Infertility in the Middle East

Infertility in the Middle East

In February, violent protests over European cartoons that mocked the prophet Muhammad broke out across the Middle East, and the United States approached a showdown with Iran over its nuclear program. The stream of unsettling news, however, didn’t deter Marcia Inhorn from a 17-day trip through Lebanon, United Arab Emirates, and Iran itself, where on March 1 she delivered a paper on Islam and in-vitro fertilization. Two decades of research on infertility in the Middle East had brought her to the region many times, including extended stays in Egypt and Lebanon with her husband and two young children in tow; her experiences in that part of the world don’t match the ominous reports often heard in the U.S. And besides, securing an Iranian visa had been too much of an ordeal to bail out.

Inhorn, a professor of medical anthropology in the Department of Health Behavior and Health Education, spoke at a University of Tehran conference, “Gamete and Embryo Donation in Infertility Treatment,” delivering a paper outlining the differences between Sunni and Shi’ite fatwas—religious opinions—on assisted reproductive technologies (ARTs). She was one of only four westerners, two of them American, invited to speak. Her audience included mullahs in turbans and robes and university women in black chadors. Inhorn herself wore a head scarf and long coat, as required in Iran of women appearing in public. If it makes an incongruous picture—a non-Muslim American woman lecturing to an Iranian audience on how Islamic beliefs influence the use of babymaking technology—Inhorn is well aware of this. It was hardly the first time she’d been in such a position.

“I always make it clear that I’m not Muslim but that I appreciate Islam,” Inhorn says. “My whole research career has been in the Muslim world, and I feel very comfortable there. The Middle East is a fascinating part of the world.”

Culture and Health

For Inhorn, the intersection of infertility, religion, culture, and gender creates a field of study so stimulating that the intellectual energy she brings to it seems inexhaustible. In addition to teaching and advising public health students, Inhorn holds joint appointments in anthropology and women’s studies. She also directs the Center for Middle Eastern and North African Studies, organizing an active schedule of speakers and conferences. Beyond the university, she serves as president of the Society for Medical Anthropology, president-elect of the Association of Middle East Women’s Studies, founding editor of that group’s journal, and associate editor of Global Public Health. And all the while, she keeps up a busy pace of travel, research, and writing.

“It tires me out just hearing what she’s doing,” says friend Robert Hahn, a medical anthropologist with the Centers for Disease Control and Prevention. “In looking at the role of technology in reproductive issues, particularly Muslim settings, she’s a pioneer.”

Inhorn joined the University of Michigan faculty in 2001, coming from Emory University in Atlanta. Her background fit excellently with the global health initiative the School of Public Health was launching, says Sherman James, then HBHE chair and now professor of public policy at Duke University. At the time, the school had no anthropologist, and James believed it needed one. “With the increasing racial and ethnic diversity in our society and the role of culture in shaping health behaviors, it seemed important to have a faculty member who could introduce students to cultural frameworks of health,” James says. “She’s just an ideal person to do that.” In fact, Inhorn and Hahn are currently editing a book on the contributions that anthropologists can make to public health. “Medicine and public health are inevitably cross-cultural enterprises, and that’s what anthropologists are good at,” says Hahn. “They can help at understanding and gaining the assistance of populations to design effective programs.”

James says Inhorn also strengthened HBHE’s course offerings on qualitative research methods, and few other faculty members focused on Muslim and Arab health issues. “Students need to know more about that part of the world,” he says, “and she is in a terrific position to educate people who are uninformed or misinformed about it.”

Mark Tessler, UM vice provost of international affairs, praises Inhorn’s leadership at the Center for Middle Eastern and North African Studies. A political scientist, Tessler also has done extensive research in the Middle East and is familiar with the challenges involved. “There’s more than a certain amount of anti-Americanism,” he says, “so automatically there’s a hesitation to be involved with American scholars. You can’t just go over and do your work. We [he and Inhorn] both work in very close collaboration with local scholars. You have to develop relationships, which is as it should be, and Inhorn’s record in this regard has been exemplary.”

In January, Inhorn and her family again will embark for the Middle East, this time a six-month stay in United Arab Emirates where Inhorn will explore her latest research interest—reproductive tourism. The term applies to the phenomenon of people traveling to other countries to undergo in-vitro fertilization.

Inhorn, who will be based at the American University of Sharjah, the emirate next to Dubai, wants to study why Arab people move from one country to another and how the diaspora bears on infertility treatments. In Egypt and Lebanon, she frequently met people who had just returned or were just leaving for jobs in the oil-rich Persian Gulf—sometimes, intriguingly, for the very purpose of earning money for IVF. United Arab Emirates is an English-speaking, high-tech international crossroads that attracts people from across the Middle East and south and southeast Asia, allowing Inhorn to interview Muslims from a broad array of backgrounds. The term “reproductive tourism,” used throughout the field, is imperfect, Inhorn acknowledges.

As her work demonstrates, IVF isn’t exactly a fun vacation.

A Lens Into Social Lives

Muslim countries in the Middle East are what anthropologists call “pronatalist” societies. Almost everyone gets married and raises children. Even among the educated, professional elite, the idea of choosing not to get married or have children simply doesn’t exist. In such societies, infertility is a source of deep anguish and social stigma. “If everyone in your village has five or six kids and you’re the only one who doesn’t,” Inhorn says, “it’s poignant.” Infertility destabilizes marriages and leaves women especially vulnerable—to divorce by their husbands and to ostracism from families and neighbors.

Inhorn first saw this social suffering when, as a graduate student at the University of California at Berkeley, she went to Egypt as part of a study on the eye disease trachoma. During interviews with local residents, she asked the standard question of how many children they had—and immediately noticed the unease this question caused childless couples. At that same time, an infertility clinic had just opened in Alexandria. Inhorn made contacts at the clinic, and thus began her long involvement with the country, which has yielded three books: in 1994, Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions, which told the stories of poor, urban Egyptian women’s attempts to become pregnant through a variety of means, from modern medicine to traditional folk methods; in 1996, Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt, recounting the daily lives of infertile women struggling to overcome the stigma of their childlessness; and, in 2003, Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt, a study of how elite couples at two Cairo fertility clinics use global in-vitro technology in accordance with local, Muslim beliefs.

“Infertility is the lens into social lives,” Inhorn says. “It brings you into medical traditions, gender identity, community relations, marriage, family life, all sorts of things.”

It also has brought her into religion. Because Islam forbids adoption, assisted reproductive technologies offer the only hope for infertile couples. When Inhorn began studying infertility, ARTs were just appearing in the Middle East. By the mid-1990s they had reached something of a golden age, despite the fact that the cost puts them out of reach for most people. For those who manage to pay, though, making a baby in the Islamically correct fashion is hugely important. “I end up being asked about Islamic attitudes toward ARTs all the time,” Inhorn says.

After years of research in Sunni-dominant Egypt, Inhorn went to Shi’ite-majority Lebanon to study infertility in Muslim men. This gave her a basis for comparison. In Sunni Islam, only the husband’s sperm and wife’s egg may be used in in vitro fertilization. Donations of sperm, eggs, and embryos are forbidden on grounds that such “outside” materials intrude on the marital act of procreation, amounting to adultery. There is also concern that offspring of the same donor could one day meet and marry, unknowingly committing incest. Indeed, many Muslims that Inhorn has interviewed, both Sunni and Shi’ite, said they wouldn’t feel that a child born from donated eggs or sperm is truly theirs. As men told her, “He won’t be my son.”

In Shia Islam, there’s greater tolerance for egg and sperm donation (although Shi’ite-dominant Iran has recently outlawed sperm donation), but religious authorities disagree on several points, such as whether anonymous donations should be allowed, whether the child should take the name of the father or the sperm donor, and whether the husband of an infertile woman needs to temporarily marry the egg donor to avoid adultery. Despite these unresolved questions, egg and sperm donations are occurring. Infertile couples whose cases are otherwise untreatable view these donations as “marriage saviors.”

Talking About Infertility

By now, Inhorn has interviewed more than 500 infertile couples in Egypt and Lebanon. With a scholar’s thoroughness and a storyteller’s ear for voice and detail, she weaves their moving biographies through her books and papers in a highly readable style. On a topic as sensitive as infertility, one marvels that so many Muslim men and women would share their stories with a non-Muslim, American professor, even one trained in cross-cultural interviewing, as all anthropologists are.

No doubt it helps that Inhorn offers everyone a written consent form guaranteeing confidentiality and that interview requests are relayed through fertility doctors with whom the patients already have a relationship. (Interviews are conducted in Arabic or English with those who are fluent.) But Inhorn also is a natural at putting people at ease and engaging them in conversation. In her Cairo study, she began each interview by introducing herself and presenting the two books she had written about infertility in Egypt. She also shared her own story of pregnancy losses, stillborn twin girls and a miscarriage. Demonstrating her familiarity with their homeland and their predicament paved the way for open discussion.

Still, Inhorn was often surprised by the candor of her interviewees. The women, she says, were particularly forthcoming; in fact, not one ever refused her request to participate. Speaking to men in Beirut—and, as a followup to that study, to Arab-American men in Dearborn, Michigan— was harder. Male infertility is rarely discussed or acknowledged, so a significant number of men refused to speak with her, probably more than the number who agreed.

“I feel fairly certain that this reflects concerns about emasculation and the need for anonymity,” says Inhorn, adding that this is true in the West as well.

The men who did agree to speak—once they were assured of their anonymity —tended to really open up, in the way that’s sometimes only possible with a stranger. Indeed, some Middle Eastern– born male colleagues told her that the men were more likely to confide their reproductive troubles to a foreign female duktura than to another man. “I feel that the interview was actually cathartic for many,” Inhorn says.

Eventually she interviewed 220 men in Beirut and 30 in Dearborn, plus about 26 men who had participated in her 1996 study of Egyptian couples. Among them she found loving husbands who longed to have children with their wives. Many hoped to avail themselves of intracytoplasmic sperm injection, a solution for male infertility in which individual sperm are extracted with a needle while the man is under anesthesia. These sperm are then injected into eggs that have been retrieved from the woman. Like other reproductive technologies, though, the cost is prohibitive for many.

A mother of two, Inhorn clearly empathizes with couples trying to achieve what for her has been a deep source of happiness. As she writes in the acknowledgments of Local Babies, Global Science: “[U]ltimately, it is my own satisfying family life that makes me realize, with special poignancy, the great tragedy and sense of loss experienced by the infertile Egyptian couples whose ardent and often unrequited desires for test-tube babies constitute the theme of this book. To them—the women and men who allowed me into their secret lives as would-be parents of Egyptian test-tube babies—my gratitude is truly profound.”

A Family Affair

 Inhorn & family

 Inhorn's husband, Kirk Hooks, calls his wife "Indiana Jones beneath that mild exterior," an intrepid journeyer who has roughed it in rural Eyptian villages with no plumbing.

In Inhorn’s home, Mom’s career is a whole-family enterprise. When she travels to the Middle East to do research, everyone comes along. Her son and daughter—Carl is 11; Justine, 8—enroll in international schools, and her husband, Kirk Hooks, takes leave of his job as a psychotherapist. Currently he works as an independent contractor at an Ann Arbor clinic.

A mutual friend in Berkeley introduced Hooks and Inhorn. Early on, Hooks knew frequent travel would be necessary for her academic career, so he mapped out his own career to be flexible. “I believe that husbands should support their wives’ professional development, and there’s no reason why they should consider their work to be more important,” Hooks says. “We’re kind of doing this together.”

Their two extended stays overseas—Beirut in 2003 and Cairo in 1996, when their son was one—required a lot of reassurances to family members, but Hooks says that’s becoming less necessary now that they’ve gone and come back twice. Despite the logistics involved with transplanting a family to the Middle East, Inhorn and Hooks wouldn’t trade the enrichment of living in another part of the world.

“You walk into people’s houses, and they’re furnished in a different style,” Hooks says. “You sit down and have food you’re not used to eating, and it’s delicious. And you realize the way we live isn’t the only way to live.”

Inhorn and Hooks value that, through direct experience, their children will grow up with a balanced perspective of the Middle East. “I hope they don’t have a naively positive view of Middle Eastern things. I don’t want that any more than a paranoid, suspicious view,” Hooks says.

The family has also gotten a front-seat view of the region’s political realities. In Lebanon, their driver was a supporter of Hizbullah, as were many Lebanese of all religions, Hooks says, because Hizbullah provided services the government couldn’t. One time they drove to the Israel border and saw Israeli and Hizbullah soldiers with guns trained on each other. They didn’t think anything would happen with them right there, and nothing did. Of course, that was 2003. Such an excursion seems unimaginable in 2006.

The family was in Beirut during the lead-up to the U.S. invasion of Iraq and then the entire active bombing stage. That was the only time, Inhorn says, that they’ve considered leaving a place. Some Americans and British were targets of violence in Beirut, and American University—where Inhorn was based—went on high-alert status. Inhorn started looking into transferring her Fulbright scholarship to Cyprus. But as soon as President Bush announced “mission accomplished,” the air cleared. “We went to Cyprus for a week,” Inhorn says, “then came back to a lovely spring in Beirut.”

Comfortably Bridging Cultures

Hooks calls his wife “Indiana Jones beneath that mild exterior,” an intrepid journeyer who’s roughed it in rural Egyptian villages with no plumbing. “But what I most admire about Marcia is how she’s always been so excellent in every important area of her life, as a mother, spouse, scholar, and educator.”

“My own dear mother just can’t be-lieve what I do,” Inhorn says. “I was so shy as a child she had to go to nursery school with me. Now she says, ‘When you cut the apron strings, you really cut them.’ ”

Inhorn’s ease with bridging cultures is an inseparable part of her professional and personal life. Having a biracial family —Inhorn is white, Hooks is African American—brings her into regular contact with diverse perceptions. It also factored into the decision to leave Atlanta for Ann Arbor. “We wanted to come back to a more progressive, diverse community,” she says. “For a biracial family in America, there aren’t many places one wants to live.”

Inhorn was raised in Madison, Wisconsin, by a Jewish father and Methodist mother who, as a middle ground, took their kids to the Unitarian Universalist church, where Inhorn heard messages of tolerance for all religions. Her father, a professor at the University of Wisconsin, frequently invited his international students and colleagues to their home. Inhorn remembers parties attended by people from Thailand, Russia, and elsewhere. All of this, plus her avowed love of National Geographic magazine, made her aware of and interested in places and cultures beyond Madison.

Writing also was an early passion. She penned poems and stories and edited her high school newspaper and then the arts section of her college paper at UW, where she majored in journalism. Her introduction to anthropology however, came not in college but, uncommonly enough, high school. To this day, Inhorn remembers that teacher fondly.

“He changed my life,” she says. “I don’t think I would have ever taken anthropology in college but for that
high school class.”

By the end of college, two legs of her future career—writing and anthropology—were in place. Then she got a job editing a medical trade magazine, which drew in the health leg to round out her professional tripod. She went on to earn a Ph.D. in medical anthropology and an M.P.H. in epidemiology from Berkeley.

Inhorn came to Michigan shortly before September 11, 2001. She feared the attacks spelled the end of Middle East research, but it’s turned out the opposite. Curiosity about the region has grown, backed up with funding for grants. This summer, Inhorn taught a course for high school students called “Islam in Practice.” “Many lived in the South, in Christian communities,” Inhorn says, “and they came to UM to learn all they can about Islam.”

Still, intellectual exchange faces obstacles. Of all her travels to the Middle East, Inhorn’s trip to Iran this year was the most arduous in simply getting there and back. As an American, she needed an invitation from a university or other institution to enter the country. Then, because there is no Iranian embassy in the United States, she had to secure her visa through the Pakistani embassy in Washington, D.C. Until the last minute she wasn’t sure the visa would even come through. It did, and with an Iranian visa on her passport, she now sets off security alerts at airports. Changing planes in Paris on her way home, Inhorn was pulled aside and required to provide proof that her business in Iran had been strictly academic. Security workers slapped a high-risk stamp on her carry-on bags, then donned latex gloves to manually inspect every item. “It was very demeaning, simply because I had been in Iran,” Inhorn says. “So that’s the particular political moment I was in.”

She recounts the trip, and this final episode, in an article for The Chronicle of Higher Education: Back in Detroit, a customs official, seeing that Inhorn had been in Iran, asked, “And they didn’t behead you?” No, Inhorn answered, they’d served her delicious food. “Ah,” said the official, “but you don’t know what was in it.” To which Inhorn responded—perhaps, she says, too flippantly—“Probably uranium.” Then she went to baggage claim and collected her souvenirs: two gorgeous Persian rugs.

By Mary Jean Babic, a freelance writer who lives in Ann Arbor; family photo by Peter Smith.

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"hand of Fatima" amuletPictured at left, a "hand of Fatima" amulet with detailed Quranic inscriptions, from Inhorn's collection. Amulets such as this one from Egypt are used to ward off the evil eye of uncontollable envy. Infertile women are sometimes accused of casting the evil eye, because they are believed to covet other women's children.

If it seems incongruous that hundreds of Muslim men and women would share their stories of infertility with a non-Muslim American woman, meet Marcia Inhorn--a global-health scholar and mother of two who's spent her life bridging cultures.