HUBS

Medical Cosmopolitanism in the Emirates

A Clinic Called Conceive

In a converted showroom, across from a shopping mall, on the periphery of a busy traffic circle, in the emirate of Sharjah just over the border from Dubai, sits a clinic called Conceive. From the outside, the clinic is nondescript. Tinted showroom windows block the typically intense sun and increase patients' privacy. The clinic's sign provides the only hint of what occurs within, as the highlighted o in Conceive resembles an oocyte being penetrated by a single spermatozoon. The modest façade of this edifice (figure 1.1) belies the interior, for Conceive is a bustling, global IVF clinic, catering to infertile couples from five continents and nearly one-third of the world's nations. At Conceive, Muslim patients from Pakistan meet with Hindu physicians from India, are cared for by Catholic nurses from the Philippines, have their embryos handled by Greek Orthodox embryologists, and receive follow-up instructions from two African clinicians, both Muslims — one from Sudan and the other from Somalia. At the clinic entrance, infertile Arabs, Europeans, Africans, and South Asians are greeted by a smiling receptionist (figure 1.2), as well as by photographs of the rulers of the United Arab Emirates, which are prominently displayed in most businesses and hotels across the country. In this multiethnic, multireligious clinic, the clinical staff mingle across cultural divides, with friendships formed after many years of working together (figures 1.3, 1.4, and 1.5). The patient population is similarly diverse and multisectarian. Although a glass wall is intended to separate the men and women in the waiting area, infertile couples from South Asia, Europe, North America, Australia, and Arab nations interact with each other across continental and gender divides, effectively ignoring the gender segregation instructions, which are printed in English. After all, English is the common language of the Emirates, where Arabic-speaking Emirati "locals," as they are often called, are outnumbered eight to one. As a result, all twenty-two clinic staff members at Conceive speak English, along with a variety of other languages, the most common of which are Arabic, Hindi, Tagalog, and Urdu. Conceive has developed a transcontinental reputation for delivering a wide spectrum of high-quality and effective IVF services within a multicultural clinical environment. These services are known by their acronyms and include intrauterine insemination (IUI), a kind of first step in the assisted reproductive journeys of many couples, in which the husband's sperm is injected directly into the wife's uterus in an attempt to overcome unexplained and less serious infertility problems; IVF to overcome female infertility; intracytoplasmic sperm injection (ICSI) to overcome male infertility; preimplantation genetic diagnosis (PGD) to test for genetic defects, check the overall quality of fertilized embryos, and sometimes select the sex of the embryo to be implanted; percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA) to extract sperm from men's testicles in cases of severe male infertility or from men who have had vasectomies but who have decided that they want more children; cryopreservation or freezing of sperm, eggs, and embryos; and care of women with polycystic ovary syndrome (PCOS), which, as we will see, is a major cause of female infertility in the Arab Gulf and is increasing around the world as women become overweight and insulin resistant.

However, according to Emirati law, Conceive does not practice third-party reproductive assistance of any kind — not egg, sperm, or embryo donation, and not gestational surrogacy — nor does it practice multifetal pregnancy reduction, a form of selective abortion for high-order multiple pregnancies (those with triplets or more fetuses). These religiously inspired legal restrictions, while extremely prohibitive for some infertile couples, have not blunted patients' enthusiasm for undertaking assisted reproduction at Conceive. Infertile couples wanting to try IVF or ICSI using their own gametes (eggs and sperm) are traveling far and wide to reach Conceive, from places such as Afghanistan, Nigeria, Sri Lanka, and Canada.

Opened on July 4, 2004, which happened to coincide with America's Independence Day, Conceive is the brainchild of Dr. Pankaj Shrivastav, the clinic's physician director, who is widely revered as the "father of IVF in the UAE" (figure 1.6). Born in India in the late 1950s, Dr. Pankaj (as he is known by both patients and colleagues) was destined for a career in medicine. The son of the director general of India's national health services, Dr. Pankaj was sent to India's most prestigious medical school, the Christian Medical College of Vellore, which was opened in the late 1800s by American missionaries and made famous a century later as the site of India's first open-heart surgery and kidney transplant. After completing his medical school training and American board certification in obstetrics and gynecology, Dr. Pankaj departed for London, where he undertook a three-year fellowship in infertility and IVF at the United Kingdom's largest private hospital. This was in the heady first decade following Louise Brown's IVF birth in England. IVF opportunities were opening up around the world, and clinics needed skilled physicians and embryologists. Thus, many British, North American, and other European-trained gynecologists began to serve as traveling "IVF troubadours," taking the art of assisted conception to other countries around the globe.

Dr. Pankaj is one such troubadour. After completing his fellowship, Dr. Pankaj was invited to follow his British mentor to Dubai, where the government hoped to open the UAE's first IVF unit as a kind of a "sister" program to its London counterpart. Until that point, all infertile Emiratis seeking IVF care were sent by the UAE government to London, an early form of reprotravel that was difficult for the UAE government to sustain financially over time. Thus, at the beginning of the 1990s, the Dubai Health Authority proposed to start its own IVF unit in the local government hospital, where Emiratis as well as expatriates could receive affordable infertility care. In May 1991, the Dubai Gynecology and Fertility Centre was opened at the government-run Rashid Hospital. Dr. Pankaj was asked to serve as the clinic's deputy director, a position that he held until 2004.

However, by the turn of the new millennium, the global landscape of reproductive medicine had begun to change. Across the Middle East, an "IVF boom" was occurring, with private IVF clinics opening in cities such as Beirut, Cairo, Casablanca, Damascus, Istanbul, Riyadh, Tehran, and Tunis. The Emirates were not immune to this...