Table Of Content

EMBODIED PROGRESS This new edition of Sarah Franklin’s classic monograph on the development of in vitro fer- tilisation (IVF) includes two entirely new chapters reflecting on the relevance of the book’s findings in the context of the past two decades and providing a ‘state-of-the-art’ review of the field today. Over the past 25 years, both the assisted conception industry and the academic field of reproductive studies have grown enormously. IVF, in particular, is belatedly becoming recog- nised as one of the most influential technologies of the twentieth and twenty-first centuries, with a far-reaching set of implications that have to date been underestimated, understudied and under-reported. This pioneering text was the first to explore the emergence of commer- cial IVF in the United Kingdom, where the technique was originally developed. During the 1980s, the British Parliament devised a unique system of comprehensive national regulation of assisted reproduction amidst fractious public and media debate over IVF and embryo research. Franklin chronicles these developments and explores their significance in relation to classic anthropological debates about the meanings of kinship, gender and the ‘biological facts’ of par- enthood. Drawing on extensive personal interviews with women and couples undergoing IVF, as well as ethnographic fieldwork in early IVF clinics, the book explores the unique demands of the IVF technique. In richly detailed chapters, it documents the ‘topsy-turvy’ world of IVF, and how the experience of undergoing IVF changes its users in ways they had not anticipated. Franklin argues that such experiences reveal a crucial feature of translational biomedical pro- cedures more widely – namely, that these are ‘hope technologies’ that paradoxically generate new uncertainties and risks in the very space of their supposed resolution. The final chapter closely engages with the ‘hope technology’ concept, as well as the idea of ‘having to try’ and uses these frames to link contemporary reproductive studies to core sociological and anthropological arguments about economy, society and technology. In the context of rapid fertility decline and huge growth in the fertility industry, this volume is even more relevant today than when it was first published at the dawn of what Franklin calls the era of ‘iFertility’. Embodied Progress is an essential read for all social science academics and students with an interest in the burgeoning new field of reproductive studies. It is also a valuable resource for practitioners working in the fields of reproductive health, biomedicine and policy. Sarah Franklin is the Chair of Sociology and Director of the Reproductive Sociology Research Group (ReproSoc) at the University of Cambridge, where she is also a Fellow of Christ’s College. EMBODIED PROGRESS A Cultural Account of Assisted Conception Second Edition Sarah Franklin Cover image: © Getty Images Second edition published 2022 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 Sarah Franklin The right of Sarah Franklin to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. [First edition published by Routledge 1997] British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-1-032-25669-6 (hbk) ISBN: 978-1-032-25667-2 (pbk) ISBN: 978-1-003-28449-9 (ebk) DOI: 10.4324/9781003284499 Typeset in Bembo by SPi Technologies India Pvt Ltd (Straive) CONTENTS Foreword by Emily Jackson vi Acknowledgements to the first edition x Acknowledgements to the second edition xv Introduction to the second edition 1 Introduction to the first edition 18 1 Conception among the anthropologists 32 2 Contested conceptions in the enterprise culture 85 3 The ‘obstacle course’: the reproductive work of IVF 112 4 ‘It just takes over’: IVF as a ‘way of life’ 140 5 ‘Having to try’ and ‘having to choose’: how IVF ‘makes sense’ 175 6 The embodiment of progress 202 Afterword to the second edition 219 Index 239 FOREWORD BY EMILY JACKSON In the late 1980s, when the meticulous ethnographic fieldwork for Embodied Progress was carried out, IVF was still a novel technology, which gave new hope and new options to people who had been unable to conceive a child. Sarah’s interviewees were aware that they had choices that had not been available to previous generations, and they were clearly grateful to have had the chance to try IVF. At the same time, the reality of being an IVF patient proved to be radically different from what they expected, and its impact upon their lives was profound and sometimes profoundly negative. Embodied Progress revealed for the first time that becoming a fertility patient can be life-changing, even if it does not result in the birth of a child. IVF is not just an intervention that can relieve infertility in some patients; rather, it can change how women feel about childlessness. In addition, even if IVF is plainly a triumph of scientific knowledge and technical expertise, it simultaneously reveals how much we don’t know about human reproduction: most IVF cycles fail, often for reasons that are poorly understood. In 1997, Embodied Progress, with its visceral and compelling revelations about the contradictions of being an IVF patient, was unlike anything that had been published before. Its finding that IVF did not – and could not – give women the closure or ‘peace of mind’ that they had anticipated before they began treatment was ground- breaking in 1997 and continues to have powerful resonance today. Before embarking on their first IVF cycle, women often think that – one way or another – it will provide them with some sort of resolution. Obviously, their hope is that that resolution will come in the form of a baby. But it is common for women to believe that even if their treatment is unsuccessful and they remain childless, it will be a comfort to know that they ‘tried everything’ and that this will help them to ‘come to terms with it’. In practice, however, Embodied Progress shows us how the technology ‘“takes over” and becomes a way of life’. Foreword by Emily Jackson vii Women who are relaxed (or even indifferent) about whether they want to have a child at the beginning of the process – imagining that they will just ‘have a go’ at IVF before moving on – become ‘desperate’ and utterly preoccupied by it. As Sarah puts it so memorably, the ‘goal of resolution becomes a receding horizon’. Sarah notes that patient leaflets tend to describe IVF ‘as a “simple” procedure, and as a “natural” one’, which is merely ‘giving nature a helping hand’. The experience of IVF is, however, more like an ‘obstacle course’. Strikingly, IVF is actually a misnomer, referring to only one part of a complex and multi-faceted process. A more accurate description would be ovarian stimulation plus follicle monitoring via internal ultrasound plus surgical egg retrieval plus IVF plus embryo transfer plus two- week wait plus pregnancy test plus (only if the pregnancy test is positive) a follow-up ultrasound scan. It is interesting, to say the least, that the name we give to the whole process actually describes the only part of it which takes place entirely outside the woman’s body. Perhaps the rest of the ‘work’ of IVF is invisible precisely because it happens inside women’s bodies, One consequence of the multiple stages of an IVF cycle is that there are also multiple points at which the cycle can fail or have to be abandoned. Before treatment, women tend to think that success or failure in IVF is binary: there either will or will not be a baby. In practice, however, women can have little successes along the way, before something goes wrong, often inexplicably. Eggs may have been successfully harvested, some eggs may have been successfully fertilised and some embryos may have grown to the blastocyst stage. Women might even experience a ‘chemical pregnancy’; that is, they have a positive result when they do a pregnancy test two weeks after embryo transfer, but they may find that they are not pregnant when a follow-up ultrasound is carried out a few weeks later. The further along this process a woman is, the harder failure becomes. All of these partial successes enable a woman whose treatment has failed to feel as though she is getting closer than she has ever been before to being pregnant. Having been ‘a little bit pregnant’, when most failure in IVF is ‘unexplained’, makes it even more difficult to give up. There is no reason why the next cycle should not work, especially since so much went right in this cycle. There is often also something else to try: a different drug regime, perhaps, or carrying out embryo transfer a day or two later. In addition to having had ‘little successes’ in the multiple stages of IVF, the process also involves gathering and recording multiple measurements of fertility. Follicles are measured and counted, and records are kept of the number of eggs retrieved and of the number which are fertilised. Embryos are graded, the thick- ness of the lining of the uterus is measured, and levels of different hormones are recorded. As Sarah explains, The very specific details, such as the sizes of the eggs, are committed to memory, and represent important signs of ‘embodied progress’. … In turn, this gives encouragement: ‘I know that I’m working’. viii Foreword by Emily Jackson IVF failure is, therefore, seldom absolute (this did not work and it will never work); rather, a failure at one stage of the process is transformed into the ‘impetus to pro- ceed’ next time. Failure thus does not give women ‘closure’; instead, it redoubles their determination to succeed, and the ‘treadmill’ of IVF begins. For many women, infertility opens up a gap between the life that they had expected to lead and an unexpected life without children. Women turn to IVF to resolve this disruption to their life plans, but instead of providing resolution, IVF opens up new gaps and disruptions. The ‘why me?’ question about infertility becomes the ‘why me?’ question about why an IVF cycle did not work. Before IVF existed, women who were unable to conceive had to either ‘get on with their lives’ without children or try to become parents via adoption. As a result of the availability of IVF, ‘getting on with their lives’ is put on hold while women exhaust the possibilities opened up by this new technology. Women report having no choice but to try IVF: once the technology is there, people are anxious to avoid future regrets that they did not do everything they could to have a baby while they still could. Thus, in addition to losing the life you thought you were going to have as a mother, while you are on the IVF treadmill, you also lose the life you would have been ‘getting on with’ in the absence of IVF. For multiple reasons, then, rather than solving the ‘desperation’ of infertility, IVF actually produces it afresh. When undergoing IVF, women found themselves both feeling ‘more fertile’ than ever before (through producing eggs and embryos, and having them transferred to their uterus), while simultaneously also feeling ‘more acutely the pain of infertility’. In 2022, the processes of IVF have been refined in order to increase success rates, but there has been rather less success in making the experience of IVF less emotion- ally burdensome. It continues to be common for fertility patients to believe that it will be easier to accept childlessness in the knowledge that they did everything they could to become parents. The reality is still very different, however. Despite the fact that we have known for decades that it can be difficult to get off the IVF treadmill, we do not seem to have come very far in helping women and couples to make the decision to ‘give up on’ IVF and stop treatment. If treatment fails, this continues to be seen not as a reason to abandon treatment but as a reason to try something else. Indeed, the view that even if IVF does not work, it might, nevertheless, serve the worthwhile purpose of giving women closure is not confined to patients themselves. In a recent article by fertility specialists and a philosopher on the legitimacy of offering treatment which has a negligible chance of success, Yovich and colleagues suggest that undertaking a futile treatment cycle might help a woman to ‘“come to terms” with their infertility status’.1 Readers of Embodied Progress could have told them that this may be a hopelessly optimistic view of the ‘benefits’ of IVF failure. Sarah’s characterisation of IVF as a ‘hope technology’ has had profound and lasting significance. Deciding not to have more treatment, after successive failures, is hard precisely because it marks the end of this hope. Even though it is the most likely outcome for almost every treatment cycle, and a third of all fertility patients remain childless, patients rarely feel prepared for treatment failure. Despite being Foreword by Emily Jackson ix ‘profoundly unrepresentative’ of fertility treatment, cultural representations of IVF continue to be dominated by babies and not by their absence Embodied Progress provides an object lesson in the importance of listening to what people say about their experiences, taking what they say seriously and not judg- ing them. When Embodied Progress was published, it was common to read feminist accounts of IVF which were critical of the technology, portraying it as yet another example of men experimenting on women’s bodies. As the work of an impeccably trained ethnographer, Embodied Progress is conspicuously non-judgemental. Sarah is not criticising the availability of IVF or the wisdom of pursuing it. On the contrary, it is clear that her interviewees felt fortunate to have had the option of IVF, at the same time as finding it much more difficult and complicated than they had expected. Embodied Progress is a riveting read, and its portrayal of IVF as a contradictory and complicated technology is as powerful today as it was 25 years ago. It challenges our assumptions about scientific progress as a simple unalloyed ‘good’, not in order to cast doubt upon the value of providing new treatment options but to show that a technology can be both life-enhancing and soul-destroying at the same time. The pioneers of IVF technology may have been doctors, scientists and the patients themselves, but in order to understand the significance of IVF, we need to turn to anthropologists and sociologists, like Sarah, and there is no better place to start than this brilliant and engaging book. Notes 1 JL Yovich, MJ Chapman, KN Keane, and J Savulescu, ‘Is 45 years-of-age the cut-off for using autologous oocytes?’ (2018) Reproductive BioMedicine Online 37: 123–125.