Patient-centered IVF. Bioethics and Care in a Dutch Clinic. Trudie Gerrits, New York: Berghahn Books, 2016, 357 pp.
The critical analysis of human reproduction and the expanding technologies of assisted conception and prenatal genetic diagnosis (united under the acronym ART—assisted reproductive technologies) is a growing field in medical sociology and anthropology. Trudie Gerrits’s book is a welcome addition to this burgeoning international literature: It offers a fascinating ethnographic case study of ART as practiced in one Dutch clinic called Radbound in the city of Nijmegen.
Contemporary Dutch policy and legislation ensure that advanced ART is accessible to all Dutch citizens who cannot conceive in a “natural” way. At the same time, the use of ART in Holland is closely regulated; many clinics, including Radbound, procure ova and sperm for in-vitro fertilization (IVF) only from prospective parents, with no donor cells and surrogacy gestation allowed. Fourteen licensed ART clinics in Holland are nonprofit and funded by the state, each offering counseling and basic reproductive services but also specializing in a subset of ART. Since 2004, national health insurance has limited coverage of ART due both to mounting evidence of their low efficacy for older couples and to the need to curb medical expenditure.
Today, infertile Dutch couples are entitled to three rounds of IVF free of charge, but only after all the other cheaper and lower-tech means of facilitating conception have been exhausted. Women over the age of 41, whose IVF success rates are low, are assessed for treatment individually, based on their “ovarian age” (the number and vitality of their ova). To avoid multiple pregnancies, in most cases only two embryos are allowed to be created and transferred to the uterus by doctors. By setting strict boundaries on the daily use of ARTs, policymakers try to prevent their abuse by couples who could conceive spontaneously. This policy helps curb what medical sociologists often call the “technological imperative,” the over-use of available technologies regardless of their actual efficiency and risks. Another policy goal is to avoid commodification of human gametes and women’s exploitation as gestation vessels, resulting from commercial use of human gametes and surrogacy in the United States and impoverished countries like India, Romania, Georgia, and Egypt, which have been sites of global “reproductive tourism” (Inhorn 2003).
Through ethnographic study of a single clinic in this national context, Patient-centered IVF reflects on how this particular form of reproductive medicine shapes lived experiences of ART, patients’ decision-making on entering and exiting the process of assisted conception, their access to information, their attitudes about and relations with care providers, and the emotional implications of IVF. Data collection methods include ethnographic observations at the clinic, a series of in-depth interviews with 46 couples at different stages of the IVF treatment, analysis of patients’ diaries, e-mail and phone conversations with them, and more.
The concept of patient-centered care—the main guiding principle of Dutch medicine and the Radbound clinic specifically—is at the center of Gerrits’s scrutiny. She contends that the logistic complexity and bioethical dilemmas surrounding ART compel us to overcome “easy assumptions” about medicalization and its driving forces, first and foremost the hegemony of high-tech biomedicine in the field of human reproduction (p. 278).
On the one hand, Gerrits praises the patient-centeredness of the clinical staff that managed to achieve rare transparency about potential health risks, limited success rates, the perils of multiple pregnancies and preterm births, and other limitations of IVF, helping the couples make informed decisions. Such risks are carefully masked in many profit-based ART clinics elsewhere in the world. The majority of her informants were highly satisfied with the personal touch and constant feedback provided by the clinical staff. In addition, the ability to share experiences and grievances with other patients via online support groups helped these couples endure the long and painful treatments with maximal possible dignity and to make decisions on whether to proceed (within the allowed IVF quota) or withdraw and achieve parenthood by other means (i.e., adoption).
On the other hand, Gerrits shows that these patient-centered practices do not necessarily solve or even alleviate the problem of medicalization. Following the reasoning of Foucauldian scholars, Gerrits shows that “providing lay people with more information and knowledge may actually increase their clinical gaze and intensify the medicalization of their condition, rather than the opposite” (p. 321). She identifies two of these patient-centered practices as particularly problematic. One is the widening stream of visualizing technologies accessible to the patients across the treatment process, allowing them to see, for example, their own gametes in the process of conception, their embryo transfer into the uterus, and sonic pictures of their developing fetus. This results in the couples’ immediate, sensual connection to their own genetic material and pregnancy development, involving them ever deeper in the process and making it difficult to pull out after initial failure to achieve pregnancy. The second problematic practice is, paradoxically, the intentional trust-building between the couples and clinical staff that sustains personal commitment on both sides to carry on with the process, even when it gets too painful or apparently futile. Thus, Gerrits exposes the unintended consequences of the highly praised patient-centered practices that perpetuate and legitimize high-tech medical interventions and sustain popular belief in their ability to “fix” human existential problems like infertility.
This Dutch case study is especially fascinating from the perspective of social critiques of medicalized reproduction in Israel (see Birenbaum-Carmeli 2016) and in other countries with less patient-centered and more interest-driven (financial, professional, etc.) approaches to ART. The Radbound clinic presents us with a holistic and transparent care system that operates in the best interest of infertile couples and alleviates the built-in ethical and iatrogenic problems with assisted conception. It does this by limiting IVF cycles under public insurance, carefully screening candidates at all stages of the process, and providing ample information, feedback, and counseling.
Indeed, one could only wish for this kind of ART practice elsewhere in the world. This book will be an inspiration not only for social scholars studying ART but first and foremost for ART professionals themselves—doctors, nurses, counselors, policymakers, and patient associations involved in this dynamic and controversial field of medicine.
Birenbaum-Carmeli, D. 2016. Thirty-five Years of Assisted Reproductive Technologies in Israel. Reproductive Biomedicine and Society Online 2: 16–23.
Inhorn, M. C. 2003. Local Babies, Global Science. Gender, Religion and In-vitro Fertilization in Egypt. New York: Routledge.