EL JUEGO DE LOS VALORES

In proposing these hybrid networks Latour does not deny the existence of reality, nor does he attribute networks to a realm of discursive illusion or social construction, but rather he emphasizes that “…the networks are simultaneously real, like nature, narrated, like discourse, and collective, like society”(Latour 1993:6).

intervention in reproductive health practices. In the 1920s and 1930s a pervasive neo- Lamarckian eugenics movement took hold in Argentina, which served the interests of building and protecting national identity through the use of state-regulated “identity cards” and reproduction restrictions to monitor the “color” of the nation (Rodriguez 2006; Stepan 1991). More recently, during the dictatorship in the late 1970s, infants and

children of the “disappeared” were illegally adopted by military families and their sympathizers (Arditti 1999; Feitlowitz 1998). In chapters two, three and four I look at how this history of state involvement in family and reproductive health interacts with current and potential economic liberalization, policies of adoption, and scientific embryonic practices. One example of such economic liberalization is that egg donation services at private clinics in Buenos Aires give the attending doctor, and not the recipient, the responsibility of matching gamete donor to recipient.

This literature provides theoretical and historical frameworks essential for

grounding this project within Argentina’s specificities. However, most of these studies do not focus specifically on health technologies and medicine as a global phenomenon that is nonetheless advanced through particular social relationships. There are particularly few social histories of medicine in Argentina to draw from, and the works that have been published in English tend to focus on health care reform policies (Armus 2003; Guerrino 2001; Lloyd-Sherlock 2000; Teixeira, Belmartino and Baris 2000; William 2000). There is no published history—social or otherwise—that details the origins of ART in

Argentina, nor in Latin America. In addition, works that address the forms that science and technology are taking in Argentina today, focus on information technologies

(Aranovich, Pardo and Noblia 2000; Sebastián 1993).15 This ethnography is therefore also a story about the high stakes of modernity involved in producing ART in Argentina, and the economic and political constraints in doing so.

Working from this background literature, I have several important aims in the following chapters. First, to examine assisted reproductive technologies outside of what is conventionally known as the “First World” in order to better understand local

variations in the practice of medical biotechnology as a “modernizing” force. Second, to interrogate the motivations and understandings about family, health, medicine, modernity and religion produced by Argentine health professionals in dialogue with their patients. Third, to ethnographically investigate daily negotiations of the local production and reception of the global apparatus of assisted reproduction. I am particularly invested in exploring the multiple ways in which experts in Buenos Aires personally and

professionally experience, understand, and thereby transform these new forms of scientific knowledge and high-tech medical care; and secondly, how biological understandings of reproduction, conception and gene inheritance in turn shape social practices and ideologies beyond the clinic and the laboratory. In the last instance, this analysis will be revealing not only of assisted reproduction in Argentina, but circulate back to “inform” the phenomena of assisted reproduction as a global apparatus as well.

15

See Brown’s “Test Tube Envy” for an analysis of scientific narrative in Argentine literature (Brown 2005). See also Sommer 1994, 1998 for a perspective on reproductive and genetic technologies in Latin America.

Figure 4. Plaza San Martin: downtown Buenos Aires. Photo by Kelly Raspberry, February 2003.

Methods of Research

This ethnography is based on three years of dissertation fieldwork conducted primarily in Buenos Aires, Argentina. From November 2002 until August 2005, I focused my anthropological gaze on the professional reproductive medicine community in

Buenos Aires. During this time, my principal research methods included participant observation, formal and informal interviews, and archival collection. I observed daily in the patient consultation sessions, operating rooms, embryology laboratories, and ethics committee meetings of four out of five of the most influential and largest private infertility centers in the country.16 My observations also included visits to: a public hospital in Buenos Aires, a small ART center in greater Buenos Aires, four satellite clinics in the provinces of Argentina, and several private clinics in Chile. I also attended

16

Unfortunately I was not able to observe at one of the five principal clinics in Buenos Aires (through passive evasion rather than outright prohibition), though I did do an interview with one of the staff doctors there.

several international conferences on assisted reproductive technology held in Uruguay and Argentina during this time period.

I laid the groundwork for this project during two preliminary research visits in June-July 2000 and 2001, when I met with and interviewed several clinic directors in Buenos Aires, Argentina and in Santiago, Chile. However, when I arrived in November 2002, Argentina as a nation was still jittery from the economic and political

destabilization of December 2001, and I encountered a different setting than the one I had based my proposal on. Given that my research focused on a group of high-tech medical professionals in the private sector, I was concerned by how the country’s economic problems would be affecting their work, and in turn my own. I soon realized that the unresolved economic crisis had affected the upper-middle and upper classes in less visible ways than the lower classes. Overall, the widespread economic difficulties weren’t deterring many people from finding ways to pay for expensive fertility

treatments, and so the large centers were operating almost-as usual by the time I arrived (I discuss the effects of the crisis in more detail in chapter one). As a result, the majority of my fieldwork requests were met with permission and cooperative interest by these research participants, particularly by the professionals in Buenos Aires.17 I enjoyed

17

I did meet with some fieldwork difficulties, some of which seem intrinsic to the nature of this project. For instance, while observation in the different work areas of the infertility clinic was essential for this project, dividing my time up this way seemed also to distance me from the patient experience and made it more difficult to track the same patient through a complete treatment cycle (about 2-3 months long). At the main center I observed in, many patients pass through the clinic in one day, and I was not always able to find out an observed patient’s dates of return. Many of these practices occur at the same time—usually in the morning—so I had to choose between attending one patient’s ultrasound, observing a different patient’s in vitro fertilization in the lab, and yet another’s embryo transfer. Although this research always primarily focused on professionals, I had hoped to have more of a patient-component than was possible in the course of this fieldwork.

In addition, I was invited to spend 3 weeks observing at the principal infertility clinic in Santiago, Chile as a comparison to the work I had been doing in Argentina. Several of the doctors at that center are the original founders of the RED organization. Unfortunately however, the clinic’s strict rules, and the director’s idiosyncratic reasoning, prevented me access to the laboratory, the surgery room, and doctor

access to more clinic areas than I originally expected, and found most everyone tolerant of my presence and receptive to my questions about their practices.18

There are several different spaces in which assisted reproduction work takes place, and I spent the majority of my observations in one infertility clinic in Buenos Aires, learning what these are and how they vary. My observations were therefore divided up into three main work sites: 1) clinical visits (patient consultations, surgeries, ultrasound monitoring); 2) the embryology laboratory; 3) staff and committee meetings, colloquia, and international conferences.

Medical Consultations and Procedures

More than any other space inside the infertility center, clinical visits involve the cooperation of a medley of actors, including receptionists, doctors, nurses, psychologists, medical residents and of course patients and their family members. I sat in on clinician and psychologist patient consultations which included both first-time and returning infertility patients. During a clinical consultation, my presence was always explained to the patient by the attending clinician, and made optional. These sessions, which lasted from half an hour to an hour, allowed me to observe different phases of the treatment process. In the surgery room I watched different gynecologists and andrologists perform oocyte aspirations, embryo transfers, laparoscopies and testicular biopsies—in a given

consultations. In the end, I was only able to attend doctor meetings, observe in the waiting room and conduct interviews with professionals—much less participation than in Argentina. The difficulty that I experienced in Chile is revealing of the local particularities of assisted reproduction practices: in Chilean society, which is more socially conservative and Catholic than Argentine society, assisted reproduction has a more secretive and taboo status.

18

I attribute the relative ease that I had in doing this project (aside from what I outline above) in many ways to my status as a researcher from the US. The possibility of name-recognition or prestige that my very presence promised to bring to the given center or professionals that I worked with was most likely a prime motivating factor. Also, I was working mainly with a group of people who share a value of research. My field of expertise (anthropology) was not well understood, but it was not threatening either.

day, four to five different procedures often take place. My presence in the surgery room was also announced to the patient, though in these cases I was one of about seven

professionals and I blended in with the others. The center that I primarily observed at also functions as a training center and has rotating residents for most of the year, this

smoothed my access into these clinical areas of practice. In all of these professional- patient encounters I witnessed the difficulties of reconciling medical knowledge and doctors’ professional aims with the unpredictability of patients’ bodies and patients’ fears and hopes for the treatment process itself.

Figure 5. Surgery area in ART center in Buenos Aires. Photo by Kelly Raspberry, January 2003.

The Embryology Lab

The clinical laboratory, where all the processing and manipulation of human gametes takes place, is also a key site of the production process, though one physically removed from most of the other actors. The crucial position of the lab in determining the success of a given assisted reproduction treatment was an important aspect of this

research, one that I originally underestimated. As a result, early-on I changed my research plan to devote more time to laboratory observations. This provided me with not only a deeper understanding of the science and technique of lab procedures, but also more

opportunities to engage in ongoing, informal conversations with the biologists about their views on the meaning of their work. In addition, I was able to observe in different

centers’ laboratories in Argentina, and saw first-hand how techniques and protocols are specific to each center.

During a typical day in the lab, fresh human sperm samples are processed and analyzed, eggs are matured in incubators and fertilized via in vitro inseminations or by micromanipulation injection of sperm, and embryos are evaluated for intra-uterine transfer and cryopreservation. While in the lab I was most immersed in the specificities of the protocols of assisted reproduction work, and at the same time distanced from the actual patients undergoing treatment. Human sperm and eggs saved in vials and

biological medium are at the same time rendered more useful for fertilization purposes, as well as abstracted from their origins in particular histories of desires and fears. In the lab, conception is reduced to a series of standardized procedures that have nothing to do with how much a couple wants to have children, or how long they have been trying to do so, but instead depends on the skill of the biologist, the conditions of the lab and the quality of the medium being used. Learning to move between these two main work sites—the clinic areas centered on patients, and the lab invariably focused on bodily materials—was central to understanding the varied components that come together to produce an assisted reproduction treatment.

Figure 6. Embryology lab and scopes in Buenos Aires. Photo courtesy of Sabrina de Vincentiis, 2006. Meeting Sites

My other primary site of observation were the meetings, colloquia, workshops and conferences that the assisted reproduction professionals in Buenos Aires conduct and attend. At the clinic, these reunions included “case rounds” lunchtime meetings during which the doctors and biologists discuss the current patients’ cases, weekly research presentations on current reproductive medicine topics (with invited international

presenters), monthly ethics committee meetings, and patient information sessions open to the public. I also spent time observing in clinic waiting rooms, giving me the opportunity to talk with patients about their treatments and also to observe the general flow of activity and people in the given clinic.

I also attended several international assisted reproduction conferences that took place in Uruguay and Argentina. These included the VII Latin American Federation of Fertility and Sterility Societies (FLASEF) Conference which was held in Montevideo, Uruguay in November 2002; the VI RED workshop in Punta del Este, Uruguay in March 2003; and the International Symposium on Advances and Controversies in Reproductive Medicine hosted by FLASEF, the American Society for Reproductive Medicine (ASRM) and the Argentine Society for Reproductive Medicine (SAMeR) in September 2003 in

Buenos Aires.19 All of these scientific meetings were attended by Latin American professionals—clinicians, biologists and researchers—as well as a handful of their international colleagues from Western Europe and the United States, so I had the

opportunity to observe international professional relationships and positionings. As these meetings also invariably had a social component, I also participated in (and observed) valuable informal conversations.

Figure 7. Embryos as visual decoration at the FLASEF 2002 meetings in Punta del Este. Photo by Kelly Raspberry, November 2002.

Interviews

To compliment my observations and informal conversations, I also carried out a total of 72 formal taped interviews. I conducted 68 semi-structured interviews in Spanish with gynecologists, biologists, embryologists, psychologists, lawyers and scientists engaged in assisted reproduction practices in Latin America. In addition, I did 12 interviews in Spanish with current and previous patients (some of whom were also professionals) who shared with me their experiences of infertility treatments in Buenos Aires. Specifically, the group of 56 professionals interviewed included a) 47 reproductive

19

The spanish names of the conferences are: VII Congreso de la Federación Latinoamericana de Sociedades de Esterilidad y Fertilidad; VI Taller de REDLARA; Simposio Internacional de Avances y Controversias en Medicina Reproductiva.

medicine specialists (clinicians, biologists) representing 17 different centers in Argentina (13), Chile (2), Brazil (1) and Peru (1); b) 9 non-medical professionals (lawyers,

researchers, assistants) in Buenos Aires involved in assisted reproduction. I had the opportunity to formally interview some of the professionals more than once. Most interviews with professionals were conducted in the office of the given professional during work hours. I interviewed patients either in a private room at the clinic, or in their home. Interviews lasted from 50 minutes to 2 hours, with 75 minutes as the average. Everyone interviewed signed a written IRB-approved consent form, which provided the option of allowing for their actual name to be used.

Archives and texts

Archival research was also important for this ethnography. I collected and analyzed a variety of historical and contemporary written materials from the clinics, the Internet, the library, and public newsstands. These materials include clinic informational literature on treatment protocols; popular media discussions of infertility, assisted reproductive technologies, and motherhood; and national legal documents on human rights.

Chapters Preview

In the chapters that follow, I seek to uncover the predominant ideologies and practices that constitute and are produced by the “local culture” of assisted reproduction in Argentina, from the viewpoints of its practitioners. In chapter one, I give a contextual history of how ART began in Argentina, identifying the major players and centers that

continue to wield influence today. Through telling this history I begin to deconstruct the notion that technology transfer is a neutral process, examining how it is actually a “translation” of sorts. In chapter two, I examine further the specificities of local production of ART in Buenos Aires and the complexities of doing ART day to day. I explain that the production of in vitro fertilization in Argentina rests on a series of moral positions about the family, motherhood, and the role of the Church in medical practice. It also requires a creative maneuvering around local social and material constraints. In chapter three I examine again the pronatalist privileging of biological parenthood, and the preference of in vitro fertilization using gamete donation over infant adoption in

Argentina. The practice of gamete donation also clearly exposes the market and

commodification aspects of ART. Using the examples of positions on paid egg donation and surrogacy, I discuss clinic directors’ attempts at separating out their medical practices from the undesirable chaos of the market. In chapter four, I focus on the creation of the hybrid entity of the morally and legally ambiguous embryo in ART work, and the various ways professionals propose to “resolve” this ambiguity. I examine two techniques in particular, embryo cryopreservation and preimplantation genetic diagnosis (PGD) to illustrate how medical technology responds to a cultural human rights discourse. I conclude this ethnography with a suggestion of how ART will continue to influence everyday Argentine life. I also begin to engage in a broader anthropological discussion of what this specific cultural account of ART in Argentina reveals about the production of biomedicine and biotechnology around the world.

INTERLUDE I

Living and Working with Assisted Reproductive Technology

“Buscar un bebé”:‘Searching’ for a Baby and Finding Infertility

I married very young, I married in 1990 and I was finishing my studies and I didn’t want anything to do with having children at that time. […] It was around 1997 that we thought “okay.” That’s it. I had already received, I had achieved quite a lot in my career and you know, everything has its time in life, and so we began trying to have a baby, and it wasn’t coming, it wasn’t coming. And well, then enough time had passed so I talked with Emilio [gynecologist] because I always had the impression that it was me. I had never had anything done to me and so they began to do all the testing, and