with infertility specialist, September 1993). In Canada, infertility statistics still remain inadequately defined, despite the Canadian Royal Commission on New Reproductive Technologies (CRCNRT) conducting three limited telephone surveys between December 1991 and March 1992. The results of these incredibly cursory studies, provided from commission contracts with Canada Health Monitor and Decima Research, have been challenged by the Social Science Federation of Canada (1992) and feminists (Basen, Eichler and Lippman 1993), who have criticized their research practices.  However, the results add to a growing public perception that  One detailed study of a single District Health Authority in England concluded that at least one in six couples needed specialist attention at some point because of an average of two and a half years of infertility (Hull et al. 1985, cited in Doyal 1987:177) This patchy information on the extent of infertility services was recognized in the Warnock Report (Wamock 1985:13). 77  procedures like IVF are a necessary and successfiul service for the 250,000 couples who  CRCNRT believe are experiencing prolonged infertility problems (CRCNRT 1993:194). The first of these Canadian surveys sought to determine the prevalence of infertility in couples in which the female partner was aged 18-44 years. Then CRCNRT assessed the prevalence of infertility in Canada in two ways: by conducting three national surveys and then synthesizing their results and through secondary analysis by examining three other 2 surveys canied out in the 1980s for other purposes.’  It concluded that 300,000  Canadian couples (eight and one half percent), who had cohabited for at least one year, at the time of the survey, were infertile. After two years of cohabitation, 250,000 (seven percent) remained infertile (ibid: 180). As long as forty-five years ago a study had placed the 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 been well recognized that female fertility decreases with increasing age and in an inverse relationship to socioeconomic status (Henshaw and Orr 1987). Similarly, Strickler (1992) indicates that social factors such as sexually transmitted disease, general levels of health and age patterns of child-bearing all have a part in determining these patterns.  (ii)  The Numbers Games The justification of therapeutic intervention has plagued the reproductive medicine  field during the 1980s.  A major problem has been both in defining infertility within  population studies and what constitutes a definition of “success” in infertility treatment.  12 See Appendix 1: The Prevalence of Infertility in Canada Surveys conducted for the Commission and Appendix 2: One-Year and Two-Year Calculations of the Infertility Rate in Proceed with Care (CRCNRT 1993:194-197). -  78  Eiyant, in a study commissioned by the Canadian Advisory Council on the Status of Women, has identified this problem in that the numbers chosen to define “infertility” affect both the perceived magnitude of the problem, and the apparent cure rate. This must be borne in mind whenever infertility rates and therapeutic success rates are discussed” (Bryant 1990:2). In its report, CRCNRT also acknowledged this common misperception and gave assurances of its intention to use the estimates it collected in the Canadian population as a baseline for tracking infertility rates in Canada in the future, as well as for comparison with other countries.’ 3 The CRCNRT in its approach based on medical evidence considered three factors as to how it defined and measured infertility for population surveys (CRCNRT 1993:181186). Firstly, it measured the endpoint, whether pregnancy had occurred, as opposed to failure to carry a pregnancy or failure to give birth to a healthy child.  Secondly, it  addressed 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 infertile  13  Caution has been advised by several groups (e.g. National Action Committee on the Status of Women (NAC) and the Social Science Federation of Canada in accepting the accuracy of the data collected by the Commission. Intense criticism of its research practices throughout its turbulent four year research period has been presented in media and feminist publications, such as McTeer 1992, Social Science Federation of Canada 92, 1993, Basen, Eicliler and Lippman 1993. This time period is based on the evidence that failure to conceive naturally after two years, generally indicates a low chance of conception without intervention. Research suggests that a normally fertile, sexually active couple not using contraception has an average monthly chance of conceiving of twenty to twenty-five percent, counting pregnancies that result in live births (Hull et a!. 1985).  f  79  15 couples who were cohabiting (married or common-law). It noted that unlike prevalence research methods the United States, it was not possible to include in the survey the forty percent of women, between ages 18-44, who do not live with a male partner. Thus it also excluded same sex couples from the population of the study. 16  Implausibly, the  CRCNRT justified this exclusion on the grounds that methods could be refined in future studies, but that infertility estimates in the United States did not differ significantly from those reached by the Commission. As feminists well know, exclusion by omission is no defense.  (iii) “A Take Rome Baby”: Measuring the Rhetoric of “Success” Problems about defining infertility not only relate to who is counted, but what is counted. The categorization of the term “success” in IVF therapy has been both confusing and misrepresentative. For example, national indicators about the success of a treatment such as 1VF is based on the individual reports of physicians and clinics providing the services. Some reporters have termed an IVF cycle as “successfiul” when gametes fuse at fertilization (a technical success). Others register success when a chemical pregnancy has occurred, which is established through an immuno-assay test of maternal urine or blood. A positive human chorionic gonadotrophin (betaHCG) will occur approximately two weeks 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 after 15  An important distinction is made between “prevalence” and “incidence”. Prevalence refers to the number of cases at a point in time, while incidence refers to the occurrence ijae over a period of time (Dorland’s Medical Dictionary 1957). A current response to the neglect of same sex couples’ desires for creating children through both donor insemination and IVF is being considered by the gay/lesbian community in British Columbia (personal communication by lesbian feminist January 1994). 80  embryo transfer (an established pregnancy) will be considered a “success”. (interview with JVF specialist March 1994) While these are meaningful in that they establish certain benckmarks that fertilization and pregnancy have been reached, they do not necessarily translate into a healthy, full-term “take home baby”. ULtimately this is the only meaningful measure of “success”. By the early 1990s the world leaders in NRTs were recognizing the importance of official registration of clinical “success” rates. The registry devised by the Society for Assisted Reproductive Technology (SART), 17 a section of the American Fertility Association and the Canadian IVF registry both encouraged voluntary registration to standardize the reporting according to certain criteria.  Although SART results are  published annually, it still leaves clients at the mercy of those unregulated practitioners and clinics who choose not to submit their statistics to a voluntary body.  The CRCNRT  report has called for immediate formation of a formal national regulatory commission, with greater powers than the existing informal Canadian TVF registry. Its mandate would prevent irregularities in statistical claims to “success” for certain treatments, as it would only license bonajIde clinics.  17  Both the Alberta Foothills Hospital IVF and the UBC WF programmes became affiliated with SART in 1991. 81  V  TUE CAUSES OF INFERTILiTY: MERGING STANDARD MEDICAL, PUBLIC HEALTH AND ENVIRONMENTAL DISCOURSES  (i)  The Standard Medical Discourse Paradoxically, while medical practices are expanding into previously uncharted  social domains of new family relationships, commerce and genetic research, the solutions to identified medical problems are being sought after in areas of society which are not normally associated with health issues. For example, deviant social practices resulting in  sexually communicable diseases and industrial and environmental practices affecting human sexual health also are being implicated as causal links with infertility problems. Most commonly, infertility problems presented in clinical practice are established within parameters of individualized mechanical or physiological failure, rather than a part of broader social factors. The causes of infertility are equally distributed between male factors and female factors, with a third category labeled “unexplained” or idiopathic (see glossary), with no identifiable causes.  Unlike the African Ndembu, who like many  18 in the West infertility is traditional societies view infertility as a collective probleni, constructed as individually created, experienced and solved.  Infertility treatments  therefore focus on individual therapies rather than looking for solutions to the causes in the larger society. Increasingly, it has been left to experts other than health practitioners, 9 Instead these experts focus on the social indicators in with a few notable exceptions.’ the public health and environmental domain, which need to be factored into the diagnostic stew of fertility problems.  18  Victor Turner’s (1969) classic study of the rituals associated with infertility monstrate the significance of commurnty participation in resolving the probleni See John Jarrell (1993) discussion of infertility in relation to toxins in the Great Lakes. 82  Established medical discourse proposes that male factors may affect from eighteen to thirty percent of infertility problems (Collins et al. 1984). Numerous articles in Fertility and Sterility, 20 the official journal ofthe American Fertility Society, point to causes, other than underlying physical factors such as varicoceles and undescended testicles, which may include exposure to lead or dibromocliloropropane (a pesticide), the mumps virus after puberty, as well as smoking and marijuana use. However, most of the preventable factors that have been studied so far affect women’s fertility. This emphasis on treatment of the female partner may in part result from a universal misperception that blame for infertility rests with the female partner. Factors such as past contraceptive history, 21 the prevalence of sexually transmitted 22 and diseases (STDs), specifically chiamydia trachomatis and neisseria gonorrheae; delayed childbirth for frivolous or career development reasons, all support non-compliance in expediting women’s “expected” role of procreation.  Other equivocal risk factors  include inappropriate lifestyle habits, such as excessive exercise, heavy smoking, substance abuse 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 inflammatory disease (PID), which commonly affects fertility, has been associated with intrauterine device (JUD) use, excluding copper-containing IUDs. Conversely, use of bamer methods and oral contraceptives have been shown to protect from STDs and PID. An inverse relationship between risk and the number of sexual partners was also indicated. For a mprehensive list of references see Bryant 1980:36-37. STDs cause twenty percent of the infertility in some populations in the United States according to the United States Congress, Office 1988. Rates in Canada have been dropping since they peaked in 1982 following a steady rise since the 1950s. Rates continue to rise for girls aged 1-4 years and 10-14 years, highlighting sexual abuse of young girls. Girls aged 15-19 were the highest risk group since 1986, 5.43 per 1,000 girls were reported to have acquired gonorrhea (see Bureau of Communicable Disease Epidemiology 1988; Parra and Cates 1985; Hockin 1985; Todd and Jessemine 1987, cited in Bryant 1990). 83  What is not voiced in the discourse is the potential effects of some drugs and devices associated with reproduction, which may prove harmful to women’s health. Rarely are harmful toxic agents in the workplace and the environment mentioned. Less evident in the medical discourse of infertility are the iatrogemc causes, whereby medical procedures may also render people infertile.  Andrew Kimbrell (1993), in his radical  critique of the technological and commercial controls in American society perpetrated through certain NRTs, cites a number of these causes that affect women’s reproductive capacities. These have been identified by The Office of Technology Assessment of the United States Congress and include infections from surgical procedures, surgical sterilizations, treatment for endometriosis, unnecessary hysterectomies, cancer treatments and damage done by contraceptive devices (Kimbrell 1993:69).  (ii)  The Environmental Discourse According to Bryant’s Report for the Canadian Advisory Council on the Status of  Women, in 1990 the Canadian Government spent $3.5 million on research in reproductive technology 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 s •  Alliance on Reproductive Health, 24 drew attention to these facts. She notes that in spite of the evidence, public health issues such as the safety of the workplace, a clean 23  Vandelac, a feminist sociologist, was one of four commissioners hired for the CRCNRT, who was fired along with lawyers Maureen McTeer and Martin Hebert and physician 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 later when Parliament had adjourned for Christmas they were fired, with no recourse for ejuttal. 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 with NAC and interested in NRTs. Their position papers were prepared for response to the CRCNRT’s Report, which was finally released November 1993. 84  environment and better programmes for control of STDs continue to be ignored. For example, questions are beginning to be raised about the fertility status of farm workers in British Columbia. These are mainly south Asian women, whose fertility is alleged to be compromised by pesticide spraying. Similarly, evidence is now being assembled, which suggests a link between pollution in the Great Lakes and human infertility.  A recent Canadian Broadcasting  Corporation documentary, Sex under Siege (1994), in the Witness series, provides fascinating coverage of original research being conducted in Canada and elsewhere, which connects infertility with toxic effluents in major waterways and with compounds found in plastics. Paradoxically, while industry is contaminating Canadian waters and rendering people infertile, other industries, are polluting other Canadian water sources in order to produce a drug which treats menopause symptoms. For example, Ayerst Organics Ltd. of Brandon, Manitoba, a division of the multinational pharmaceutical company, Wyeth Ayerst has recently been implicated in pollution of the Assiniboine River. In order to produce the drug, Premarin, which manages post-menopausal symptoms, the company dumps “a murky and deadly stew, {into} Brandon sewage lagoon four, abutting the Assiniboine River .the waste from a controversial plant that processes the estrogen rich ..  urine ofpregnant mares” (Regush 1994:72).25 Industry has been accused by the International Joint Commission, amongst other 26 The groups, of long-term neglect in cleaning up of dangerous industrial chemicals. 25  This pregnant mares’ urine (PMU), referred to locally as ‘superjuice’, is collected from mares under inhumane conditions, which has environmentalists, animal rights activists and feminists rallying against its production, especially since synthetic forms of estrogen and rogen substitutes are available on the market (Regush 1994). These chemicals include especially chlorine-based pollutants, such as DDT, PCBs and many pesticides, as well as by-products of the chemical, pharmaceutical and plastic industries, which are routinely dumped in the Lakes. Current research links some of these 85  CRCNRT report cited conflicting studies of effects of exposure of pregnant women to PCB bioaccumulation in the Great Lakes. One study associated lower birth weight and smaller head size in the children of affected women, while the other study did not confirm it (CRCNRT 1993:290). A growing number of cases have been reported of defects in 27 babies born to women exposed to toxins in North America. With the perceived increased prevalence of infertility has come the promotion of science and technology as the correct solution to cure infertility. With the complicity of the media has come the notion in the public perception that technical advances may assist in the management of infertility problems.  While surgical correction can permanently  restore damaged tubes, technology such as 1VF in conjunction with superovulation therapy offers only artificial solutions.  It does not cure infertility. Firstly, it offers a  circumventory solution to mechanical (anatomical) disorders, such as obstructed fallopian tubes. Secondly, it creates temporary mimicry of normalcy for physiological (hormonal) disorders of reproduction. As yet little attention is given to socio-environmental factors leading to infertility, whose resolution lies in an entirely different social realm from biomedical therapy. To date, the debate on NRTs has tended to focus on the technologies themselves, rather than the antecedents that are beyond the technical realm.  chemicals, which act like synthetic sex hormones, to reproductive damage to the offspring of animal and humans exposed to them (Vancouver Sun, April 12th 1994: A7). See also Wrell 1993. For example, a high incidence of anencephaly, a rare defect in wirich babies are born with 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 the effluents pumped from the industrial plants of these Mexican border towns along the Rio Grande (Vancouver Sun, January 20th 1992). Tn Vietnam mass abortions have been occurring following ultrasound detection of abnormalities in fetuses of women, two generations after the wholesale spraying of dioxin-containing herbicides, such as Agent Orange (Manthorpe 1994). 86  VI  AN 1YF PROGRAMME IN BRiTISH COLUMBIA  (I)  A Short IListory During the 1980s in response to the rapid acceptance and institution of the 1VF  technology, 1VF clinics opened worldwide.  The British Columbia 1VF programme’s  inception occurred in 1982, at the University of British Columbia, four years after the first 1VF baby, Louise Brown, was born in Oktham, England. It was established within the Division of Reproductive Endocrinology, Department of Obstetrics and (3ynaecology. The inception of the programme was the collaborative work of Gomel, the Department Chairman at the time, Ho Yuen, the present medical director and divisional head, and infertility specialists Rowe and McComb, laboratory director Moon and the first IVF medical director, Poland.  Dr. Moon, the gamete and embryo laboratory director,  reminiscing on the difficulty of getting a successful programme started recalls: Dr. Gomel initiated it, but everyone chipped in to establish the lab. and it took a long time to get our first success in 1983, because at that time the operating room was situated in the basement, the laboratory was situated on the third floor of the acute care unit at UBC. I had to jump around, you know. 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 Brown was born, to Cambridge’s Addenbrookes HospitaL Funding from the unlikely source of the Daily Mail newspaper eventually led to their relocation in the present site, Bourne Hall, a Jacobean mansion. In Edward’s historical account of those early days, when they could not generate operational funding, because development of 1VF had ignited a fiery debate between science and ethics, he reminisced:  87  But instead of a large, filly-serviced clinic with operating theatres, patient beds, and a supporting staff to cope with a heavy schedule of operations, we were offered two rooms in old Addenbrookes’ Hospital; an ancient operating theatre up on the third floor, and a shed on the ground floor for our laboratory. Eggs collected from patients upstairs would have to be taken downstairs for fertilization, and embryos would have to be carried upstairs for replacement in their mothers. Upstairs, downstairs with such precious cargo seven or eight times a day (Edwards 1989:12). -  The neglect of the physical plant resulting in practical inconveniences in both programmes is symptomatic of the early days of operating 1VF facilities with lack of funding, 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 perception has persisted in the medico-political arena of funding. Apart from the province of Ontario, Canadian medical plans have never funded the total 1VF procedures. However, once 1VF became available in British Columbia, there has been no shortage of enrollment in the programme. It has registered routinely about forty patients each month and has a waiting  list of about one year. Up until 1988, some JVF related procedures in the Vancouver programme were covered by the British Columbia Medical Services Plan (Newman 1992).  Oocyte  retrievals were performed by the relatively invasive and expensive surgical technique of laparoscopy, which required a general anaesthetic. This procedure was paid for by the medical plan, as was the embryo replacement, which was billed at that time as artificial insemination by husband, ATH.  During 1988, less invasive and less costly oocyte  retrievals using vaginal ultrasound gradually replaced laparoscopy. Gamete Intrafallopian Transfer (GIFT) also was offered to patients as a variant of 1VF. In this procedure the oocytes are retrieved either by laparoscopy or under ultrasound guidance and then introduced with sperm immediately into the fallopian tube ofthe woman. For some clients this procedure has been considered more acceptable for religious reasons than creating 88  embryos in vitro. The procedure was discontinued by the programme in 1988, except on rare occasions, because its success rates were not any better than 1VF and “the procedure was more invasive and required a general anaesthetic. Also it did not answer the question of fertilization potential for the couple. At least with TVF we knew what the fertilization 28 (one of many telephone potential was and GIFT never answered that question”. interviews with the IVF nursing director to corroborate data. April 1995) As part of a policy to check escalating health costs, in July 1988, the British Columbia Medical Services Plan (MSP) decided to withdraw funding for the IVF 29 Provincial governments have always been responsible for health care, since procedures. 1867. However, in 1988, the federal government decided to progressively withdraw its funding contribution through provincial transfer payments, which put greater pressure on provincial government budgets. This has resulted in provincial governments paying more than the approximately fifty percent that they have paid since the block funding programme was introduced in the early 1970s. 28  A departmental memorandum, covering the month August 16th September 16th 1987, reflects that the sample of GIFT cycles perfonned was very small. In that month only five GIFT procedures were performed and no pregnancies resulted. In contrast, twenty-five patients were induced for IVF, twenty-two of which went to embryo transfer, seventeen after lap aroscopy and five after ultrasound retrievaL In these cases fertilization potential had been proven. There were, however, only five positive pregnancy tests in this oup 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 five publicly funded clinics and several private ones. Patients at the public clinics paid for their own drugs, which cost $1,000-$3,000 per cycle. On February 17th 1994, IVF, except for women with tubal obstruction, was one of several treatments or procedures struck from the list of insured services in Ontario, along with routine circumcision of newborns and repair of earlobes deformed by pierced ears. The Ministry of Health and the Ontario Medical Association drew up lists ofnonessential services to be considered for delisting, in order to cut the province’s health insurance billings by $20 million. (Brooks 1994:970971). -  89  These budgetary changes affected IVF services in a piecemeal fashion. Whereas the initial medical consultation and investigative procedures remained covered by the provincial medical plan, the surgical procedures were not. The IVF laboratory procedures were 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 to one hundred percent through provincial or private insurers.  By 1989, there were  additional costs for cryopreserving and storing pre-embryos. In consequence, whereas in 1985 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. (Newman 1992:5).30 By the end of the 1980s, the costs had tripled according to a Vancouver Sun newspaper article: 1VF now costs $3,500 per cycle, with success rates of 15-20%. The clinic performs 300 procedures a year and 75 babies have been born by IVF since the program started in 1982. Cryopreservation has been available since spring 1989. 50% ofthe embryos survive the process and 6-10% result in pregnancy following implantation (Stainsby 1989:A5). These increased costs were not reflected in noticeably improved outcome statistics of the programme. Prior to 1989, the programme kept an informal, in-house accounting of 1VF statistics. The TVF success rates and the percentages of the indications for clinical treatment 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 incremental increases in success rates for each phase of the treatment cycle (see Table 1). But as noted in earlier, “success rates” of IVF, both nationally and internationally, have frequently  30  See Appendix B for a breakdown of schedule and fees as ofAugust 8th 1988. 90  been misleading. To create uniformity in reporting practices by clinics submitting their statistics to a voluntary registry, reporters were requested to break down the numbers for each of the stages of lyE cycle outcome. These included statistics for the number of 1VF cycles initiated, the number of embryo transfers, the clinical pregnancy rates, as well as the number of live, full tenn birth, including multiple pregnancies and abnormalities. As of 1991, following the policy of other countries, such as Britain, Australia and the US, the University of British Columbia 1VF programme started to submit its statistics to the 32 Canadian IVF Registry, 31 as well as the United States SART Registry.  The Canadian Registry was set up by Dr. Arthur Leader ofthe University of Ottawa. SART, the Society of Assisted Reproductive Technology, is affiliated with the American Fertility Association and is responsible for collecting statistics from all of the 175 registered clinics. This figure includes four clinics in Canada, which joined in 1991, of which the UBC 1VF programme is a participant. 91  I  I  a  )  00  Z6 -  —  — — —  .<  O ‘.0 ‘.0 ‘.0 ‘.0 00 00 00 00 00 00QV  0 00  Q  a —  . .i ‘.0 00 i’.) V 0  z u )  tr1 -  C)  Hc )  —  I—  ‘—  .  Q  —1 00 Ui Ui  —  .  0 0  — 00  . -  .  O 00 ‘.0 -1 I) O i-?’ C  0  L  .  o  —  S  o  00Vi  0  I  WI ,,  C  cr  S S  0  I T1  00000J  z  p  —  - i’.) c L.) 00 0 0 a •- ‘— ‘ 0 0 0000Ui0’  CL)  0  <  c’CD  -  The pregnancies rates recorded in 1985 (20.6%) were high because treatment at that time was restricted to women under thirty-five years old and with a diagnosis of “pure tubal 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 success rates. Whereas in 1989 pregnancy per embryo transfer were 16.4%, in 1992 they had improved by 9% to 25.5% pregnancy per embryo transfer.  As the following table  indicates, when these outcome statistics are viewed in terms of percentage of live births per transfer cycle the improvement over four years is less than 6%. Whereas in 1989 they were 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 are less than forty years old when they sign up for treatment. “Couples must be in a stable relationship, IT[V-negative, and without evidence of unstable or untreated psychiatric iiiness or other conditions that would be contraindications for pregnancy. Since the use of donor gametes is not currently feasible in this program, couples must provide their own oocytes and sperm, thus excluding men with azospermia and women with ovarian failure” (Fluker and Ho Yuen 1993:883).  93  Table 2. Indications for Treatment from 1989 to 1992 Indication Tubal Disease inoperable or 1 year post reconstructive surgery Endometriosis unresponsive to medical or surgical treatment Unexplained 3 years duration Male Factor should have 1 million total motile sperm recoverable per ejaculate Multiple and Miscellaneous infertility factors  Number 1282  Percent 57  207  9  178  8  168  8  404  18  Source: Fluker and Ho Yuen 1993:883  Between 1985 and 1993, at the Shaughnessy Hospital site, there were 2239 treatment 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 or more babies for each cycle started. By 1993, the total cost including medications (on average $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 (Fluker  and Ho Yuen 1993:883-884). By this time, lyE treatments were beginning to be offered for some male factor infertility and for women over forty years, who were already enrolled in the programme. No oocyte donor programme or gestational surrogacy arrangements have been made available to clients.  (ii) The Current Situation of IVF in Vancouver During the period of the research project, the 1VF staffs offices were located in different parts of Shaughnessy Hospital For example, the IVF medical director, who was 94  also the university divisional head of endocrinology and infertility; a reproductive endocrinologist, the laboratory director, scientific researchers and clinical research staff and support staff were all located in offices in the academic wing, close to Children’s HospitaL Here the two endocrinologists and the gamete laboratory director also fliliuiled their university research and co-ordinated their teaching commitments as geographical lull time professors (GFT).  Meanwhile the nurse co-ordinator, nursing staff  social  worker/counselor and two support staff were situated in the Jean Matheson Wing, along with two other infertility specialists, who were also GFT professors in the Department of Obstetrics and Gynaecology.  Three IVF biologists, with occasional assistance from a  doctoral candidate, carrying out research on discarded oocytes, under the direction of the laboratory director, worked in the gamete laboratories. These were located beside the operating rooms. The 1VF ultrasound technologist worked part-time with the IVF programme, and part-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 sophisticated and 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 the core staff, four reproductive surgeons, who conducted private Obstetric/Gynaecology practices, specializing in infertility, in Vancouver were also associated with the programme to assist with oocyte pickups and embryo replacements.  This enabled the surgical  procedures 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 maintained strong ties with each other through the network of long Shaughnessy corridors. 95  The  mission control for this amorphous body of people was managed from the nursing co ordinator’s office, as she was responsible for the smooth daily running of the programme’s interface with a continual rotation of clientele. The overall acinjinistration was directed from the medical director’s office, on the other side of the hospital.  Apart from their  professional cohesiveness and weekly staff meetings, the staff came together for occasional social events, such as an annual Christmas dinner. Operating room staff; which included a Shaugbnessy Hospital anaesthetist and two operating 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 as any embryo transfers scheduled. In part, this is the reason why the waiting lists for 1YF have continued to be approximately one year. In part, it has been due to the ability of the reproductive endocrinologists to schedule time to see patients in clinics two or three times a week for the necessary medical counseling and treatment arrangements. During the hospital fieldwork period, throughout the summer and fall of 1993, room 10 was the only operating room in use and the hospital was in the final stages of its closure and largely deserted. A few nurses still clustered for their breaks to chat and eat in the nurses lounge attached to the operating suite. In February 1993, the Provincial Government declared the closure of Shaughnessy Hospital, in order to save $45 million a year. The wards, which had previously been fill ofveterans, when the hospital was part of the Department of Veteran Affairs, and later as University Hospital, Shaughnessy site, were now full of hospital beds, equipment, filing cabinets and boxes, which could be seen through the open doorways.  A sense of  abandonment and dejection permeated the long corridors and uninhabited rooms.  The  hollow shell of a once vital hospital was reflected in the abnormally loud sound of footsteps periodically coming and going down far off corridors. Previously, having been 96  employed as a clinical physiotherapist for five years in the hospital, I experienced strange flashbacks, as I looked into the well-known rooms.  I saw instead the images of old  veterans, busy stafl an atmosphere of warmth and friendship, which had now receded into this spectral shell of a once Important veterans’ hospitaL On November 24th, the last ovum retrieval was performed and two days later, the final embryo replacement brought a final closure to the 1VF oocyte retrieval/embryo transfer part of the programme at Shaughnessy HospitaL By the end of November 1993, the official closure of Shaughnessy Hospital had occurred, leaving behind the administrative, patient intake and research part of the 1VF programme. They continued to function surrounded by construction workers, who had begun to reorganize the physical aspects of the hospital shell that were to be inhabited by the adjacent Children’s • 33 Hospital. Unlike the high profile media coverage of the closure of Shaughnessy Hospital, staff  lay-offs and reduction of critical services, the fate of IVF in Vancouver was shrouded in silence. Over the winter, uncertainty among the staff prevailed about the fate of the IVF programme, as decisions about space allocation at the Vancouver Hospital and Health Sciences Centre remained unclear. The 11/F staff took their normal one month break from treatment services in December.  Some staff reductions were made at this time.  A  secretary was lent to another department part-time, one of the casual nurses was laid ofl while another took maternity leave. The social worker/counselor and an 1YF technologist were laid offwith severance packages.  The spinal unit had afready moved to Vancouver General HospitaL This hospital has since been renamed Vancouver Hospital and Health Sciences Centre (VH[ISC), in response to the consolidation plans for the major Vancouver hospitals. The Shaugbnessy cancer clinic had relocated at Burnaby Hospital and the adult cystic fibrosis clinic at St. Paul’s Hospital. 97  (ffl)  An Uneasy Separation In early March 1994, the 1VF program started up services again, this time based at  two hospital sites.  The procedure room and JVF laboratories were relocated at  Vancouver Hospital. Only the IVF laboratory staff moved to their new premises in the old maternity building, on the fifth floor of the Willow Pavilion, which after more than half a century of birthing babies was to become the place of artificially creating them.  The  administration and patient services remained at the defunct Shaughnessy Hospital. The IVE laboratory was dismantled at Shaughnessy Hospital and equipment was moved to the new site. The microscopes, the incubators and the two big tanks in which the embryos were cryopreserved were transported by the company responsible for their maintenance.  During the two months before IVF services commenced again, the  laboratory staff reorganized their equipment in the newly renovated space, which seemed larger than the previous laboratories. Extra space also had been made available for the sperm micro manipulation equipment 34 on a solid marble bench, which would be run by the Ph.D. candidate in embryology, supervised by laboratory director, once she had defended her thesis. During this time the chief tecimologist had run trials with mouse embryos to check that the cryopreservation tanks had not been effected by the move. She was completing further trials on the day before the first retrieval “Beautiflil embryos”, she said in delight of the mouse embryos she had frozen two days earlier as a final trial  “I wish all the  One of the latest innovative reproductive technologies is intracytoplasmic sperm injection (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 have resulted 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 Canada using ICSI (Murray 1994). 34  .  .  .  98  .  human embryos froze so well”. Over the winter after the IVF programme closed, when the tanks had remained at Shaughnessy, under lock and key.  VU  CONCLUSION  There has been a long history of medical interest in understanding the beginnings of human life.  The scientific medical discourse is well represented in a chain of theories  about conception models which stretches back to classical times. IVF is just a modem link, and one among a number of recent tecimo-medical applications on humans which has arisen from this legacy of embryological research.  However, there is a fundamental  difference between research on dead embryos obtained in the past from abortions, embryo flushings and in teaching hospital based embryo collections, and a living pre-embryo that is created in the TVF laboratory. It is now possible to nurture, examine and manipulate the pre-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 in vitro, prior to the development of the primitive nervous streak, nevertheless it takes on a life-of-its-own, despite its dependency on laboratory support systems.  There is a  subliminal recognition at this stage of its potentiality for the vested interests of both research and the marketplace. The effects of alienation and reification automatically place the pre-embryo in a dependency relationship other than its biological symbiotic relationship to the woman, who produces the oocyte, gestates the resultant embryo and will in all likelihood be the primary nurturer and caregiver of the child.  This other dependency association made  possible by envisaging the pre-embryo as a separate entity, albeit with human potentiality,  99  brings it tinder the purview of scientists, who reason its value as a highly instructive information-bearing piece of human matter. Its relative moral or social valence beyond the laboratory 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 gateway into future avenues of embryological research, which perhaps may offer the final solutions to how life begins. However, a different view of the pre-embryo emerges when it is placed in the simple 1VF model of human infertility therapy. Here the complex social organization around creating pre-embryos to provide babies for infertile couples masks the potential for other research. As fast as IVF clinics open up around the world, so do the banks of frozen embryos. The future of those embryos is of limited concern to the health providers in the IVF clinics, procedure rooms and laboratories.  The salient  epidemiological discourse is clearly directed towards an identified need of a delined population of infertile Canadians wishing to produce families. While frozen embryos have limited used in the IVF treatment domain, the by-product of the therapy, large numbers of supernumerary pre-embryo is of greater significance in the research field. In general the clinical momentum is directed towards refining treatment protocols and trying to improve the statistics, “the numbers game”, which legitimates and validates the provision of a largely unsuccessful and expensive service. Political and public interest in infertility is also a fairly recent phenomenon. Problems of adoption, the availability of medically corrective infertility procedures and the need 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 industrial toxins are damaging human fertility. Thus infertility is no longer constructed as a private grief it is a highly charged political matter. This is apparent in the public process and subsequent report of the Canadian Royal Commission on New Reproductive 100  Technologies. Currently, the medical, public health and environmental discourses are all focused on the causality of infertility problems and in linding medical cures. Meanwhile frozen pre-embryos accumulate in cryopreservation banks in clinics that remain unregulated.  So in a relatively short period of time, infertility has moved from private  grief and social stigma, to entrepreneurship and national politics; from individual needs to moral discourse.  101  ChAPTER 4 TIiJ MEDICAL-TEChNOLOGICAL DISCOURSE:  CREATING AND FREEZING PRE-EMBRYOS  The 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 and  values which are the subject of this study. The fieldwork experience for this research is that represented by a broad overview of the treatment routines of the University of British Columbin IVF programme, which provides an introduction to the medico-technical activities of creating, transferring and freezing pre-embryos.  The narrative presents a  particular view of a social organization in a specific 1VF programme setting, based on the interplay of science, technology and medical practice. It creates a descriptive context for more abstract discussion of the pre- embryo as an emerging social category.  The  perspective examined is that presented to me by IVE service providers and my own observations. It does not reflect the view of patients undergoing the procedures, whom I did not interview, but rather a view of the patients in relation to the provision of the technology. Firstly, the different phases of the 1VF procedures from the time of enrollment  through an 1VF treatment cycle are outlined.  Then I  describe the cryopreservation  process of freezing pre-embryos, including the circumstances which led up to freezing becoming one of a number of options for dealing with supernumerary embryos. A thick description gives an account of the standard oocyte retrieval, fertilization, embryo transfer 102  and embryo freezing processes, that to the observer are bewildering technical details and yet to the practitioner are a matter of routine fact.  It exemplifies how personal and  cultural experiences of specific technical knowledge are accepted as common practice. Often this makes the researcher’s task more challenging. “Social scientists interested in problems of technical change rarely ponder how people make sense of the technologies they use or what their sense making may imply for patterns of social organization” (Barley 1988:497). The medical discourse of pre-embryos requires an intimate knowledge of a sequence of medical and technological interventions through which pre-embiyos are created, stored and replaced in women on a daily basis. As this research attempts to make clear, the different knowledge bases of the health professionals involved in IVF means that they 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 cumulative  build up of investigations, which couples undergo on the long path from initial concerns with inability to conceive, through to the final decision that all other treatments have failed.  This technology is often seen as the last chance of having a baby and before  resorting to adoption or accepting a childless lifestyle. As Mathieson, a researcher for a British government Member of Parliament comments Waiting is the most common experience for infertile people. Waiting to see their own doctor, waiting to be referred to a clinic, waiting for the outcome of tests and waiting to see whether the treatment has worked (Mathieson 1986:5 quoted inDoyal 1987: 179).  103  In British Columbia, couples are referred to the University of British Columbia IVF programme from all parts of the Province. Sometimes a local specialist in obstetrics  and gynaecology has done the early investigations into possible causes of infertility. When this has not occurred, which is becoming more common, the clinic infertility specialists must initiate or reorder the battery of diagnostic tests. These range from simple patient initiated charting of the female ovulation cycle, to testing factors in the male partner’s sperm that affect fertilization, to x-rays of the female genital tract through hystero salpingograms and diagnostic surgical laparoscopy.  Sometimes the therapy is the  regulation of ovulation with drugs, while at other times, surgical correction of obstructed fallopian tubes is the solution. At the point when all other appropriate forms of treatment have been ruled out, and 1VF appears to be the only hope, then the long wait for IVF treatment begins over again. Initially, when clients inquire about enrolling in the WF programme, they are placed on the waiting list. It is approximately one year before they will be eligible for an IVF consultation.  This leads to some patients turning elsewhere for more prompt  treatment, especially if advancing age is a critical factor. When they reach the top of the waiting list, each couple attends a two and one half hour orientation session at the hospital, 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 the evenings. For various reasons it was not a successfid strategy. Within a few weeks of the orientation session, patients were required to show their intent to proceed with treatment by submitting a $500 non-refundable deposit. When an 1VF treatment cycle was started,  104  the balance of the payment became due in the form of certified cheques or money orders on the first day oftreatment. At this time they were truly “on board”.  (ii)  Counseling the Clients The “counseling” of clients before, during and after an 1VF treatment cycle is  undertaken by doctors, nurses and the social worker/counselor from their different professional perspectives.  Considerable value is placed on educating and reassuring  patients, as they have to absorb a lot of information about the treatment process, as well as to come to terms with the high incidence of failure.  In this way the staff attempt to  prepare patients to deal with the emotional aspects of a highly technical procedure with poor success rates. However, differences of opinion about what constituted counseling exist among staff members. The social worker/counselor feels that preoccupation with the treatment aspects sometimes replaces the counseling aspects for some patients, in that some may feel rushed into making premature decisions.  IVF nurses feel that patients  normally have ample time to consider their options, because “the year wait-list allowed couples time to gather information for the most part, they seemed well informed and had -  afready decided to have treatment”. 1 They still have ample time to reconsider, as it is often another four months before they become eligible for treatment. After the counseling session with the nurse, who tells them that they are now at the point where they can book a treatment month if they wish, they are asked to wait a further two to three weeks before  calling back to enroll. They are assured that delaying a decision in no way influences losing a  place on the programme.  These differing perspectives reflect the different  The nurse co-ordinator commented that the challenge to informed decision-making is more likely to have be to faced when there is a short or no wait-list, as may soon occur when the private, Genesis clinic opens. 105  professional epistemologies about the relative values of educating and counseling, as expressed by social workers, nurses and doctors, as well as differing expressions of the patients’ best interests. Coping with the reality of the high failure rate of 1VF and making further decisions about 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 the injections, drawing blood, but a good part of it is the counseling aspect. Not deep counseling like N. does, but just the general counseling that is associated with giving positive and negative results, once their cycle is completed and dealing with their questions before and after they come for treatments. The social worker/counselor, with fifteen years of experience in adoption and infertility, as well as individual, couple and family counseling, sees each couple before starting the IVF treatment. Often this counseling takes place during the busy orientation session. However, she is always available to them for further assistance by telephone or in her office. Her position in the programme is unique in Canada, although much more common 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 people who 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 places in Canada don’t have them”.  The Canadian Royal Commission on New Reproductive  Technologies (CRCNRT) recommendation #119 has stated that “{C}ounseling be an integral part of assisted conception services and be offered either on-site or by referral to appropriate professionals” (CRCNRT 1993:551). However, the report notes that patients surveyed by the Commission found this aspect of their experience at 1VF clinics the least 106  satisfactory, 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 or administrators and that it is unclear as to whether these staff members had specialized training (ibid: 550). While the Commission recommends that clients should have access to a social worker/counselor, it is not explicit about how this should be achieved. In this sense the very complicated area of counseling is glossed over and diminished by the 2 The University of British Columbia IVF programme is not alone therefore in its report. emphasis on ensuring that patient’s are thoroughly educated about the complex IVF protocols, sometimes to the detriment of providing the objective counseling that may be necessary for some people, who for a variety of reasons, may require considerable advice on whether it is in their long term interests to proceed. Once the decision to enroll in treatment is made, the decision-making reverts to that of the endocrinologist, who then must individualize the treatment management.  (ffl)  “Calling the Pergonals”: Calling the Shots The complex realm of the first phase of the 1VF treatment, the ovulation induction  phase, exemplifies the fine-tuned protocols and critical decision-making patterns, which are legitimated though the filter of the reproductive endocrinologist’s scientific knowledge. 3 is a relatively new field within the specialty of obstetrics and gynaecology, Endocrinology 2  witnessed the avoidance of answering this question, when it was put to the Chairperson of the Commission, Patricia Baird, when she presented the McCleery Lecture gFebruarY 23rd 1994) to an academic audience at the University of British Columbia. Endocrinology involved the clinical management ofhormonal problems. Early remedies in the field included treatment of women for amenorrhea (absence or abnormal stoppage of the menses) with bromocriptine, and with galactorrhea to counter excessive or spontaneous flow of milk. More recently, the field of endocrinology has promoted the widespread use of estrogen hormone replacement (EHR) therapy for pen- and post menopausal women. Swiftly this was followed by the mandatory addition of a 107  and the drug therapies developed in this field are among many which demonstrate the rapid changes in clinical and laboratory research which are translated into patient management. In the case of IVF, the first phase of treatment that women undergo is ovulation induction. A critical sequence of drugs replicates the normal hormonal pattern leading up to ovulation, but more powerfully, such that multiple ova develop in the fluid-filled fofficles of the ovaries, instead of just one as in natural ovulation. The medications are selected by the endocrinologist according to each individual patient.  These include  clomiphene 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 normal endogenous pituitary action and replace it with a more controlled one. In the University of British Columbia 1VF programme ovulation induction usually starts between days three and five of each patient’s menstrual cycle and lasts for five to ten days. 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 is provided at the Easter Seal House or Heather House for the ten to sixteen days of the WE treatment cycle.  progestational agent to the 0 estrogen because of fears of increasing risk of breast cancer Speroff 1984). This protocol has changed slightly since the time of the research, as about eighty percent of the patients give their own injections at home. 108  Some patients, who live within reasonable commuting distance of Vancouver, may continue to work through this phase. However, the physical and emotional toll on stamina is high and often women take sick leave or use disability insurance. A few may even give up work entirely during an 1VF cycle. The morning coffee hour offered by the programme acts as a support group for patients, who are going through the treatment cycle at the same time. As noted in my earlier pilot study of the IVF waiting room, women coming in for their daily blood work and scans often socialized with one another. I witnessed the relaxed attitude of some women, who appeared to be familiar with the protocols and chatted familiarly with other women, in contrast to those women, or couples, who appeared withdrawn and apprehensive. Some women knew the nurses by name and left in a 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 times for the couple, particularly the woman (Newman and Zouves 1991; Daniluk 1988). In the past, one in five treatment cycles might be canceled prior to oocyte pickup, for a number of reasons. Now there are fewer cancellations with the new gonadotropliin releasing hormone protocol.  Sometimes the drugs cause an irreversible premature ovulation to  occur, or there is a poor ovarian response or an ovarian cyst may be detected on ultrasound on the first day of treatment and requires delaying the cycle for resolution of the cyst. After months of waiting 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, frequently couples, who have been unable to conceive a child and eventually have sought medical solution, go through a transformation of sell saying “I am infertile” and become desperate  109  for treatment at any cost and will not cease, if ever, until they have tried hard and long enough for a solution (Williams 1989b; Modell 1989; Sandelowski 1991). In research on twenty Canadian women concerning their motivation to participate in 1VF therapy, some of the frustrations of the women are recounted by those who have had their treatment cycles “canceled”, when they are afready advanced in the procedure and have invested more emotionally. Yet they continue trying: Marilyn I was really disappointed. I was really upset. Andrew took me out to dinner, and I don’t drink, but I had a drink because I was really upset. And he didn’t know what to do for me. So it was very frustrating at that point. And again, I felt like I had let him down, I’d let myself down. I think it was more of a rude awakening, because it had gone so well in July and 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. Pm never going back there! They’ve had enough! Pm not a guinea pig any more (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’s get back in (she laughs) (Williams 1989b: 130). -  . .  -  The preoccupation with what clients call “100% genetic parenthood” and with “the product of a fill biological baby” (Modell 1989:133) leads them into treatment compliance with the expectations of their doctors for controlling “the odds of success” for a “last chance baby”. This ethnographic study of an American IVF programme demonstrates that while the technology may seem innovative, in reality it is conceptually conservative in upholding traditional ideas of heterosexual sex. “{T}he ‘obsessive’ desire of infertile people for a child of their own” (Stanworth 1987:22) 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 an  110  infertile woman as “barren woman’s suffering”, a disparaging comment registered by British 1VF pioneers (Edwards and Steptoe 1980:47). Those women, who undergo repeated IVF cycles, run the risks of experiencing the side effects from the powerful, superovulatory medications. These may range from those which are usually associated with a normal menstrual cycle, such as breast tenderness, mood swings, backache and some bleeding to occasionally, hot flushes or headaches, and closer to the time of retrieval, lower abdominal twinges or cramps. Very rarely, in less than 1% of cases, ovarian hyperstimulation occurs, where the ovaries become very enlarged and fluid accumulates in the abdominal cavity. Symptoms of vomiting, diarrhea and excessive weight gain may be experienced, or if very severe, shortness of breath and chest pain. In this event, hospitalization for bedrest and close observation are indicated. These drug management problems are clearly explained to patients in the University of British Columbia IVF Programme Patient Manual. The close daily monitoring of the menstrual cycle of each patient by blood tests determines the hormone levels, such that when estrogen has reached a certain range and when ultrasound scans have detected that the appropriate size and number of fofficles has been attained, the human menopausal gonadotrophin (hMG) injections are discontinued. Every morning one infertility specialist is responsible for “calling the pergonals”, which requires reviewing each patient’s chart and adjusting the individual medications. In this way the attending physician does not have to actually see the patient, just check the 5 When the critical point is reached, then two nights or thirty-six hours before the chart. oocyte pickup, the woman is given an intramuscular injection of Profasi (hCG), which 5  One of the cnticisms of the University of Bntish Columbia IVF programme is that patients do not have their own infertility physician, who can give a sense of continuity and security as each patient goes along the 1VF roller coaster. This attention to individualized treatment is one of the advertising hallmarks ofthe new Bellingham clinic. ...  .  .  111  recreates the natural luteinizing hormone (LH) surge that normally triggers ovulation. This induces the final maturation ofthe eggs, which are then ready for collection. The egg retrieval 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 of conception, which express women as passive objects, awaiting active male control and penetration within the private domain of coitus.  These mysteries of the act of  insemination and conception are conveyed by the tensions, dynamics and role playing that accompany the relatively short oocyte retrieval procedure. The surgeon symbolizes the power of the male partner to control the submissive female body, to repeatedly probe, to inflict pain and to intrude into and beyond the secret domain of her reproductive self Conversely, 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 Drama While each IVF oocyte retrieval procedure is a unique event, there are  commonalties to the routine sequences for each IVF retrieval and these give meaning to what Koenig (1988) calls the social creation of a “routine” treatment. 6 At Shaugbnessy 6  According to Koenig “When a new procedure has evolved over the mysterious boundary into the territory of standard therapy, it cannot be denied... .As with TPE {therapeutic plasma exchange) a new treatment may or may not be efficacious; it might be risky. The moral imperative for the treatment overrides these concerns. It becomes unthinkable for the physicians not to perform the treatment. The social inevitability of therapy takes on a moral tone; the experience of the technological imperative becomes a moral imperative for 112  Hospital, the procedure takes place on a daily basis in the operating room, ORb, starting around 8.00 a.m. and is performed by one of the reproductive surgeons, who is on call for 1VF that day. In all probability the couple may never have met this surgeon before and 7 they may well be attended by another one for the embryo replacement two days later. Not surprisingly, a feeling of both success and apprehension accompanies each couple, who has reached the point of the oocyte pickup. The woman is prepared for the retrieval, as if undergoing any other form of daycare surgery.  She is gowned, draped and given a small amount of short-acting  intravenous medication for relaxation and pain control if necessary.  Meanwhile, her  partner is producing a semen specimen in a room across the hail from the gamete 8 This specimen will be prepared in the laboratory for mixing with the oocytes laboratory. later 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 which is reminiscent of a hospital birthing procedure. Ironically, if he is not ready, they start without him and he comes in later. There is a disjuncture between the private realm of the couple, who are finally about 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 experience  action. Hence the creation of a moral imperative is a social process, the end result of the routinization and consequent acceptance of a new medical technology” (Koenig J,,988:486). The new Bellingliam clinic in Washington State, which is soliciting British Columbia clients with their attention to personalized services, has capitalized on this inconsistency in the Vancouver programme (promotional flyer mailed to British Columbia infertility pecialists). If there is a problem for the male partner in producing a semen specimen, the couple may obtain it at home and bring it with them. 113  9 while the surgical team is attending to that other medical world out of sight behind alone, the ultrasound monitor at the other end of the patient’s body.  I was drawn by the  similarity to a husband-attended caesarian section, where the lower half of the woman’s body is screened from the couple’s view. An ultrasound momtor° is placed over the abdomen facing the surgeon, while another monitor faces the couple, so that they can likewise view the retrieval.  The woman has become very familiar with the ultrasound  monitor during the ovarian scans, which she has received three or four times during the superovulation phase.  However, this time it is combined with the ovum retrieval  procedure, which she will feel with varying degrees of discomfort or pain. In the case I describe here, this particular patient has refitsed anaesthesia and is alert, unlike a procedure 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 further assistance.  With a transvaginal ultrasound retrieval, usually only some high vaginal  freezing is necessary, unlike in the past, when oocyte pickups were carried out under general anaesthetic, through the 1aparoscope. There is an atmosphere of hush and the overhead 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, seemed livious to the people surrounding them. Ultrasound imaging originated in sonar detection for submarine warfare, but was not incorporated into obstetrical practice until the early 1960s, some years after its acceptance in other medical diagnostic fields (Gold 1984 cited in Petchesky 1987:65). In the early 1960s ultrasound was also used therapeutically as a physical therapy modality for swift solution ofinflamed tissues. This was the pioneer procedure developed by Patrick Steptoe, which made possible the gle 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 tapes that they find relaxing, which can be played on a recently acquired portable cassette player. 114  As I sit on the surgeon’s left side, the ultrasound monitor is directly in front of me. It is connected to the ultrasound transducer, which is about one inch in diameter and symbolically reminiscent of an engorged penis. High frequency sound waves sent from the transducer rebound and are converted into electricity, so that a computer can plot the information 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 she  explains to us what we are seeing on the monitors. In monochrome, the screen displays the shapes of the ovaries and the uterus, but at an angle.  As one’s eyes become  accustomed to the created images of the reproductive organs, the clear shapes of the enlarged fofficles come in and out of view, as the transducer is moved.  They appear  somewhat like spherical cysts of varying sizes; one is noticeably large. A large internal iliac artery is outlined and later the intestines. In OR 10 all eyes are focused on the two monitors, thereby directing attention away from the experiencing woman and towards the anatomy of the female reproductive organs.  Petchesky notes in her study of maternallfetal ultrasound how fetal imagery  replicates the paradox ofphotography to give “the appearance of ‘objectivity’ of capturing ‘literal reality” (Petchesky 1987:62).  As a visual society, we have become adept at  voyeurism, at virtual reality, disassociating ourselves from the empathic response to pain and “being there”. We do this all the time when we watch on television news footage of some horrific event.  Similarly, Barthes (1982:62) has pointed out that photographic  images are always based in a context of historical 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 ultrasound 115  transducer. She advises the patient that she will feel an uncomfortable prick as she pierces each ovarian fofficle.  The first fofficle pops and quickly deflates as the follicular fluid  containing the egg drains into the test-tube, which is attached to the aspirator, by a long rubber tube taped to the patient’s left leg. As the surgeon deftly pricks one fofficle after another, they miraculously deflate and disappear in the grey ovarian outline. Meanwhile the nurse, who is sitting by the patient’s left knee detaches each test tube, as it fills; gets up and hands it through the window between the operating room and the gamete laboratory to the biologist. The biologist is sitting out ofthe couple’s view at a small table monitoring and logging the test-tubes as they are passed to her. She calls back into the OR a number, only when one or more ova are found in the contents from each test tube, which another biologist is viewing under a high powered microscope. Within ten minutes, the surgeon has punctured each of the fofficles, which she can see in the left ovary. She then scans the whole organ, as some fofficles are less easy to see than others. Sometimes the fofficular fluid is clear, at other times bloody or tinged with pink. In this instance, eight eggs have been found in the left ovary, although more than eight test tubes have been passed into the adjacent laboratory. Halfan-hour has passed in a flash for me, ifnot for the stoical patient. Some ultrasound pictures, which have been taken before the retrieval started lie on the console and one shows that only one enlarged fofficle is visible in the right ovary. As the 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 which response the surgeon apologizes, in a mechanical way, as she has done each time the woman 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 are both withdrawn, but together, somehow unconnected from the efficient, swift activities 116  going on down our end of the table. Every so often, the surgeon swivels her stool to the side 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 and everyone exclaims with pleasure, although in fact it does not contain an 000yte. In this case, bigger is not equated with better. There are no other fofficles to be found in this ovary. The surgeon removes the aspirator to check that it is not clogged. She introduces another one and re-scans the ovary unsuccessfully searching for more foiiicles. She takes some fofficular fluid in a search for stray oocytes. By 8.40 a.m. the procedure is completed and the operating room team is mobilized in 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 is slipped on to it. The anaesthetist, who has had nothing to do, helps move the patient and wheels her outside into the hail, where the surgeon speaks reassuringly to the couple. The nurse picks up the intercom and says “Room 10 is ready for cleaning”, the cue for the cleaner to enter the room and lethargically push a mop around in preparation for the next patient, who is waiting.  ifi  A WINDOW OF OPPORTUNiTY: INTO TILE lAB.  (i)  A Mecca of Machinery The microscopic exercise of the egg hunt goes on in the adjacent laboratory. It is  connected to the operating room by a small corner window, through which follicular fluid and later pre-embryos are passed. This is a world completely off limits to the patients,  117  where two or three of the three busy biologists rotate daily through a myriad of technical processes. They prepare medium and sperm, monitor ova and later pre-embryos not only for replacement, but also for cryopreservation for use in later replacement cycles. The two IVF laboratories are considered as an extension of the operating room, so that anyone entering must be correctly gowned. They are kept scrupulously clean, and equipment is handled wearing disposable gloves. biologists wear masks.  When gametes are handled, the  In the laboratory attached to the operating room, there is a  microscope, housed within a laminar flow hood, which is used solely to observe and handle the oocytes and embryos. An incubator for the oocytes sits beside it. On another counter a microscope is used for magnifying sperm samples and beside it an incubator for 13 before mixing with the oocytes. the sperm samples, which are artificially capacitated Under the counters are kept all the sterilized and packaged supplies.  A counter for  paperwork is close to the table and chair beside the window linking the laboratory with the operating 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 patients undergoing the superovulation induction process. The serum is heat inactivated in a water bath at 56°C. and sterilized through 0.22 urn ifiter unit This laboratory is crammed full of equipment, consonant with what Reiser and Anbar describe as “(T)he landscape ofmodern health care is filled with machines” (1984:3). There is the sophisticated ultra pure water  13  Capacitation under natural circumstances is a process whereby motile spermatozoa must undergo alteration during their time in the female reproductive tract in order to develop the ability to fertilize eggs. After sperm have ‘escaped’ from the irihibitory factors within the liquefied seminal plasma in which it travels, capacitation involves several changes that alter the plasma membrane of the sperm to allow an acrosome reaction. This process is mimicked in vitro by separating the sperm from the plasma and capacitating it in a physiological saline solution supplemented by serum albumin and energy sources (Soules 1989:191-192). 118  system along one wall, which provides pure water for the procedures. On the counter is a freezer, which has been programmed to freeze embryos loaded in slow cooling 0.25 ml straws.  It slowly steps down (slow cooling) the pre-embryos.  Two large  cryopreservation tanks and the liquid nitrogen relill tanks sit on the floor. A small desk provides space for the technologists to do their paperwork and on the wall a fan plays incongruously above all the freezing equipment on a warm summer day, in an old hospital bereft of air-conditioning. Very few people ever venture into these technological Aladdin’s caves. Requests by 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 many centres a video monitor, attached to the laboratory microscope is placed in the operating room for patients to view their ova and embryos. The 1VF programme has not been able to afford such equipment from its limited budget, despite it proving to be an indispensable piece of equipment in the animal IVF laboratory in the Animal Science Department at the University of British Columbia.’ 4 In some cases, the programme has given the patient a clean 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 in the United States, who expeñence recurrent pregnancy loss, use to mark the loss of a 15 potential baby.  14  On one of my visits to the 1VF facilities in the University of British Columbia Animal Sciences 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 the ibryos magnified under the microscope on the adjacent television monitor. One of these caskets was displayed by Sherokee use, an expert in recurrent pregnancy loss at a lecture in Women’s Health Centre, Vancouver, on May 20th 1993. I was told of another symbolic marker of the loss of a fetus in the release of coloured helium balloons up into the sky. 119  (ii)  Egg  ,,16  Care  As the test tubes are handed in rapid succession through the connecting window between the laboratory and operating room, the biologist logs twenty-five aspirates from one 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 for the surgeon’s information, but also to boost the couples’ morale. The couple in this case has withdrawn consent to my observing their retrieval procedure at the last minute. I am told that the couple are overwhelmed by the ordeal, and in consequence unnecessarily tense about intruders into what they perceive as a very personal experience. I am invited to remain in the laboratory to see what for me seems the even more personal experience of the fertilization oftheir gametes. While one biologist is logging the aspirates, the other is examining the samples under the microscope, which is housed in a flimehood. The procedures are performed swiftly and deftly, with silent concentration. First, the biologist draws up in a pipette about a teaspoon of aspirate into a petri dish and examines it for oocytes.  She sucks off the  oocytes into another petri dish, mixes it with some medium mixed with the patient’s serum and then covers it with a lid. This serum has been prepared from the blood samples of the patient, drawn during the sup erovulatory work-up the week before. The serum is used as a 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 after the retrieval process.  The granulosa cells in the remaining aspirate is put aside for  graduate 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 and laboratory notes, conference papers, etc. 120  Once an oocyte is picked up from the fofficular fluid, it is placed in a culture dish and washed with PBS medium about two times Finally the oocyte is cultured with a special medium (JIF1O) containing seven point five percent of the patient’s heat inactivated seruni Then the dish is placed in the incubator to await the insemination procedure. Each dish is labeled with the female patient’s surname and colour coded from among six rotating  colours. One shelf of the incubator is reserved for each patient undergoing a retrieval that day. In this way safeguards are implemented to ensure that there is no chance of mixing up 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 to three 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 only available until lunch time and anyway there is much else to be done by the surgeon and the biologists. 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 laboratory equipment is swiftly cleaned in preparation the next case.  (iii)  Insemination and Syngamy: Technology versus Nature 7 in a room across the hall, Once the male partner has produced the semen sample’  one of the available biologists examines a specimen under the microscope.  Under  magnification, the tiny drop of semen on the slide appears like a pond, full of active tadpoles, surrounded by bits of floating debris and intriguingly irregular shaped cells. This  17  One half to one teaspoon of sperm is produced by a healthy, fertile man. Each ejaculate contains between 200 million and 500 million sperm. But only one sperm is required for fertilization to occur (CRCNRT 1993:147-148). See glossary. 121  semen will be kept in an incubator in the main laboratory in a test tube, supported at a 300 angle and covered with some of the medium containing the female partner’s serum, in order to enhance “swim up”. This process facilitates the “goo& or motile sperm to swim up to the top of the sample, which then appears clear as the dead sperm remain at the bottom. The clear portion or supernatant is drawn up with a pipette and introduced into a clean tube and centrifuged. The resultant sperm pellet is washed twice with the medium containing maternal serum and the number of motile sperm in the final preparation are counted. Finally, the concentration is adjusted to about 50,000 sperm per drop.  The  biologists 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 insemination finally occurs, by placing a drop of the prepared semen sample on to the oocyte enveloped in its culture medium in the petri dish. This usually takes place about three to five hours after retrieval.  Then the fertilized oocytes will be left overnight in their dishes and  examined the next morning when they have reached the pronuclear stage. At this time, the best are reserved for embryo transfer the following day, while the rest, if there are any and 18 Within twenty-four if the couple so desires, are frozen for future use in a natural cycle. hours of the sperm penetrating the oocyte, the process of syngamy (see glossary) has occurred, when the nuclear membranes of the two pronuclei dissolve and the chromosomes unite.  “Although the genetic constitution (the genome) of the zygote is  established 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 the 18  A natural cycle is one in which a woman has not undergone superovulation, or only minimally, in order to replicate the optimum time for an embryo replacement. it is used commonly by women, who have excess preembryos stored in the freezer. A natural cycle replacement is also substantially cheaper and less invasive than an 1VF cycle. 122  egg only” (CRCNRT 1993:153).  A few hours after syngamy occurs, the process of cell  division, cleavage, causes the cells to split into two, then four, then eight, sixteen cells and so on.’ 9 Usually, the pre-embryo created through IVF is replaced at the two to four cell stage.  (iv)  Cleaving Embryos: Watching, Waiting and Wastage The period between the ova retrieval and the embryo transfer, when the cleaving  cells are left to their own genetically programmed sequences, is a critical and liminal time for both staff and patients. Human intervention is at a minimum. It is a period during which the patients after leaving the hospital have to wait. The biologists can only watch over their charges and ensure that no outside factors interfere with the optimum conditions for cell division.  In part the lack of knowledge about and therefore  engagement with this process for patients is a means of self-protection, because they have been primed to the poor fertilization success rates of IVF technology. One 1VF nurse explained her view of why patients use this distancing process: I have talked to couples about that period before implantation. They are trying to keep it very clinical in their minds, because that’s their way of protecting themselves, ifthe treatment fails. They don’t want to think of it as the death of this embryo or that they have failed the embryo. They want to put 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 technology about which patients have very little comprehension.  In normal conception in vivo, this division occurs at about eighteen hour mtervals to form a clump of blastomeres, each one of which becomes successively smaller. However, the clump remains about the same size, about the size of a period at the end of this sentence, until implantation occurs. 19  .  .  .  .  .  123  .  According to the differing epistemologies of 1VF health professionals, such as medical, nursing, laboratory, counseling, a variety of perceptions about the conceptus in its early stage are expressed. For example, the IVF nurses, who work most closely with infertile couples through daily monitoring ofhormone levels and in counseling them about their concerns about treatment, tend to define the pre-embryos in relation to the potential parents. One nurse swiftly elides her definition of the embryo with the concerns of the potential parents: The embryo is the joining of two cells. But it is more than that, to these couples, the embryo has such emotional significance, because many of these couples have never achieved a pregnancy before and to them, even if they don’t become pregnant from the treatment, I think that the realization they have created an embryo, even Wits in the lab., its meaningful to them. Pm talking generalizations here and obviously there is a difference from one couple 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 woman form and its something pretty special and its just not possible to create a human embryo, due to external problems that the couple have. With the help of research and science they are able to accomplish that. In distinction, those scientists, 1VF technologists and 1VF physicians, whose epistemology is based in embryology tend to focus on the pre-embryo as part of a developmental process, in which their skills are critically involved. A biologist describes the arbitrariness with which cell division occurs and the potential failure of pre-embryos to develop. The embryo is like two cells that come together, but it could potentially become something, but you don’t know because there are a lot of factors that will make it a human being.  124  In natural conception, each of the cells in the blastocyst cluster is totipotentiaL This means that any of the cells has the ability to become the true embryo and subsequent fetus. Each cell has an independent, genetic constitution, a genome. But most of these By seven days after fertilization, the outer  cells are not destined to become the embryo.  ring of cells, called the trophoblasts, begin to invade the lining of the uterus, (the endometriurn) and eventually become part of the placenta.  The plate of cells which  becomes the embryonic disk separates two fluid-filled spaces, which become the amniotic cavity. It is from this disc that the embryo itself develops. By about 14 days after fertilization, implantation is complete, and one or two days later the first indicator of a body axis becomes visible. Called the primitive streak, it appears as a heaping up of cells at one end of the embryonic disk. Thus, the embryo proper develops from just a small fraction of cells that make up the zygote before implantation. Only at this point, (15 or 16 days after fertilization) can individual embryonic development truly be said to have begun, because only with the development of the primitive streak is it possible to tell whether one embryo, multiple embryos, (identical twins or triplets) or no embryo at all is developing (CRCNRT 1993:158). In reality, more than ninety-nine percent of the zygote develops into the trophoblast and other supporting tissue, such as the placenta, chorionic viii, amnion etc. It is for this reason that some people prefer to use the term pre-embryo for the zygote prior to implantation. The long journey from two cells to complete human being “makes it open to the risks of errors and dysfunction. In fact, only half of all fertilized eggs survive embryo and fetal development and result in live births.  The remainder are lost sometime between  fertilization and the end of pregnancy, many of them before implantation and many within the first few weeks ofimplantation” (ibidl6O). This knowledge ofthe common wastage of gametes and embryos associated with natural intercourse and conception, in vivo, allows 125  many of the IVF staff to keep biological realities in perspective and therefore not to be consumed 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 I don’t have problems with discarding embryos no. I don’t lose sleep over discarding embryos because that is the choice the gamete providers have made and have to live with. I don’t think anybody has a right to interfere with that kind of decision. -  The laboratory director perceives the pre-embryo objectively from a scientific standpoint, unclouded by moral theology: Conception outside the body gives a lot of confusion. Most of us put too much emotion on the embryo and it’s unnecessary. They are just simply 12 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 fertilized and disappear, aborted or rejected, by the body. Also, the 1VF embryo is only at the two to eight cell stage, early embryos less than 8 cells. Even if we transfer to the mother, what is the success rate? 20%.? Can you accuse me that I am murdering 80% of the embryos. Once the embryo is attached to the mother’s womb, is growing and healthy, then I would call that the real potential then. -  Likewise one of the IVF physicians, with expertise in endocrinology, situates the pre embryo in terms of its critical dependency on human or artificial nurturers for its future development. An embryo, a zygote is the structure that is formed following the fertilization of an egg; an egg that is fertilized by a sperm which as it starts to divide becomes a zygote and an embryo, which is human tissue -living tissue; but incapable of living without tremendous support from the 1VF lab or 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 technical aspects and patient care, also refines her definition in embryological terms, according to both her specialized professional knowledge and her socialization to the practical situation ofpatient care. 126  I have problems with calling it (the pre-embryo) an embryo when I am talking to the couples, telling them about the embryo replacement procedure, because for me it is an embryo when it has a form to it after implantation. 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 is focused clearly on its biological, extendible status as human tissue, which is sometimes subject to rejection. The ability to think both in terms of the social relationships around the embryo and linearly about the pre-embryo as part of a biological developmental process pervades the rhetoric of 1VF, whether or not there is formal knowledge of human biology.  The experience of biological aging is a universal phenomenon, which Leach  points out is associated with our odd concept of time passing as “a discontinuity of repeated contrasts” (Leach 1979:228).  Likewise, we tend to take for granted the  connected sequencing of the biological progression from embryo, to fetus, to infant, to child and so on.  (v)  The Embryo Transfer Within thirty-six hours of fertilization the pre-embryos, which will be somewhere  between the two to eight cells stage, will be ready to be replaced in the woman. This event occurs in the same procedure room as the retrieval but in a far less tense atmosphere. It is a relatively simple, speedy and low-tech procedure. Earlier, one of the other biologists loads each of the pre-embryos from their individual petri dishes into a catheter in such a way as to create the minimum of damage to the pre-enibryos. The surgeon, this time assisted by one of the 1VF biologists, introduces the pre-embryos in the catheter, attached to a long, narrow tube, high into the woman’s uterus, usually without any local freezing. Emotions are often running high at this point for the couple, for whom it may be the first time that they have come so close to a pregnancy. While the woman 127  relaxes 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, there is the fourteen day wait until the pregnancy test is performed, even if the patient starts to bleed in the meantime. Several weeks later ultrasonography will identify and confirm an implanted embryo. For some the long wait is over, to be replaced by the anticipation of an uneventful gestation and birth; for many others the decision-making process starts all over again. For others the failure to conceive brings to a closure the attempt by a couple for their own biological child. Many more couples’ hopes rest on their pre-embryos, which are frozen solid in the large cryopreservation tank in a laboratory, which they are never permitted 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-EMBRYOS  The western cultural infatuation with technology 20 clearly revealed by some anthropological studies (Koenig 1988; Bassett 1993) demonstrates that there are unexplained social processes, which occur when practices become accepted as routine. In the 1VF laboratory the equipment associated with the freezing procedures form a  20  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 precise definitions, at least at this stage of the research in progress” (1987:3). They distinguish three layers of meaning 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 to activities or processes and the third refers to what people know as well as what they do the know-how. -  128  substantial part of this machinery, which is routinely utilized by the technologists. “Ordinariness”, “standard therapy”, this familiar pattern of routine make their workplace social life possible. “{H}abituation makes it unnecessary for each situation to be delined anew, step by step” (Berger and Luckman 1966:53-54).  For example, common  acceptance of routine practices makes it possible for the IVF laboratory director, who is not even located on the same hospital site since the removal of the gamete laboratory to the Vancouver Hospital and Health Sciences Centre (VHHSC), to rest assured of the smooth running of the complex protocols. Even when the 1VF programme was based at Shaughnessy Hospital, his office was located in another part of the hospitaL  On  weekends, sometimes one biologists works alone. Thus there is an implicit reliance on and confidence in the integrity and competence of the biologists to follow the accepted protocols and for the machines to do their job.  (i)  A Chffly Climate A standard procedure, according to strict protocols, for selection and freezing of  embryos is followed by biologists at the IVF programme. The freezing of pre-embryos takes place on the morning after the oocyte pickup at the two pronuclear stage. 21 If there are five or more embryos, the best three are reserved for replacement the following day and the remainder are frozen. Delaying the freezing until the day after retrieval allows for the 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 the observer.  The calm expertise of the doctors and biologists, born out of years of  experience when applied to the oocyte pickup, insemination and embryo replacement  21  See diagrams in CRCNRT report 1993:151-7. 129  procedures is also replicated in the freezing process. In the laboratory, where the storage tanks reside, the biologist prepares the cryoprotection solutions, which protect the pre embryos for their freezing plunge. First, she clearly labels three centrifuge tubes and then prepares three solutions in which the embryos are rinsed prior to freezing. The solutions are of different concentrations, 22 which are then jilter-sterilized through double-stacked lilters in the correct order, using the same ifiter system. The biologist then labels and sets up three petri dishes (Falcon 3001), each of which is filled with one of the filter-sterilized solutions. Each solution is mixed well, as the prop anediol (PD) tends to separate quickly. Then each pre-embryo is rinsed in the 20% media for about three minutes, then placed in 1.5 M PD for fifteen minutes and then finally in 0.1 M sucrose plus 1.5 M PD for five minutes. At this stage the pre-embryos are ready for loading into special cryopreservation straws. Each straw, called a French straw, is carefully labeled with the date, the patient’s name, laboratory number and straw number.  The loading procedure involves a steady  hand to attach the coloured end ofthe straw to a mouthpiece adapter set. Using the other end of the straw as a pipette, the straw is loaded first with a small volume of sucrose solution, then air, then embryo plus sucrose solution, then air again and a small volume of sucrose solution again, then air, then crito seal to hold all of the above in place.  One  embryo 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. The biologist then places the straws in the cell freezer (Planer KRYO 10) in preparation for the required slow cooling process, before the icy plunge into liquid nitrogen. 22  Solution 1, labeled as 20% D-PBS (Dulbecco’s Phosphate Buffered Saline) contains 4 ml. 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 M sucrose + PD, contains 5 ml. 1-5 M PD (solution 2) + 0,171 g. sucrose. 130  Prior to loading, the biologist, using a razor blade, makes a diamond shaped 23 The goblet is window in each of the goblets to be used. This window is for seeding. fitted into the cane, which is lowered into the freezer.  The cell freezer is manually  activated to begin the cool down process. When the cell freezer is ready for loading the straws, it beeps. Then the straws are placed inside the goblets. Each straw is positioned so that the embryos gravitate away from the site of forceps’ contact during seeding. The cell freezer automatically decreases from room temperature to 70C at 20C per 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 -5 0°C per minute until -140°C is reached. At this point the biologist removes the canes with forceps and plunges them into the large liquid nitrogen tanks on the floor, into which they are placed in the rack, which is then lowered into the tank and the lid replaced. Every so often the biologists 1111 up the big tank with liquid nitrogen from a smaller tank. This is performed by a method reminiscent of science fiction movies, whereby the liquid nitrogen is transferred through a makeshift paper funnel, enveloped in clouds ofnitrogen steam and poured into the tank.  (ii)  More than Enough: Freezing Choices In the early years of 1VF, before ovulation induction and the retrieval of multiple  ova became commonplace, there were no excess pre-embryos available for freezing.  The seeding procedure involves the forming of ice crystals on the straw. A thermal 23 flask 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 the freezer. The cold forceps are brought into contact with each straw and held for a few seconds. If ice crystals do not form, the seeding procedure is repeated. 131  During the 1980s, three developments occurred to pave the way for freezing of human embryos.  Firstly, 1VF as a therapeutic modality became more enticing to potential  participants. This was due to the introduction in 1987 of routine use of the minimally invasive 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 with increasingly sophisticated ovulation induction protocols. The rationale was to enhance the chances of greater ova production in the ovaries and better quality ova. More ooctyes facilitated a greater number being retrieved and fertilized, over and above what a couple would need for one replacement cycle.  Thirdly, advances in the animal sciences and  bovine industry showed that not only could embryos be successfully frozen, but quality control of embryos could be enhanced. Although of tangential interest for human IVF at that time, immunity from diseases in some parts of the world, transportation and international marketing of embryos had improved dramatically the cattle industry in 24 Canada, which has become the world leader m the industry. Overtime the IVF programme has instituted several changes to the drug protocols it had been using to stimulate oocyte production. In 1982, only pure IiMG (Pergonal) was used, while by 1987, both clomiphene citrate and Pergonal were being administered. In 1988, GnRH analogs (see glossary) were introduced for a select group of patients, who either tended to ovulate early or had a poor response to ovarian stimulation.  Use of  analogs 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 the University of British Columbia, for his assistance in explaining both the research and industrial applications of bovine ovum retrieval, in vivo embryo flushing and embryo freezing and transportation. I appreciated his staff allowing me to observe the procedures. His own studies on cloning embryos were also of assistance. 132  with improved “success” rates.  Therefore as of April 1994, despite some internal  dissension among the endocrinologists, GnRH analogs are now routinely used in the 25 programme. In late 1989, the University of British Columbia IVF programme started to freeze pre-embryos, in order to deal with the supernumerary pre-embryos.  Cryopreservation  when linked with superovulation, solved the problem of what to do with the excess embryos created from retrieval and fertilization of multiples ova. Since 1989 the number of embryos in the freezer has increased to the point where on July 7th 1994, there were 807 embryos in the freezer. As in other centres, little attention has been paid to the consequences of stockpiles of unneeded pre-embryos or if a clinic decided to close its operation. Table 3. Number of Embryos Remaining in the Freezer Tanks per Year between 1989-1994  69 86 161 293 185 106  1989 1990 1991 1992 1993 1994  Although success rates with frozen embryos are poor, about eight percent clinical pregnancy rate per embryo transfer, the procedure is now offered routinely as one of three options of 1VF treatments.  Despite the poor odds of success, the majority of IVF  participants choose freezing. For example, in the last six months of 1993, seventy-five  25  Although it is too early to predict, early results suggest that this may improve not only the likelihood of successfiul retrievals, but also better fertilization rates. .  .  133  percent of couples elected to have their embryos frozen, although in reality only twentyfive percent had embryos available for freezing. The number of supernumerary pre-embryos possess important long-term personal effort and legal issues for both the couples and the laboratory. Both partners must choose and consent to one of the three options concerning disposition of surplus embryos, which is explained in the general IVF Consent Form. The first option, (freezing) permits the retrieval and insemination of as many oocytes as possible and the replacement of three or 26 in that retrieval cycle, while freezing the remainder for future four pre-embryos replacement in a later cycle. With the second option (selection), couples reject freezing of pre-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 replaced in that retrieval cycle and the remainder are either technically fixed on slides for research purposes or discarded. The third option allows couples concerned by moral aspects to reject both freezing and selection of pre-embryos, because they may involve possible destruction of extra pre-embryos. In this instance, a maximum of six mature oocytes are retrieved and inseminated and in the unlikely case that all six fertilize, they will all be replaced. With this procedure there is a risk as high as 30% of multiple pregnancy. If that risk is unacceptable to the participants, then the number of oocytes inseminated may be reduced to four. For some patients the dilemma of wasting oocytes, which they have consented to not be fertilized, may also be a problem. All the participants are also made  26  Transferring more than four embryos carries a significant risk of multiple pregnancy. The Voluntary Licensing Authority in the United Kingdom and the IVF Special Interest Group in North America recommends that a maximum of three, and under special circumstances four embryos be replaced in one cycle. As of January 1995, the University of British Columbia programme changed its policy to transfer no more than three preembryos in order to minimize risks of multiple pregnancies. 134  27 a technique whereby aware of the further option of selected termination or reduction, certain post-implantation embryos are eliminated by one of a number of surgical techniques (1VF Consent Form revised October 1992).  (iii)  It’s Just a Matter of Time Unintentionally, the cryopreservation procedure had created an unforeseen  problem as to what should be done with all the unneeded pre-embryos, which could not be frozen indelinitely. It has became standard procedure in the programme to store pre embryos 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 is shortly approaching when the five year limit will be reached and when a decision will have to 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-embryos were stored by the end of 1990, have demonstrated some of the problems occurring with large banks of frozen pre-embryos. In both countries legal inhibitions had deterred both infertile couples from “adopting” a pre-embiyo for implanting and donors from donating The latter would remain legally responsible for their pre  their suqlus pre-embryos.  embryos, even if they donate them to another couple. 28 Likewise the recipient couple would not be the legal parents of children produced from the donated embryos” (Medical Post 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 this techniques to remove one of the three embryos/fetuses that have implanted, because she es not want to have triplets. In most Australian states, the father, usually the genetic one, is the legal parent. Yet the woman, who carries the embryo of another couple, has no legal right to the resultant child. .  .  135  Recently, Dr. Armstrong, scientific founder of the 1VF programme at University Hospital, London, Ontario and professor of obstetrics and gynecology at University of Western Ontario and University of Adelaide, warned that Canadians should take steps to avoid possible legal problems. He stated in an editorial article that Couples should sign a legal document when they begin an 1VF programme to choose between destroying, saving or donating the embryos to another couple or for research of early fetal development. That’s when the gene expressions are formed, which can be helpfhl in researching the cause of cancer, for one (quoted in Medical Post 1992:21). The 1VF nursing co-ordinator, who helped revise the University of British Columbia IVF cryopreservation consent form, while acknowledging that “the consent form is subject to judicial interpretation and any couple could take it to court”, felt relatively secure that patients’ interests were being observed.  However, in certain  circumstances patients’ frozen pre-embryos could revert to the programme’s control, with the potential for litigation over ownership of pre-embryos, which has occurred with cases in the United States. (discussed in the next chapter). lam used to our scenario here, where the couple have the control, up to a point, I guess, because there is a time limit imposed, the five year limit. So if the embryos are not replaced within that five year time, the control reverts to the clinic, who would then dispose of them. If the couple cannot be reached, there are certain conditions imposed in the consent form and one is that if couples have embryos in the freezer, that couples must maintain contact with the programme, at least once a year, so that we know of their intent. That is to avoid those situations where we loose track ofthem. She goes on to explain the expanded control of the 1VF programme, in the situation of a marital breakdown: A few times people have written to say that they want their embryos disposed of because the marriage has dissolved. That is a stipulation in the consent form also, that if the relationship dissolves the programme gains 136  control of the embryos. It would then dispose of them. There is another that couples are given a choice that in such an event that the program gains control, that they have another choice of offering the embryos either for donation or to dispose oftheni She noted later, however, that the programme does not as yet have either a pre-embryo or ova donation programme. However, they do have stored the pre embryos of a couple, who did not want their pre-embryos frozen for themselves, but neither did they wish them to be destroyed. They chose to have their surplus pre embryos frozen for donation at a later time. In the meantime, they had a baby and the couple have not contacted the clinic again. The programme has received ethical clearance from the University Ethical Review Committee, therefore it is probable that donation ofpie-embryos may become an option in the future. The consent form also stipulates that if there is a death of one of the partners, who have pre-embryos frozen, that the clinic gains control over those pre embryos.  The moral right of a clinic to make these kinds of stipulations has  apparently caused concern for some patients, because they feel the remaining partner may 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 at some future time.  Shore (1992) discusses some of the gendered inequities  surrounding posthumous use of pie-embryos in relation to The Warnock Commission in Britain. The 1VF programme had decided that the consent form would remain in effect for five years after the validation, but as the co-ordinator noted “it is too early to say how the five year time frame will work, because we haven’t reached five years yet, since we started at the end of 1989, and thee probably all been replaced. We probably have a  137  29 Although some effort is made to keep track of patients with few left from ninety”. embryos in the freezer, one 1VF staff member chaffed “some people totally forget they have frozen embryos”.  IDENTIFYING RISKS AN]) ACKNOWLEDGING TILE V COMPLICATIONS  In the absence of national and international legislation on assisted procreation, each 1VF programme is responsible for developing its own individual treatment policies within ethical guidelines. While university operated IVF research programmes are more stringently monitored by ethics committees, private programmes, driven by both consumer and entrepreneurial interests are less scrutinized.  However, in the wider domain of  international concerns about the quality of practice involving an increasingly complex array of infertility treatments, recent events are shaking the medical and pharmaceutical communities 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 year epidennological study in the United States into the relationship between the effects of ° proposed that 3 fertility drugs and ovarian cancer. The Whittemore et a! (1992) study nuffigravid (never having borne children) women, who used fertility drugs were at increased risk of 2:1 to develop ovarian cancer, in comparison with fertile women. The A 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 of ovarian cancer between 1956-1986. It was conducted by the Collaborative Ovarian Cancer Group in the United States, which confirmed findings from many other studies, which concluded that oral contraceptives, pregnancy and lactation were substantial protectants against ovarian cancer. 138  authors supported their contention that treatment with fertility drugs were implicated, rather than some underlying ovarian disorder, based on their evidence that there was a higher risk associated with a diagnosis of infertility after 1970, the time at which fertility drugs were introduced to the United States, compared to those diagnosed between 196 11970 (Whittemore eta! 1992; 136:1184-1203). These  lindings provoked  an  immediate  and  concerted  response  from  pharmaceutical manufacturers of gonadotrophins, followed by the American Fertility Society (AFS), National Cancer Institute and the United States Federal Drug Advisory, all of which found the study flawed. Experts immediately tried to reassure patients, pointing to various defects in the study. Arguments were made to refute evidence of a claim of causal effect in 1993, at a special session on ‘fertility drugs’ and ovarian cancer, to a standing room only crowd of delegates, at the annual meeting in Greece of The European Society of Human Reproductive Endocrinologists and the International Fertility Society, The American Fertility Society criticized the small sub-division of the study, when balanced against the estimated 28-30% of all infertile women given ovulation inducing drugs. The European Society of Human Reproductive Endocrinologists suggested that the increased risk of ovarian cancer might be related to the underlying defect rather than the therapy used to treat the disorder. It maintained that the risk was less than one in five thousand, and that “this limited risk should be balanced against the benefit of achieving birth” (Reported in IVF News 1993:2, a newsletter published by Organon Canada Ltd.). The delegates argued that a few anecdotal reports in journals concerning borderline ovarian cancers associated with ovarian hyperstimulation syndrome would require investigation as to whether there is a true causal relationship or is mere coincidence. The Federal Drug Advisory estimates that since fertility drugs were licensed in the United States, chiomiphene citrate and IIMG in the late 1960s, there have been more 139  than twelve million cycles prescribed and yet no increase in cases of ovarian cancer commensurate with the rise in prescription. Likewise, the British National Institutes of Health’s surveillance of 3100 women, who had undergone 1VF, recorded no cases of ovarian cancer (ibid). The general consensus was that doctors should advice their patients of the risks. A collaborative study, reported by Lunenfeld, ’ who is credited with the 3 development of human menopausal gonadotropliin, found no increase in cancer risk from IiMG/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 also explain its weaknesses. We must also tell them that nulliparity, infertility and polycycstic ovarian disease have been consistently reported risk factors Hereditary factors, for carcinoma of the breast and endometrium. environmental factors such as high galactose consumption have all been linked to an increase in ovarian cancer risk (Lunenfeld quoted in Infertility News 1993:2). -  -  The strategy of presenting a unified front has not been one followed by all infertility specialists in the international community.  Schenker and Ezra (1994) in an  extensive review of the potential complications of assisted procreative techniques have acknowledged the iatrogenic effects of 1VF therapy and the importance of control of complications before and during assisted pregnancies. 32 While the authors agree that assisted reproductive treatments should be allowed as a first choice, it should only be so in well controlled circumstances and preceded by thorough investigation of infertility Bruno Lunenfeld, American Journal ofEpidemiology 1987:780-790. These Israeli authors cover complications associated with ovulation induction, notably associated with ovarian hyperstimulation syndrome (OHSS) and the potential to develop genital cancers; problems associated with extra corporeal methods that are used for 1VFET, GIFT and ZIFT, in which problems associated with laparoscopy, anesthesia, oocyte retrieval and laboratory procedures are identified; and complications of assisted reproductive pregnancies, such as spontaneous abortions, ectopic and heterotopic pregnancies, congenital malformations and multifetal pregnancies and the course and delivery of such assisted reproductive pregnancies (Schenker and Ezra 1994:411). 140  problems. They conclude with the caveat that while “{M}any of us consider cost as an important  factor of assisted reproductive practice. We believe the main problem is not  cost but the complications of this mode of treatment, which may result in permanent damage or even death to patients who otherwise are healthy” (Schenker and Ezra 1994:411-422).  VI  CONCLUSION  In less than twenty years the “science of the impossible” has become the “ART of the possible”. What appears to the untutored outsider as a world of science fiction made reality, for the 1VF staff creating extra-uterine life is a routine daily experience.  The  regimented protocols embody specific interpretations about what constitutes clinical expertise and rational practice.  The latter are envisaged as neither arbitrary nor  experimental Yet Gordon’s (1988) analysis of the arbitrariness of medicine points out that there is a commonly held belief that the scientific endeavour is to develop increasing and better clinical science for medical practice, which assists the  art  of making medical  judgment “more rational, explicit, quantitative and formal” (1988:258).  So applying  scientific principles to patient therapy with the goal of maximizing success rates is the unitary  focus of 1VF staff.  In this way they see themselves as providing a clinical  services, rather than doing biomedical science.  The focus on the IVF results is that  number count more fertilizations mean more pre-embryos, which imply more chances at -  implantations, which ultimately translate into more “take home babies”. The attention is deflected away from concern with investigation of the biological processes of infertility and conception, which distinguishes the epideniiological and clinical research.  141  The ethos of the University of British Columbia 1VF programme embodies a generally cautious, conventional and conservative approach to 1VF patient treatment, which it views as morally correct. The staff are well aware of the experimental nature of some of the more controversial and risky applications in common use in other centres and the 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, neither do they envisage a ready acceptance of them in their programme.  The nursing co  ordinator voiced the general satisfactory consensus with the ethical, conventional nature of the IVF programme in this way: I feel really dedicated to it and I know that this programme is very conservative. When I go to these (international fertility) meetings, I really feel like the country cousin, as far as what we offer here to couples. But in many ways, it makes it a lot easier. In contrast to the recently emerging international medical discourse about the potential iatrogenic effects of superovulatory drugs and other 1VF applications, there was at the time of my ethnographic research a remarkable confidence in the drugs, which it was reasoned had surely been tested properly in animals trials before being marketed on humans. There was also a general lack of interest with the long-term consequences of unneeded pre-embryos, The ramifications of IVF were considered as beyond the purview of daily practice and as belonging in the remote political and regulatory realms of law and government to rule on in light of CRCNRT’s recommendations. The University of British Columbia IVF programme is not market-driven, although it has legitimate concerns about cost recovery. The production of supernumerary pre embryos and their cryopreservation are justified as a provision of additional services to consenting patients and as methods for maximizing the chances of not only creating many pre-embryos, from which the best can be selected for transfer, but also as a cost-effective 142  mechanism for facilitating natural cycle transfers of frozen pre- embryos, despite the minimal success rates. It appeared to me that little thought has been given to the social consequences of donating andJor selling pre-embryos to third parties, nor to research projects involving pre-embryos as infonnation bearing entities or for preimplantation diagnosis and genetic manipulation. These applications have little relevance in the practice ofthe simple model of IVF, which facilitates individual customer service. Both the patient oriented staff in the clinics and the laboratory staff work towards the common goal of providing a much desired baby for the contracting couple. However, beyond the social organization of the TVF programme is a less obvious facet of the IVF process, which has little to do with human interaction.  Despite the highly technical  nature of the 1VF processes, the creation of pre-embryos is a combination of technology trying to replicate nature as well as nature-in-action. The issue at hand is yet another variation of the old nature/culture controversy. No matter how culture medico-technical culture of IVF  -  -  in this case the  manipulates social environments, the facts of biology,  the genetic blueprints and genetically programmed responses of the human organism dictate the final outcome ofthe technology. Scientists as yet do not know why ovaries of female 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 create an ovarian environment to produce many, not just one mature oocyte per month, ready for insemination. At present, scientists know little about exactly how nature triggers the action of syngamy and cleavage of the developing pre-embryo. This is a miracle, which occurs unaided by human intervention in the quiet of the laboratory, free of human observation. If fertilization does not occur, no triumphs of technology can intercede in the action. Likewise the technology of embryo transfer facilitates deposition in the uterus of the gestational woman, but it cannot control the subsequent implantation into the 143  receptive uterine wall. This remains at the discretion of natural factors, which are still poorly understood, as attempts at rectifying recurrent pregnancy loss in normally fertile women conlirm. In reality, IVF is still an experimental technology which attempts to replicate piecemeal every aspect of natural conception and so far has only solved some parts of the puzzle. Similarly, genetic engineering programmes are experimenting on pre-embryos as ready-made sources of genetic information. It is to the advantage of genetic engineers that 1VF provides a limitless supply of otherwise surplus discarded embryonic material, which has been artificially created in a controlled and hermetically sterile laboratory  environment.  144  ChAPTER 5 ‘1iLI LEGAL DISCOuRSE: ‘IHE CASE FOR THE PRE-EMBRYO  In Canada, assisted procreative technologies are developing swiftly in a largely unregulated legal vacuum. However, a number of committees and commissions have been mandated in the last two decades to provide a legal framework based on guiding principles rather than laws. Reproductive  Last in this long line is the Canadian Royal Commission on New  Technologies  (hereinafter  referred  to  as  CRCNRT),  recommendations were bypassed by the federal government in July 1995.  whose  Instead it  presented an interim measure, calling for a moratorium against nine technologies, and indicated that legislative and regulatory restriction would eventually follow (Bryden 1995:A5). This fell far short of the anticipated outlawing of specific technologies and the immediate formation of a National Regulatory Commission on NRTs, which would strictly regulate all the technologies. There have not been any legal cases brought before the Canadian courts as yet about the status of pre-embiyos, however, a number of interesting cases have occurred in other jurisdictions, which have relevance for Canadian cultural values.  These court battles  demonstrate some of the potential problems that may arise when pre- embryos are orphaned, require custody, or their ownership is challenged. They represent the challenge to a construction of the pre-embryo as a new social and legal category which is neither property, nor person; and how to consider its alienations and transfers as gift or commodity.  In terms of the matrix of social relations surrounding the pre-embryo, it 145  poses complex issues of who has vested interests in and rights to its versatile disposition. The present state of legal understanding demonstrates the confusion surrounding fertility clinic responsibilities and enforceable state controls.  I  CANADIAN VALUES AND GUIDING LEGAL PRINCIPLES  One of the major controversies surrounding new reproductive technologies, in general, 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 analyzed within a discourse of ethics, which examines those values and objectives that would be furthered through such regulation. 1 The law usually lags behind the social dimensions of biomedical issues. Political scientist, Blank notes this in relation to NRTs: The cultural and institutional frameworks of society largely define the boundaries within which technological development proceeds. Prevailing values although open to pressure for change by technology, are resistant to major and rapid alterations. Established institutions, too, resist change and attempt to minimize alterations. Although not always capable of maintaining stability, they moderate changes. Societal priorities therefore always reflect existing social values and structures. (Blank 19 84:4) The present Canadian constitutional and legal regime provides a useful framework within which regulation ofNRTs might be carried out. In the opinion of the Canadian Bar Association (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 evidence based report. These ethical principles included individual autonomy, equality, respect for human life and dignity, protection of the vulnerable, non-commercialization of reproduction, appropriate use of resources, accountability, and balancing of individual and collective interests (CRCNRT 1993:52-5 8). 146  which have been developed from existing legislation and jurisprudence, have served to guide the processual attempts in Canada to promote, protect and preserve entrenched socio-legal values. However, it cautions that the proliferation of “the use of reproductive technologies should be subject to review when fundamental social and legal, as opposed to medical issues, arise” (CBA 1990:14).  In its submission in November 1990 to the  CRCNRT hearings in Vancouver, the general legal issues that it broadly identified as the subject matter for regulation at that time were the status of the child, parentage and birth registration, artificial reproductive technologies, medical records, agreements for the gestation and delivery of a child and the surrender of custody (“surrogacy”), research and experimentation on human genetic material, and judicial intervention in gestation and childbirth (CBA 1990:4). CBA argued in favour of a sociological view of the individual as opposed to biological reductionism because “{T}he fact of biological reproduction, particularly the use of non-natural means of conception, should not be separated from the social aspects of childbirth, child rearing, and family relationships” (ibid: 15).  Thus legal concerns about  NRTs continue to focus on socially accepted ideas about the salience of “the family”, 2 while still allowing for new forms of family to be incorporated under its ample penumbra. Therefore the impetus has been to develop NRTs within a framework of contemporary societal values so as to diminish conflicts between those people most directly affected by them, such as parents, children and reproductive caregivers, as well as the broader implications for society in general. Furthermore, since it is women who bear 2  This strategy is currently being implemented with legal recognition of the desire to be considered family and share spousal benefits in the case of long-term same sex relationships. As yet these principles have not been applied to NRTs. An impending challenge in British Columbia reported in the Vancouver Sun exists over the controversial issues of access by lesbians to artificial insemination by donor (AID) (Wigod 1993a:A1). Another case has been reported in England (Lightfoot 1994:1). 147  the greater risk of such technologies, it is their interests and opinions, in particular, which should be recognized. Historically, legal principles have evolved through instruments such as the 3 the Canada Health Act and provincial and Canadian Charter of Rights and Freedoms, territorial legislation.  Together they have embraced a consensus which asserts legal  principles, which preserve values of individual autonomy and human dignity.  The  Canadian 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 such aspects of NRTs as informed consent, access to technologies, rights to knowledge about affiliation, 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 TILE UNITED STATES In contrast to the non-litigious Canadian climate ofnew reproductive technologies,  several cases have occurred in the United States, which are helpfiul in developing an understanding about how the pre-embryo may be socially constructed as potential person or as potential property of some party with vested interest. While decisions were made in  The Canadian Charter of Rights and Freedoms is contained in Part 1 of The Constitution 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 report notes that Canada as a founding member of the United Nations and a participant in the development of international human rights covenants has used the language of these international instruments to shape the Charter. In effect the Charter acts as a bridge between its international obligations and its domestic laws (Cook 1991:1). 148  each case eventually, the convoluted court processes demonstrated the uncertainties that arose about how to categorize the pre-embryo.  (i)  Reos In the early days of IVF, a wealthy American couple were killed in a plane crash in  Brazil, in June 1984. The Reos had been attending an IVF clinic in Melbourne and had left two frozen pre-embryos there. Problems about the limits of decision-making about reproductive issues and the rights of the unborn arose from this event.  While the  Australian Wailer Commission, which had been appointed to consider such issues, suggested that the “orphaned” Reos pre-embryos be thawed but not implanted, the Provincial government of Victoria later voted that they should be implanted into one of the many volunteers (Gallagher 1987: 197). This did not happen. Inheritance and succession are issues that all societies attempt to regulate to ensure social stability. The Reos case is a good example of the complications that can ensue when inhentance patterns become muddied by creating pre-embryos, particularly in a transnational context. 4 Legal confusion occurred because the Reos couple did not leave a will.  Questions arose as to whether the frozen pre-embryos should be considered as  persons and therefore have rights to the large Reos inheritance. If a gestational surrogate was implanted with the pre-embryos, could she make a subsequent claim to the estate on behalf of the child and herself? Other heirs also existed, who also had a claim to the estate. The legislation proved to be so complicated and difficult to interpret that no action was taken until 1987, when under relevant California law, the court decided that the The Report of the Law Reform Commission of Canada (1992) warned about the complexities of “procreative tourism”, which can occur when NRTs service provision are utilized andJor gametes/preembryos are produced, stored and br transferred across national boundaries. 149  hiorphanedu pre-embryos had no rights to the estate and Mrs. Reos’ mother was found to be the sole inheritor ofthe estate (Kimbrell 1993:92).  (ii)  Davis v. Davis, Kass v Kass and Jones v. York A number of cases have occurred in the U.S., which demonstrate further  difficulties of decision-making surrounding the pre-embryo.  Each case challenged the  fundamental question about the nature ofthe pre-embryo as property. Two cases involved a quarrel between the biological parents of frozen embryos as to who had the ultimate control over their destiny. The other case involved a dispute between a couple and and IVF clinic, where their frozen embryos were stored. “In no case, however, has the status of the embryo been presented more clearly and 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 unsuccessful attempts with IVF, decided to try the new freezing programme offered by the Fertility Centre of East Tennessee. In this attempt, nine pre-embryos were retrieved and two were unsuccessfully implanted. The remaining seven pre-embryos were frozen; but before the Davises could use the pre-embryos, Mr. Davis filed for divorce. A bitter and protracted custody 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 legal status of frozen pre-embryos. The trial court in the first instance ruled that life begins at conception and incorrectly held that pre-embryos were morally equivalent to children and that 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 that the 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 wrong 150  reason, because using this logic, every pre-embryo created through 1VF would have to be implanted 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 that women’s efforts to control their procreation and pregnancy behaviour would be jeopardized by this ruling, the Tennessee Appeals Court in 1990 overturned the ruling. The appellate court looked at the procreative liberties of both parents, and stated that the husband had a “constitutional right not to beget a child where no pregnancy had taken place” (Davis v Davis, No. 180 Tenn. Ct. App., Sept. 13 1990:4). It was reasoned that Mr. Davis thereby had the right not to procreate, even though he had consented to create 5 the pre-embryos m the first place with the intention of becoming 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 unwanted fatherhood, than for his ex-wife to undergo yet more invasive 1VF cycles.  Raymond  makes a strong case that these allegedly equal rights to parenthood decisions are false equivalents. The Supreme Court of Tennessee in June 1992, in criticizing the appeals court for viewing the pre-embryos as property, took the middle ground. “We conclude that pre An interesting reversal concerning a potential father’s procreative liberty occurred when a former boyfliend, Jean Guy Tremblay, of a Quebec woman Chantal Daigle, argued that his self-interest in becoming a father should take precedence over Daigle’s right to have a therapeutic abortion. In the emergency session in August 1989, the Canadian Supreme Court’s unanimous decision quashed the injunction a Quebec court had granted Tremblay to prevent Daigle having an abortion. To ensure that no woman ever had to endure a similar ordeal to Daigle’s, the court said “We have been unable to find a single decision in Quebec or elsewhere which would support the allegations of “father’s rights” necessary to support 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 the argument about “father’s rights” (Makin l989:A5). 151  embryos are not, strictly speaking either persons or property, but occupy an interim category 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 husband was awarded control of the frozen embryos resulted in the final destruction of the pre embryos at Junior’s request. Mary Sue and Junior would have to start over again with new partners using IVF if they wanted to have children. There was disappointment that the case failed to answer the question of whether to consider the pre-embryo as person or property (Crockin 1993:10). If they are property, then who owns them clinics, donating -  parents or recipient parents? In a current case in Nassau County, Kass v. Kass (1995), the New York Supreme Court reached a different conclusion from Davis v. Davis. In Kass, the judge held that a woman had the right to control the future outcome of the pre-embryos she created with her husband. When she petitioned for divorce, the only contested issue in the divorce was the possession of the five frozen embryos, which she wished to gestate and her husband wished to be donated for research (Jaeger 1995:16).  So in this case, the wife was  entrusted with the right to control their destiny, thereby rejecting the rights of the divorcing husband on the grounds that a man, whether manied or not, cannot control the conception nor continuance of a pregnancy. The judgment, in noting that a woman has the sole right to use contraceptives and to terminate a pregnancy, stated “The fact is that in vivo husband’s rights and control over the procreative process ends with ejaculation.. .It matters little whether the ovum/sperm union takes place in the private darkness of a fallopian tube or the public glare of a petri dish” (ibid).  The court’s argument in this case  is consistent with feminist beliefs that women should have ultimate control over their reproductive decisions.  152  Unlike the middle position decided in Davis, that embryos are neither persons nor property, but nevertheless deserving of special respect, another United States’ case, ified in Virginia, York v Jones, decided in 1989, that pre-embryos should be treated as commodities. This case was cited as an important precedent by the appeals court that decided Davis. The dispute concerned a conflict between a couple and a clinic over the ownership and control of the couple’s frozen pre-embryos stored at the prestigious Jones Institute 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 a California depository in Good Samaritan Hospital, Los Angeles. There Risa York would be implanted with those pre-embryos under the supervision of Dr. Richard Mans, who challenged his competitors in Norfolk with the taunt, “When a physician starts owning embryos and making decisions for his patients, there’ll be no stopping anyone who has anything to do with pregnancy from getting involved” (quoted in Raymond 1993:6 1). The federal court of Virginia ruled that the frozen pre-embryos, which they referred to as “pre zygotes” were the “property” of the couple and the Jones clinic only held those pre embryos in bailment (trust) for the couple pending their later use. Neither the welfare of the pre-embryos during their transportation across the continent, nor the interests of the clinic in ensuring their secure preservation were considered to have any legal relevance (Kimbrell 1993:97).  Essentially they were considered the property of the gamete  producers to do with as they chose. These cases represent early attempts in the United States to define the legal status of pre-embryos, and suggest that they may well join sperm and ova as full-fledged commodities.  Lawyer and policy director of the Foundation on Economic Trends in  Washington, D.C., Andrew Kimbrefi, has argued the analogy between commodi1ring fetal parts and pre-embryos.  “(W)hile Congress has forbidden the sale of fetal parts, it is 153  unlikely that they will do the same for embryos, due in part to the view that so-called pre embryos or pre-zygotes are merely “masses of cells” (Kimbrell 1988:98). However, he envisages a time in the not distant future when “as reprotech advances, we will soon see our first headlines announcing the first sale of an embryo and perhaps even the first patenting of a human embryo for research use” (ibid).  (iii)  Oocyte and Embryo Donation As the case law and legislation develops, the destiny of gametes and embryos will  probably become subject to tighter legal controls as circulating commodities.  United  States legislation has recently been drafted concerning ova and embryo donation, which point to a growing acceptance of and market in both gametes and fertilized ova. This suggests an elision of the two entities as similar in nature for legal definition. To date the focus has been placed on using family law to protect the resultant progeny of such rudimentary tissues, rather than a concern for research uses or the practice of marketing human tissue. For as long as the social and legal purview is on the consequences for family of assisted conceptions, there will be little concern about the pre-embryo as a reified entity, which can be used to assist important medical research. Recently, two American states, Florida and Texas, have drafted and lobbied for egg and embryo donation. Oklahoma passed an egg donation law in 1990. Both states have given legal recognition to children born of egg and pre-embryo donation. In both test cases the recipient gestational woman and her husband are considered the legitimate parents of the child, in the same way as donor insemination (Crockin 1993:10). Tn these cases the best interest of the child is the pre-eniinent consideration. Even in cases where parental 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., a 154  New York Family Court case, where a lesbian relationship overrode the request for unsupervised visitation with the child’s biological father (ibid: 11).  (iv)  Fetal Tissue Commerce and Research Although the sale of fetal parts in the United States has been prohibited, this  situation may be changing as a result of federal permission being granted to carry out a clinical trial to transplant fetal tissue for treatment of Parkinson’s disease. A $4.5 million research project in the field of neural fetal tissue transplantation for treatment of forty Parkinson’s disease patients has recently been authorized. The American research group had already performed the first transplant in 1988, despite a national moratorium on this type of research (Weber 1994:46). Likewise, in 1988, Canadian medical researchers at Daihousie University applied for ethical review to perform the first Canadian transplant of neural fetal tissue for treatment of Parkinson’s disease. However, a similar ban as in the United States delayed this research trial until 1992 (ibid). Fetal transplants had already been tried in Mexico, the United Kingdom and Sweden. In Canada, considerable ethical debate has been raised by this innovation. One concern is that perhaps pre-embryos in the future could be gestated in vitro beyond the present seventeen day restriction to a point where differentiated tissues would be sufficiently advanced for use in research. If a culture medium can be perfected, it may even become possible to grow pre-embryos for the explicit purpose of providing tissue and organs for human transplantation purposes. The benefit here would be that anonymity of donor could be respected if pre-embryos came from a reserve pre-embryo bank. Abby Ann Lynch, director of the Canadian Westminster Institute for Ethics, in calling for strict criteria, has stated: “I think I would be concerned about the source (of the fetuses). You must absolutely guarantee that you are not growing embryos in vitro for the purpose of 155  being able to take its brain for transplant” (Povenko 1988:A5 and A8). In a recent study surveying Canadian doctors’ attitudes towards transplantation of electively aborted human fetal tissue, although they were not asked about use of pre-embryoaic tissue, they did consider fetal tissue donation often to be analogous with organ donation (Mullen, Williams and Lowy 1994).  CREATING A CANADIAN LEGAL FRAMEWORK FOR REGuLATING PRE-EMBRYOS  ifi  Unlike the free enterprise, private health care system in the United States, as yet there have not been any controversial law suits in Canada relating to pre-embryos. In this sense, the Canadian legal system has had more time to consider how pre-embryos, created through IVF, should be socially and legally classified, although the outcome still remains unclear.  The Canadian process has evolved through a series of committees and  commissions, 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 human pre-embryo. These include property law, laws pertaining to persons, family law, patent law 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. Varying degrees of control may be exerted by the different levels of government, by professional medical associations, hospital boards and health care professionals.  (i)  The Context of Canadian Health Regulation Constitutionally, health issues cannot be controlled by a single level of  government. The federal government retains the ability to regulate, which is based both 156  on its interest in national health and welfare and within its national jurisdiction to enforce the criminal law and control budgetary allocation of scarce health funds. The Canada Health Act behaves as the cornerstone of the health care system and its framework is intended to provide a broad social and health security net for all Canadians.  The system is based on five criteria, comprehensiveness, accessibility,  universality, portability and public administration. 6 Unfortunately, despite the ideals of the Act, medical services are not implemented in a uniform manner across Canada, but 7 Provincial governments are responsible for regulating according to provincial discretion. those matters related to health, such as control over hospitals and over health care workers, hospital administrators and professional medical associations within their jurisdictions. Provincial government funding of health is based on social and political rather than medical criteria. How this fits within the framework of the Canada Health Act or the Canadian Charter ofRights and Freedoms is as yet undefined. The power of provincial governments to regulate health services has been idiosyncratic in defining what constitutes the practice of medicine.  This has been  demonstrated in two instances in the area of reproductive issues where certain reproductive technologies have been considered not umedically required”. The Canadian Bar Association (CBA 1990) argued in their brief to the CRCNRT that “(T)he new 6  Comprehensiveness ensures a minimal level of insured health services, which are mandated 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 to reasonable levels ofhealth services, regardless ofwho they are and where they live or their financial status. For a comprehensive examination of the Canada Health Act, see Sheila Iaftin (1989). In Canada, there is no uniform definition of the practice of medicine. Therefore provinces interpret differentially the Medical Practitioners Act of 1979, which broadly defines the composition of medical practices and the Medical Act of 1989, which specifies the actual service and the profession ofthe person performing the service (CBA 1990:32). 157  artificial technologies constitute remedies and treatment for infertility, a human condition which may result from disease and which may be regarded as a defect. Application of these technologies therefore probably constitutes the practice of medicine in law” (CBA 1990:32). In both the cases cited by CBA, women’s reproductive autonomy has been compromised.  In 1985, the Alberta government unilaterally de-insured surgical  sterilizations, 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 services were not yet available in the province, they were automatically deemed as not “medically required” and therefore ineligible for insurance under the term of the Medical Services Act, R.S.B.C. 1979, c.255, s.1. CBA further points out that “such legislative action cannot, however, be considered conclusive since it ignores the link between infertility and disease or defect and the invasiveness of the procedure” (CBA 1990:32).  Technically IVF can only be  performed by an appropriately licensed surgeon in an appropriately licensed facility. The socio-economic effect has been to make those services available only to those who can afford it, in flagrant contravention ofthe principles of the Canada Health Act.  (ii)  Canadian Commissions and Committees for Regulating New Reproductive Technologies (NRTs) The mainstream legal discourse about NRTs in Canada has developed during the  1980s from a plethora of influential commissions, reports and surveys. These preceded the piece de resistance, the recent report Proceed with Care, published in two volumes by the Canadian Royal Commission on New Reproductive Technologies (1993). In general, 158  these documents have reiterated the importance of national standardization and monitoring, national approval of research and accreditation and licensing of research and treatment facilities.  This legal discourse has  attempted to  co-ordinate  and  compartmentalize thinking about an otherwise amorphous, uncoordinated series of reproductive practices, which are developing largely unchallenged and uncontested. Beginning in the early 1980s, Canadian legal investigations have included the report of the Advisory Committee on the Storage and Utilization of Human Sperm to the Minister of National Health and Welfare, Storage and Utilization of Human Sperm (1981), the Ontario Law Reform Commission (hereinafter referred to as OLRC) Report on Human Artficial Reproduction and Related Matters in 1985; The Working Committee of the Quebec Department of Health and Social Services, Rapport du comite du travail sur les nouvelles technologies de reproduction in 1988.  In the same year the Bar of  Quebec published Rapport du comite sur les nouvelles technologies de reproduction. A year later, following the Quebec Department of Health and Social Service Report, a supervisory framework in Quebec for embryo research was proposed “that would require official approval for current projects and prohibit trade in embryos or the creation of human embryos solely for research” (CRCNRT 1993:65 7).  However, to date no  legislation in Quebec has been presented to date. In 1987, the Medical Research Council of Canada in Ottawa published Guidelines on Research Involving Human Subjects, which upheld the fourteen to seventeen day limit on maintaining pre-embryos for “non-therapeutic” research in the in vitro state and recommended that embryo research only be conducted to improve knowledge and the treatment of infertility. It also reinforced the need for donor consent and for local ethics board approval for research on pre-embryos, and the unacceptability of transferring pre embryos that had been subject to experiment, as well as limitations on certain kinds of 159  research, such as cloning. Two years later on the other side of the country, in British Columbia, in 1989, the Reproductive Task Force of the British Columbia Branch of the Canadian Bar Association released Reproductive Technologies in 1989. AJso in that year, the Law Reform Commission of Canada (hereafter referred to as LRCC), before it was disbanded, had published two working papers, Crimes against the Fetus  8  and Biomedical Experimentation Involving Human Subjects. It had been called in  an attempt to advance the public debate and to complete its trilogy studies in the area of medical law and procreation. The conceptual nature of gametes and embryos is an issue with which Canadian legal scholars have also wrestled for nearly a decade. LRCC had been 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, the commercialization of procreation, the human body and its products and substances; and the legal status of gametes and embryos” (LRCC 1992:1). It had been called in order to develop a consistent national social policy on NRTs, because the reports of the Ontario Law Reform Commission in 1985 and the Barreau du Quebec in 1988 had expressed diametrically opposed views on a number of fundamental aspects of the issue. The LRCC recognized that the ambiguity surrounding the status of the pre-embiyo gives rise to moral and social objections that have appeared with the creation and freezing of surplus embryos. What is at issue here is one’s image of the embryo. Is it a thing, a person, a potential person, or something else?.. .We might ask ourselves in more general terms whether we wish to treat gametes and/or embryos differently from other parts of the body or alienable cells, or 8  In Working Paper 58, Crimes against the Fetus, the Commission’s major recommendation is that the fetus merits criminal law protection, which the Criminal Code presently does not achieve adequately. A new chapter would be included in the Code and a new offence of “foetal destruction or harm would be incorporated to make it a crime to purposely, recklessly or negligently cause death or serious harm to a foetus” (The Lawyers Weekly. March 17 1989). 160  in other words, create a special regime suited to the specific nature of gametes and embryos” (LRCC 1992;5 1). In general, all the preceding reports reflected the substance of the Medical Research Council guidelines concerning embryo research.  Each recommended that  systematic regulation and monitoring of research be carried out in order to ensure the guidelines  were  being  applied  consistently  (CRCNRT  Similar  1993:658).  recommendations have been made by the two Canadian Professional Associations involved in embryo research, the Canadian Fertility and Andrology Society and the Society of Obstetricians and Gynaecologists of Canada, in their Combined Ethics Committee report 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 volume OLRC Project report, Human ArtfIcial Reproduction and Related Matters in 1985. Legal scholar, Bernard Dickens (1992), who had worked on the report, discusses the OLRC Project in terms of the three general orientations proposed to develop legal responses to artificial reproduction and surrogate motherhood.  One position  accommodated individual’s private ordering of their reproductive behaviours. included donation, selling and receipt of reproductive services.  This  Another approach  accommodated several levels of regulation to enhance individual reproductive preference, while a third approach prohibited or frustrated these individual options.  Finally, the  Commission “rejected both extremes of the private ordering and the prohibitory approach in favour of a hybrid approach. Different techniques of assisted reproduction were found to warrant different legal approaches” (Dickens 1992:62). Because it was released after  161  9 it led several critics to conclude that OLRC Commissioners the British Warnock report, had simply adopted the Warnock approach. According to Dickens (1992:47) this was untrue. However, there was congruence between Warnock and OLRC recommendations in the areas of gamete and embryo donation, IVF and related techniques. The OLRC did depart from Warnock and most other reports on NRTs in its recommendation on surrogacy. Guided by the confiLsing developments that obfuscated the legal decision-making concerning the Scarborough, Ontario surrogate motherhood case in 1982, and the report of 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 ‘legal rights’ and ‘legal duties’ of biological parents and their spouses and of medical practitioners and other personnel involved, the ‘legal procedures’ for establishing and recognizing parentage of children, the applicability of custody and adoption laws and the bearing of medical and related evidence on legal issues” (Dickens 1992:52-53). Not surprisingly in a Canadian political climate where children’s rights were beginning to emerge, the focus of the Project was not on infertility per se or the concerns of those with fertility impairment, but on protecting “the best interests of children” born through artificial means of reproduction. At this time the discourse of infertiJity promoted both by the medical establishment and the newly emerging special interest groups  The Wamock Commission, chaired by philosopher Dame Mary Warnock had been called by the British Government in 1984. Its recommendations were not translated into law until 1991 when the British Fertilization and Embiyology Act was passed after much controversial public and political debate. In February 1990, the House of Lords decided 234 to 80 to allow research to continue on human embryos for 14 days after fertilization under the control of a new statutory licensing authority (Wintour 1990:3). 162  concerning infertility awareness about the plight of infertile people was still largely unheard.  The terms of reference thus restricted the Commissioners’ approaches.  Otherwise, emphasis might equally well have been put on the best interest of couples, or protection of women’s interests, or the concerns of disabled peopl