Review of Substantial Relations: Making Global Reproductive Medicine in Postcolonial India. Sandra Bärnreuther, Ithaca, NY: Cornell University Press, 2021, 192 pp.

Reviewed Book

Substantial Relations: Making Global Reproductive Medicine in Postcolonial India. Sandra Bärnreuther, Ithaca, NY: Cornell University Press, 2021, 192 pp.

Substantial Relations: Making Global Reproductive Medicine in Postcolonial India. Sandra Bärnreuther, Ithaca, NY: Cornell University Press, 2021, 192 pp.

Book cover of Substantial Relations. A plain white background with two petri dishes.
Cover of Substantial Relations (2021)

Maya Unnithan

University of Sussex

This is a story of the journey of in vitro fertilisation (IVF) as a medical intervention in India. In this fascinating account, Bärnreuther charts India’s contested role in the shaping of global infertility treatments, from an era of skepticism and marginalization of Indian reproductive medicine in the 1970s (exemplified by its marginal position of being a source of hormones derived from the urine of pregnant Indian women for a Dutch pharmaceutical company) to being a major global player in reproductive medical science and treatment. She examines the relationships within hospitals, among patients, and through the fields of science and technology that are created through the flows of biological substances (e.g., hormones, gametes, eggs, sperm)—hence the title “substantial relations”—that form part of IVF processes. In particular, Bärnreuther explores how these vital “repro flows” (citing Inhorn’s concept) are enabled/disabled as they circulate within a political terrain where value and authority are attributed to scientific knowledge and technological expertise emanating from the Global North.

The first two of six chapters examine the politics of India’s position in global reproductive medicine between the 1960s and 1980s, describing the country as a site for the extraction of “raw material” rather than as a contributor to the production of knowledge. This is despite the efforts of a few Indian reproductive biologists (especially Subhash Mukherjee working in Calcutta) who pioneered efforts to create a test-tube baby at a time when similar efforts were taking place in Europe (with the birth of Louise Brown led by Edwards and Steptoe in Britain in 1978). The Indian efforts were regarded with skepticism by the global scientific community and largely viewed an “innovation out of place” for a number of reasons Bärnreuther highlights, including the “questionable” methods of the trials and the shaky evidence so produced. Bärnreuther then describes the “take-off” phase of infertility treatments and the huge expansion of the IVF market in the private and public sector between the 1980s and 2000s, which characterized the transformation of India into a major force in reproductive medicine globally. Interestingly, the diversification of providers and treatment led to a very uneven and inequitable landscape of IVF provisionwithinthe country—a point that could have been further explored and its impact examined.

The second half of the book draws on empirical data collected and concerns the narratives of patients in Delhi. Bärnreuther describes patients’ attempts at IVF in terms of their experience of “reproductive temporalities” (waiting, delays, and disruptions around their failures to conceive) and how this was explained in terms of social pressure (the “hurry” to conceive) as well as the alienating disconnect from the temporal rhythms of the clinic (duration between treatment cycles and events leading to the wait for conception after the embryo transfer).

When IVF attempts did not bring forth positive results, relations often broke down (such as Anita’s disappointment and trust in her doctor, p. 89), even as the results might be explained as inevitable, “up to God,” and in one’s karma. Bärnreuther illuminates how patients often acceded to the doctor’s knowledge and thereby contributed to reinforcing the authoritative position of the medical provider and the power of medicine more generally. The inevitability of being caught in “cycles of hope” is another key observation that underscores the helplessness and ultimate seduction that the technologies of assisted procreation hold out for women and couples who are infertile (very poignantly brought out in Neha’s account (p. 93), as she decides on a morally and culturally challenging option of third-party IVF cycle using donor eggs).

The moral challenges of IVF reach their peak in the book in discussions held by the interlocutors around what are regarded as “inappropriate relations” and decisions of when to stop further technological intervention. As in many parts of the world where religious ideas and patriarchy align, there is greater castigation associated with the use of donated sperm compared to eggs. While patients could source semen from male kinsmen, there were nevertheless ideas of disputes over property that prevented the practice, further restricted through Indian state regulation requiring anonymized donation. The discussion around egg sharing profoundly revealed how the circulation of substances both uncover and influence ideas of relationality. The idea of egg sharing betweenunrelated infertile couples as routinely accepted and unproblematized signaled a certain emotional distance in respondents’ relations with this bodily substance. This was further reinforced by a sense that “eggs belong to doctors.” These fascinating insights about the ownership, alienation, and control over reproductive material lead us into questions about ethical practice, discussed in the concluding chapter.

In the final chapter of the book, we meet embryologists in laboratories facing uncertainty in making judgments about the quality of eggs and embryos, rendering every decision they take, as Bärnreuther points out, an ethical one. Discussion among embryologists is contentious and covers a diversity of opinions, particularly around the extent to which interventions such as intra cytoplasmic sperm injection are promoted. What is even more interesting is the absence of contention among doctors and patients when it comes to the issue of embryo disposability. Embryos are never really “left-over” because of the accepted practice of re-implantation following a failure and cryo-preservation, paid for by the patient. While the increasing availability of technologies such as the embryoscope decrease the dilemmas around egg and embryo selection, it remains unclear whether this implies that decisions become more ethical in the process. Some further discussion on this question would have added further depth to this fascinating chapter.

Overall, this book stimulates reflection on the shifting dynamics and political andsocial engagement that accompanies the practices of reproductive medicine in India. Bärnreuther has done well to connect local clinical engagement and practices to a global perspective on the production of knowledge framework. I especially enjoyed the descriptions and new insights on the morality of sharing “natural” reproductive substances as narrated by providers and users of IVF services alike. On the internal dynamics of reproductive medicine within the country, I would have liked Bärnreuther to push the analysis further on issues of the inequitable landscape of clinical provision (public/private/corporate) she encounters, as well as on the “engineered socialities” (of doctors and patients alike) in the making of substantial relations. The book is a recommended read for all scholars working in the area of infertility/fertility and kinship studies.