Specialization in Action

Abstract

This article has two objectives: the first, to analyze the professionalization process of assisted reproduction (AR) in order to see how AR is consolidating into an independent field within medicine, and the second, to see how AR arrived and was assimilated into Mexican culture. As opposed to other projects that have traced back the story of a particular specialty to see how it emerged as such, this article looks at an ongoing process: specialization in action. By analyzing the data collected through three years of multisited ethnography using tools offered by the sociology of professions and the history of medical specialization, I identify specific moments in which AR is gaining cognitive, normative, and evaluative consolidation, structure, and independence. This leads me to suggest that AR might separate from gynecology and become an independent specialty within medicine. I offer examples to support this argument and show how AR has developed into a biomedical service, a professional biomedical field, and a biomedical business.

Keywords

medical specialization professionalization assisted reproduction medical sociology science and technology studies

Introduction

Assisted reproduction (henceforth AR) is a variety of procedures that involve substances, techniques, instruments, machines, and individuals all working toward helping people have offspring. Today, it is still mostly considered an area of gynecology. However, there is a growing trend among Mexican AR specialists to care only for infertility and AR users and no longer see women throughout pregnancy or treat gynecological issues that are not related to infertility and AR (e.g., menopause). Likewise, people in need of reproductive assistance search for what they call “AR specialists,” gynecologists specialized in human reproductive biology who work in professional AR clinics, and not simply “general” gynecologists working in offices. Moreover, there are professional associations, journals, academic events, and commercial endeavors dedicated exclusively to AR. Could all this suggest that AR will become an independent specialty within medicine instead of remaining a subspecialty of gynecology? If so, what implications would this have for AR, its practitioners, and its users?

This article suggests that AR could indeed become an independent medical specialty. To argue this, I trace AR’s development in Mexico, highlighting the different elements suggested by the sociology of the professions (Freidson, 1999; Larson, 1977) and the history of medical specialization (Reiser, 1990; Stevens, 1966; Weisz, 1994) as key in the consolidation of a profession or, in this case, a medical specialty. Scholars within these traditions point toward the importance that epistemological, technological, practical, commercial, and political factors have in the process of professionalization and specialization, something that my data also suggest. However, most of their work follows a historical perspective, allowing scholars to tell the story while knowing the outcome in advance (e.g., see Halpern, 1992). In contrast, this article offers a prospective view of specialization; paraphrasing Latour (1987), it is specialization in action or in the making.

Before moving on to the case of AR in Mexico, I remind the reader of the main elements suggested by George Weisz and Stanley Reiser as key in medicine’s process of specialization, and then I offer a brief overview of the research methods employed in this article and how they relate to the ideas suggested by Elliot Freidson and Sarfatti Larson regarding the process of professionalization.

Analytical Framework: Professionalizing and Specializing Medicine

Medicine’s professional structure as we know it today (with generalists, specialists, and subspecialists) began taking shape in the first half of the 1900s and picked up pace during and after the two World Wars (Reiser, 1990; Stevens, 1966; Weisz, 1978). At the dawn of the 19th century most doctors were generalists. Specialists were usually seen with suspicion because they were considered to have a narrow spectrum of knowledge and skills and to be capable of attending only one type of ailment and body part and not the body as a whole. By the mid-20th century things were changing. Patients started seeking specialists’ attention, medical students became interested in becoming specialists rather than generalists, and generalists were losing faith in their skills and knowledge. Being a generalist became less appealing. They were commonly depicted as overwhelmed with large numbers of patients suffering all sorts of ailments, with few technologies to aid them and earning little money. Specialists, on the other hand, were now seen as having lighter workloads since they attended only specific cases, with more access to sophisticated technology and earning better wages. Which were the factors that made medicine’s specialization possible?

Literature on the history of medicine indicates that medicine’s specialization process followed different paths in different places, depending on a variety of cognitive, socioeconomic, political, technological, and scientific factors, as well as the role played by individual people, organizations, institutions, technology, and morals and how the different health care practitioners were viewed and arranged socially (Reiser, 1990; Rosen, 1944; Stevens, 1966; Weisz, 1978, 1994, 1997). In this section, I highlight the elements that resulted in the French and the North American medical fields to specialize for two reasons. First, contemporary Mexican biomedical professional structure, practice, and training are highly influenced by the French and the North American models (Finkler, 2004), and second, because the elements suggested by the authors I draw on echo the elements I found relevant in the case of AR.

According to Weisz (1978, 2003) the social and intellectual ambiance in France during the 19th and 20th centuries was fertile ground for the flourishing of specialization and for it to seem as a natural and advantageous thing for society and for the medical community. Capitalist ideas, the theory of evolution, and the Cartesian tradition of dividing the object of study to achieve greater depth of understanding and control were spreading within society. Within the medical community, technological factors and the proliferation of the localized pathology paradigm provided an “axis along which certain specialties were able to develop” (Weisz, 2003, p. 538; see also Rosen, 1944), but it was not the sole explanation to medical specialization. Weisz (2003) points out other important factors. First, the unification of medicine and surgery gave unity and strength to the field, allowing it to then split internally without fear of losing force within society. Second, the way the medical community was organized around a system of institutions and knowledge networks created a large, thriving, and previously nonexistent research community. Third, the practice of splitting hospitals into specialties in order to avoid contagion provided better training for future medical practitioners, since it gave them the opportunity to have access to sufficient numbers of “interesting” patients for each category of disease and the possibility to compare and analyze them using a manageable corpus of literature. All this contributed to the advancement of medical knowledge through rigorous empirical clinical research because specialized hospitals demonstrated “the validity of specialties by producing knowledge based on larger numbers of clinical cases than could be seen in general hospitals or private practice” (Weisz, 2003, p. 553). As depicted here, the paradigm of localized pathology and the belief in specialization as a way of advancing knowledge found an echo in all these areas: jurisdictional, epistemological, practical, and educational. All this eventually changed the way the medical degree was structured and the functioning of medical practice.

Reiser (1990) underlines the importance that emerging medical technologies (which allowed to visualize, hear, measure, and touch the body in a new way) had in the process of medical specialization (Rosen, 1944; Stevens, 1966). These technologies changed the diagnostic procedures for patients and physicians and affected the organization of medical practice. He argues that due to their high cost, doctors had to find ways to offer and afford them. In the United States, one option was to form cooperatives of doctors with different specialties, who could share the expenses of the equipment and the necessary auxiliary personnel (e.g., nurses and secretaries). In a way, these cooperatives became a complex, high-tech, multiheaded generalist. By the mid-1970s many practitioners had adopted this model in one way or another. Cooperatives received criticism because they were considered key in turning medical practice into a business. Critics claimed that their operation resembled an assembly line or a department store: Patients were treated impersonally and in parts, responsibility was diluted among the members of the cooperative, and patients were frequently sent out for unnecessary, costly tests (Reiser, 1990). As I later describe, some Mexican AR specialists also resorted to this type of professional cooperation as a way of dealing with the technical and economic costs of specialized medicine and thus faced similar criticisms.

The authors mentioned above offer a detailed historical account of how medicine internally subdivided into specialties and subspecialties and how these acquired a professional status. In the following section, I look at AR’s ongoing process of specialization and professionalization in Mexico. I draw on data generated through three years of multisited ethnographic work (Marcus, 1995) carried out at three AR clinics (one public and two private), five professional meetings, and nine patient-oriented events. I also conducted several reflexive interviews (Hammersley & Atkinson, 2007) with AR professionals and users and analyzed media representations, marketing strategies, documents produced by professional associations, and the academic syllabi of four areas related to AR (gynecology, urology, andrology, and biology of human reproduction), all part of the medical degree offered at the National University (Universidad Nacional Autónoma de México [UNAM]). The vast heterogeneous data generated were then analyzed following the observations of Sarfatti Larson (1977) and Elliot Freidson (1988).

Larson (1977) and Freidson (1988) mention three dimensions in which occupations need to acquire autonomy in order for them to achieve the status of professions (see also Goode, 1960). First is the cognitive dimension, which refers to a body of abstract and specialized knowledge and a set of specific techniques that require prolonged training. The profession is responsible for and has autonomy in determining these training programs. Second is the normative dimension, which includes establishing a code of ethics that is self-imposed and justifies the privilege of self-regulation granted to them by society. Third is the evaluative dimension. Professions have the autonomy to establish their accreditation systems and tend to participate in shaping legislation that pertains to their profession. All three dimensions grant the profession a degree of autonomy and prestige within society, but nonetheless this privileged position has to be “secured by the political and economic influence of the elite which sponsors it” (Freidson, 1988, p. 72).

The remainder of this article is organized into three parts. The first part, The Early Years, covers the period prior to AR being available in Mexico up until the establishment of the first clinics and training programs. For this I go back to the early part of the 20th century and trace how ideas and services related to the biotechnological manipulation of reproduction were established. I pay attention to the different reproductive discourses, the pro- and antinatalists’ attitudes, the biomedical view on (in)fertility and sterility, and the arrival of human reproductive biology (Section 1.1 Biomedical Management of Reproduction: Contraception-Assisted Reproduction). Then I describe who was responsible for organizing the first AR training programs and where these took place, the type of “AR school” that was introduced, and how all this, the whos, the hows, and the wheres, influenced the type of AR that is now practiced in Mexico (Section 1.2 The Genealogy).

In the second part, The Established AR Profession, I look at the structure of Mexican AR once it became fully established as a medical practice. I describe what an AR clinic is and what distinguishes it from other medical offices, particularly the gynecological office (Section 2.1 The “AR Clinic”). I introduce the local, Latin American, and international professional associations and how they operate (Section 2.2 The Professional Associations). Then I look at the development of the ancillary or paramedical professions: biologists and andrologists (Section 2.3 The Ancillary AR Professions).

The third and last part offers, first, a discussion regarding whether AR is actually becoming an independent specialty (Section 3.1 Discussion: Could AR Be a New Medical Specialty), now considering the information laid out throughout the previous two parts, and then a reflection on the consequences this would have and about what needs further consideration (Section 3.2 Conclusion).

Part 1: The Early Years

1.1. Biomedical Management of Reproduction: Contraception and Assisted Reproduction

The technology, the knowledge, and the social discourses that surround contraceptive techniques and technologies to assist reproduction are like two sides of the same coin. In both cases, the object of manipulation is reproduction; in both the manipulation is done using biotechnologies; in both there are issues of gender equality; in both reproduction is framed as a human right; and both pertain to the biology of human reproduction. This suggests that the presence of discourses and actions oriented toward family planning could have facilitated the introduction of AR into Mexico. In order to appreciate this relationship, we must first see how the “coin” of reproductive control came into circulation within the Mexican context.

During the early part of the 20th century, Mexico’s perspective was one that favored population growth. People depended on family for help to work the land, for help to run business, and for care during illness and old age; the more children one had, the more work that could be done and the higher one’s likelihood of survival when ill. However, due to low life expectancy and high mortality rates, the number of pregnancies and live births did not indicate the number of children that would make it to adulthood. Thus, pronatalist attitudes were strong among people and policy makers. Public health clinics did not advertise or sell contraceptive methods nor did they practice abortions (Gutiérrez-Sánchez, 2000; Gutmann, 2009; de Márquez, 1984; Mejía, 2007; Vallarta-Vázquez, 2005; Zavala de Cosío, 1992). However, by the 1940s, Mexico’s economic growth allowed for better education programs and better health systems, contributing to lower mortality rates (Gutiérrez-Sénchez, 2000) and leading people to think about childbearing in a different way. They no longer had many children so at least some would survive but instead had the number of children they desired because probably all of them would live (de Barbieri. 2000).

As part of this scenario and as a response to a series of articles regarding infertility published between 1905 and 1940, a group of physicians became interested in infertility as a medically treatable health matter (Vázquez Benítez, 2008). They felt there was a need for research on the biological, clinical, prophylactic, therapeutic, and social aspects of infertility and thus founded, in 1949, the first national professional association regarding sterility, The Mexican Association for the Study of Sterility, as well as its professional journal, Studies on Sterility (Vázquez Benítez, 2008). These pioneers, as well as the places in which they worked, became central in structuring AR in Mexico.

Years later, when academics and politicians in the United States and the United Kingdom claimed that the “demographic explosion” of Asia and Latin America would lead to catastrophic scenarios, Mexico was brought into the trend of adopting family planning programs (Caldwell, 2001; de Barbieri, 2000; de Márquez, 1984; Najam, 1996; Soto Laveaga, 2007). As a result, Mexico received support to research reproduction in order to improve contraception (de Barbieri, 2000; Segal, 1966). By the mid-1960s, Mexico’s official agenda was still mostly pronatalist, but nevertheless some academics, politicians and health professionals, mainly within the private sector, embraced the idea that overpopulation resulted in negative consequences, and thus favored family planning programs (UNAM, 2014). Nongovernmental organizations began researching hormonal contraceptives and establishing fertility clinics in urban and rural areas (de Márquez, 1984; Zavala de Cosío, 1992). Within the general population, some people were already using some family planning methods (CONAPO, 1999; de Márquez, 1984; Zavala de Cosío, 1992). This growing concern with overpopulation also permeated the professional association. Several of its members shifted their attention from sterility to contraception, leading them to change the name of the association to the Mexican Association for the Study of Fertility and Reproduction (Vázquez Benítez, 2008).

Concern with population growth resulted in the establishment of fertility services and research departments in two of the most important government-run hospitals in Mexico City (UNAM, 2014). With this, reproductive biology became institutionalized as a health service and as a research area (Gual-Castro, 2000). These hospitals had a laboratory researching the biomedical aspects of hormones, an area that offered service in reproductive endocrinology and infertility, and a family planning clinic. Hence, the same area offered two services, one to overcome infertility and the other to inhibit fertility. By 1967, these two hospitals, in partnership with the two largest and most prestigious public universities, opened the first training programs in reproductive biology (Gual-Castro, 2000; UNAM, 2014). Interestingly, it took almost two decades for a private university to offer the program, which it did in alliance with a private AR clinic in 1991. In 1979 the first clinic in Nuevo León was established. This is important because it is in Nuevo León where one of the first successes of AR was achieved in Mexico (Universidad Autónoma de Nuevo León, 2011).

A great shift occurred in 1974. Mexico’s official stand began a process of radical transformation, from favoring large families and natural fertility, to promoting fertility control, delaying and spacing pregnancies, and reducing family size (INEGI, 2001). Contraceptives became available in the public health sector and cogent family planning campaigns were put in motion. In the beginning these campaigns focused on family size; later, they changed to echo other strong social movements present during the 1960s and 1970s, such as the feminist and the human rights movement, which placed health as a human right (Austin, 2001; Evans, 2002; Fukuyama, 2002; Mann et al., 1994). These campaigns began emphasizing the idea that women had the right to information, to biomedical fertility control methods, and to values such as individualism, responsibility, and empowerment (de Barbieri, 2000). The pertinence of these messages was strengthened by the multiple problems triggered after repeated economic crises (1976, 1982, 1994), urban overpopulation, and severe pollution.

By 1985, the year in which the first AR clinics appeared in Mexico, family planning campaigns were in full swing, commercial barriers were coming down, and processes such as consumerism (Jameson, 1993), commodification (Sharp, 2000; Verhey 1997), biomedicalization (Clarke, Shim, Mamo, Fosket, & Fisherman, 2003), and globalization (Giddens, 1990) were kicking off. The discursive characteristics of this particular scenario played an important role in allowing AR to flourish as it did because, among other things, these discourses highlighted the idea that individuals were now responsible for their reproductive lives and could control them through biomedical means through contraceptive pills or fertility drugs.

As described, from the 1940s onward, reproduction in the form of (in)fertility has been framed as a biomedically manageable health issue and has been treated by biomedical professionals as a distinct area of knowledge (i.e., biology of human reproduction). This idea was present in family planning campaigns and in the establishment of research centers and health services focused on controlling reproduction. Family planning campaigns established the scientific space for research in reproductive hormones, the public space for services related to controlling reproduction, and a discursive space for the idea that reproduction can be biomedically administered. AR flourished within this space. As the following section will depict, by the late 1980s and early 1990s, the endeavor of overcoming infertility became central to a group of gynecologists and the professional association again changed its name (in 1993), now to the Mexican Association of Reproductive Medicine (AMMR; Vázquez Benítez, 2008).

1.2. The Genealogy

Between 1985 and 1986, two groups of physicians established the first private (in)fertility clinics in Mexico and soon after the first public service began operating. These three groups of gynecologists were the first to offer high-complexity AR, the first to call themselves AR specialists, and the first to offer training programs. This is why most of today’s AR specialists share them as their forefathers. As part of their programs, they would bring Latin American specialists trained and working in the United States to lecture and train their teams. These invited lecturers were experts in cutting-edge technologies used in the United States, but more important, they were able to understand the cultural elements that shape the patient-physician relationship in Latin America, they were aware of the peculiarities of the local health system, and they spoke Spanish, something crucial since not all team members spoke English. This unique combination made them key figures in the process of importing AR; they made it adaptable to the health service and accessible to local gynecologists and biologists.

Spain was another important actor in this story. By the mid-1990s, a group of doctors who had studied in a Spanish clinic returned to Mexico bringing with them new ways of organizing the clinic’s activities, responsibilities, and interactions with patients. In 2002, this same Spanish clinic opened a Mexican subsidiary and soon started offering training programs for physicians and biologists. With these two incidents, a new outlook on how to organize AR clinics and a new set of treatment protocols was imported, one that recognized the centrality of both the biologist and the lab as crucial for good reproductive rates. However, some complained that the Spanish model operated unaware of the local sensibilities, highlighting the importance of tailoring imported protocols and managing schemes to fit local needs and possibilities.

Part 2: The Established AR Profession

2.1. The “AR Clinic”

AR procedures are complex. They demand highly specialized equipment, tailored facilities, specific knowledge, and a multidisciplinary team. It is physically and technically impossible for one doctor to do all that these procedures require. Hence, the standard gynecological office, with only one doctor and a nurse, is not enough. Financing the costs of the specialized equipment and the qualified staff is difficult for someone who is just starting a practice or lacks the clientele to cover the expenses. This dilemma was seen as a problem by some and as an opportunity by others. Some would refer their clients to AR clinics and hope that, on success (i.e., pregnancy), they would come back. Others would sublet the equipment and staff from senior doctors. This meant junior practitioners were able to hold on to their own clientele and keep on learning from the senior doctor, while the latter gained extra income to pay for the laboratory’s maintenance. One doctor came up with the idea of being a consulting expert, providing gynecologists the necessary AR equipment and offering them consulting services and guidance throughout the process. This “consulting model” was tailored to the established gynecologists who, while having demand for it, did not have the necessary infrastructure or experience to offer AR. By subscribing to this model, non-AR gynecolostist could have access to an AR clinic, with all the facilities, specialized advice, and professional high-tech equipment, allowing them to offer AR services to their patients without having to give them up. The Spanish clinic established a fourth option, the “network model.” Clinics that have followed this model have one large, well-equipped hub clinic, which centralizes the expensive aspects of the protocols, and many smaller satellite clinics across a large geographical area that offer the less technologically demanding parts of the protocols. By doing so, the network can reach out to more corners of the city and country and thus attract more clients. In some cases, the hub clinic is located abroad. In these cases, the first part of the treatment (diagnostic tests, preparation, and ovarian stimulation) is offered in the Mexican branch, after which patients fly to the hub for the final stages (egg aspiration, fertilization, and embryo transfer).

It is worth noting that because AR is mostly an unregulated service, the practices of referring patients, outsourcing services, or working within the network model could lead to potentially problematic scenarios. Who has custody over frozen gametes and embryos, the subletting doctor or the patient’s doctor? What happens to the frozen embryos of the subletting doctor’s patients if the clinic goes bankrupt or if there is conflict between the owner of the clinic and the subletting doctor? What happens to the clinical records when the treating doctor leaves a particular clinic? These and other scenarios have not been contemplated by the different legal analysts who write about AR or by the people drafting the regulatory initiatives, and I am unaware of any empirical data pointing toward answering these questions.

By the end of the 20th century, the expansion of AR services was evident and the AR clinic had consolidated as a specific type of health care facility, expected to have certain features that make it clearly distinguishable from the gynecological office. These things include, for example, high-tech equipment for conducting the procedures (e.g., micromanipulation systems, ovum aspiration pumps, CO2 incubators, etc.) and environment control systems (e.g., special paint on the walls, double-filtered air, controlled temperature, controlled lighting, pressurizing modules, and laminar flow chambers). Likewise, people working at AR clinics—be these physicians, biologists, embryologists, or technicians working at the labs—were expected to fulfill certain certification and membership requirements (i.e., diplomas and certifications form validated institutions and membership to a recognized AR professional association). Finally, a certain working etiquette was also emerging, which included respecting counter-reference (particularly in cases where AR specialists receive patients from non-AR gynecologists), following a progressive treatment path (instead of jumping into high-complexity techniques without first trying out the low-complexity ones without a justified reason), and considering male factors as part of the diagnosis scheme.

Although these expectations contributed to the characterization of what an AR clinic should be, there are three other elements that clearly distinguish it from other biomedical consultation offices: the way they are named, the use of marketing schemes, and their financing options. Clinics usually have a name, a slogan, a logo, and a website that (re)produces the clinic’s own identity, independent from doctors. Clinics are named using acronyms that highlight specific things, and by doing so, they construct the field of AR in particular ways. Sometimes they stress the female role (e.g., Inmater) or the aspect of life (e.g., Instituto Vida) or they prioritize conception (e.g., Concibe) or genetics (e.g., Ingenes). This particular naming practice also facilitates a process of individuation where the clinic becomes independent from the physician, allowing both to exist without each other. There are cases where the doctor who founded and directed a clinic leaves it, yet the clinic continues to exist with other physicians directing it, while the founder establishes a new one. Similarly, users can mention the clinic they go to without specifying the doctor’s name, or vice versa. Consequently, due to the structure the new clinics are taking, patients are no longer “the doctor’s patients,” they are becoming “the clinic’s patients.” Clinicians have found that this offers them the possibility of working as a team, which is a practical way of dealing with the protocols’ demand for constant supervision.

Regarding marketing, it is a trend for clinics to advertise in media (e.g., television, radio, magazines, and “giant billboards”), and to organize information talks and participate in commercial expos (e.g., Expofertilidad). During these events, clinics raffle free consultations, give out discounts for future treatments, offer financing options, and invite former clients to present highly emotional testimonies of success. During the expos, promotional videos constantly loop showing images of micromanipulators, laminar airflow hoods, centrifuges, incubators, and gametes and embryos, reinforcing the idea that AR clinics are high-tech sites where complex procedures are carried out. All over the stands you see images of babies, happy couples, and smiling doctors, stressing that AR clinics are also about the human element. In adverts, in websites, and during these events, clinics use slogans that invoke the emotional elements that characterize the experience of infertility, such as the desire of becoming a parent and the despair of not being able to. These ideas are then woven with messages of power and knowledge on how to overcome this problem: “We know what you feel, and we know how to solve it.” Consequently, marketing discourses depict AR as highly technological and highly human. Health insurance companies in Mexico do not cover AR treatments. Therefore, users have to either pay out of their pocket or turn to the financing schemes devised by banks and clinics for users who cannot afford the treatments otherwise. These financing schemes consider AR as a distinct matter apart from gynecology. This is perceived in the list of procedures they cover, most of which were intended to improve personal image (e.g., bariatric and plastic surgery, dermatology, hair implants, and dental treatments) and do not include traditional gynecological matters.

2.2. The Professional Associations

Professions have institutions and associations that regulate and evaluate their work. These associations usually develop and implement codes of practice, offer updating courses and peer evaluation programs, and issue credentials (Freidson, 1999; Harrison, 2007; Larson, 1977). In the case of Mexican AR, there are four professional associations that in different ways carry out these tasks. The American Society of Reproductive Medicine and the European Society for Human Reproduction and Embryology act as portrayers of cutting-edge technology and of innovative protocols. Membership is highly regarded locally. The Latin American Network of AR (RedLARA), established in 1992 as a quantitative data registry, is now a multipurpose body. In addition to being a database that offers standardized information useful for conducting research, it is a training body, a certifying organ; it evaluates the performance of clinics and is a platform for discussing ethical and legal issues surrounding AR’s use. It publishes documents about the association’s consented position on aspects such as the preferred marital status of users, problems surrounding gamete donation, preimplantation genetic testing and research, and cryopreservation of conceptus (Zegers-Hochschild, 1998, 1999, 2002). The AMMR has been, since its origin, an association dedicated exclusively to reproductive matters. As already mentioned, its focus has fluctuated following the country’s needs, from infertility when there was need for population growth, to fertility when the need was to halt reproduction, to infertility again with the advent of AR. AMMR operates independently from the National College of Gynecologists and Obstetrics, proving once more that reproductive matters, specifically AR, are dealt within the biomedical community as distinct and independent from gynecology. The work done by these professional associations aims to establish and maintain certain standards among the community of AR professionals in at least three aspects: cognitive (by offering courses, workshops and conferences), normative (by establishing protocols and codes of ethics), and evaluative (by certification processes).

This and previous sections have highlighted some of the moments and aspects that suggest AR is separating from gynecology. They have focused on the emergence and establishment of AR training programs, AR services, financing schemes, and the consolidation of the AR clinic and of the professional associations. But what about the other professionals that work in these clinic? The following section will look at these other professionals and at their process of professionalization.

2.3. The Ancillary AR Professions

Since the development of ICSI (intracytoplasmic sperm injection) in 1992, attention to male infertility has grown and andrology (the study of men as reproductive beings) has begun to attract more attention (Schirren, 2005). Therefore, AR specialists, who until now came from gynecology, are having to decide if they will become more involved in male reproductive issues and thus incorporate andrology as part of their everyday practice, or if they will leave that to andrologists and work side by side with them. As of today, it is not clear which way the story will go. Within the medical school syllabus, andrology is a topic studied as part of courses offered to urologists, gynecologists, and endocrinologists (the last two, only if they are studying Biology of Human Reproduction; UNAM, 2009, 2014). This might suggest that andrology is only a topic and not a field. However, if we look at conferences’ and clinics’ websites, it appears more distinctively as a profession and area of expertise. At the 2007 annual meeting of the AMMR, there was a thread called “Tendencies in Contemporary Andrology” during which presenters talked about the urgency of considering male-factor infertility, but more important, they talked about andrology as a profession. Likewise, clinics now advertise their “Andrology Department” and their staff of “andrologists” highlighting their specific knowledge and skill. This might indicate that andrology holds some epistemological independence (Freidson, 1999; Larson, 1977) with its own “complex body of knowledge” (Halpern, 1992, p. 995), but andrology still does not have its own training program. Some AR gynecologists are concerned that if andrology develops into a full specialty, they will lose control over the AR procedure and market. Therefore, for andrology to achieve full independence and be recognized and established as a medical profession, it still needs to negotiate with the dominating profession: gynecology. Elsewhere, there are journals, professional associations, and specialized courses in andrology: for example, the American Society of Andrology (1975), the British Andrology Society (1977), the International Society of Andrology (1981), and the former International Journal of Andrology, now Andrology (1977, with an impact factor of 3.6). The question is, will andrology be incorporated into the AR field, allowing then for AR to see the reproductive process from both the male and the female perspective, or will andrology become an independent field and work side by side with AR, as does gynecology? If andrology is taken into AR, it might mean that reproduction could be seen as an integrated male/female process and no longer only the latter.

AR clinics house other professionals with specific types of knowledge and skills playing important roles within AR services. However, since AR is still a new area of expertise, their roles and responsibilities as well as the boundaries of their professional control are still being drawn out. Picture the image of an ovum being pricked by a needle holding a sperm; this is one of the most circulated AR images, the “poster child” of AR as a biotechnology. This image is of ICSI, a highly complex procedure performed by the “AR biologist,” not by the AR clinician. This image simultaneously reveals (because it shows) and conceals (because it is never credited as being done by biologists) the fact that biologists perform and look after crucial parts of the AR process, such as gamete preparation, fertilization, and embryo incubation. Nevertheless, biologists are rarely given the opportunity to interact with the patient, their involvement with the ovarian stimulation process is limited, and they are only marginally included in the professional activities of the AR field. Within the clinical setting, AR biologists feel they are not taken into account as much as they should. Considering their role in the outcome of the procedures, they wish they had the opportunity to explain to users what they do. In spite of being trained to detect the differences in ovum quality depending on the stimulation protocol, they feel they are not consulted enough on ovarian stimulation issues. Furthermore, there is the matter of responsibility. According to some biologists, they are frequently blamed for unsuccessful cycles, both by physicians and fellow biologists, but only occasionally praised when the cycle is successful. Within the professional setting, things were quite similar. At professional conferences, biologists and gynecologists held independent sessions with little crossover, suggesting a clear division of labor and knowledge as well as a lack of interest among neighboring occupations (Halpern, 1992). Recently, biologists have been accepted as subscribed members of AMMR, that is, members who pay fees but do not need certification. In 2012, approximately 20 out of over 400 members were non-physicians, the majority being biologists. This might suggest a step forward in the negotiation process; however, as with andrology, it is too soon to tell if this means they are close to achieving specialist status.

Part 3: Discussion and Conclusion

3.1. Discussion: Could AR Be a New Medical Specialty?

Biomedical specialization has been linked to certain sociocultural aspects, economic and political possibilities, and market demands for certain types of health care professionals of the society in which they emerge and develop (Reiser, 1990; Stevens, 1966; Weisz, 1978, 1994, 2003). Professionalization has commonly been described as the collective effort, undertaken by members of an occupation, to achieve control over its cognitive, normative, and evaluative dimensions (Freidson, 1999; Halpern, 1992; Larson, 1977). This effort includes the following: claiming epistemological autonomy, seeking legal monopoly and control over the service they offer and over the occupation’s division of labor, establishing self-regulatory methods and regulatory bodies (e.g., professional associations and codes of practice and ethics), and controlling educational institutions and licensing standards.

As I have described throughout the paper (see Table 1 for a summary of this), AR has acquired epistemological, technological, normative, evaluative, and occupational independence, and the sociocultural aspects, economic and political possibilities, and market demands for this type of health care are there. AR holds a complex cognitive dimension (Larson, 1977), known as biology of human reproduction, with a solid corpus of knowledge large enough to justify the existence of specialized associations, journals, and conferences. At the workplace, within public opinion, and in the legal realm, we again find that AR is quite independent. AR specialists hold their own distinct workplace, which is structurally, functionally, and materially different from other medical offices and even from a standard gynecological facility. Non-AR gynecologists and AR specialists also see each other’s work as distinct. In many cases, graduating physicians directly join the AR workforce without ever practicing first as gynecologists. AR practitioners have high prestige within society and are usually viewed as a different type of medical professional, as indicated by the growing market seeking their specialized services (Stevens, 1966). Within the legal realm, there have been over 18 proposals to regulate AR, and all of them make it clear that they pertain exclusively to AR (González-Santos, 2011). Another element that distinguishes AR specialists form gynecologists (and for that matter, from other biomedical professionals in general) is their use of marketing strategies. Furthermore, AR is strengthening its institutions (e.g., professional associations and professional training programs) and it is manufacturing its history. The AR community has produced some writings and events to commemorate itself (Vázquez Benítez, 2008) where it remembers the landmark events (either for their success or the controversies they generate) and notable figures who have passed away or attained recognition (e.g., 2010 Nobel Prize). Having a common history with identified (and in some cases even mythologized) ancestors and landmark moments, such as crises that have been overcome, gives the AR community inner strength, stability, and cohesion. Finally, gynecology does not seem to be fighting to retain AR as part of its realm of practice (cf. Halpern, 1992). Therefore, if the AR field holds distinctive cognitive, normative, and evaluative dimensions that differ from gynecology and it has a common history, one could at least suspect that the path toward becoming an independent field within medicine is being paved.

Table 1.

The Specialization Stage of AR: A Summary.

Has AR acquired independence in the following areas?		Is this unique to Mexico?
Epistemologically	Yes, AR’s specific epistemological area is known as biology of human reproduction.	This is not unique to Mexico; however more work needs to be done regarding the medical curricula at different universities.
Technologically	Yes, AR employs technological systems that are specific to the field. For example, micromanipulation systems for ICSI, ovum aspiration pump, sperm counting chambers, etc.	In general terms, the same systems are used in most places.
Workplace	Yes, the AR clinic or service is usually separate even when it operates within a hospital, and it has very specific requirements making it identifiable.	Although this is not unique to Mexico, more comparative studies are needed to see if AR clinics are similar across countries.
Self-regulation and evaluation	Yes, AR has its own professional associations that certify its professionals and its own specialized conferences and journals.	There is need for comparative studies to see how the community of AR practitioners regulates and evaluates its work in other places.
Legal dimension	Mexico still lacks a specific regulation or law covering AR at a federal level. There have been a number of proposals to regulate the use of AR specifically.	Laws and legal regulations are not the same in any two countries, nor do all countries have laws and regulations pertaining specifically to AR.
Market niche	AR has a unique market niche that includes infertile, gay, lesbian, and transgender couples and single women and men seeking to be parents, as well as people seeking to avoid genetic diseases or in search for a particular genetic makeup in order to serve as a donor for siblings or kin.	Although in most places people use AR for similar motives, a comparative study would still be needed.
Marketing strategies	The AR community of professionals use all media outlets including social networks to advertise their services and they organize recruiting events such as Expo Fertilidad, dedicated exclusively to infertility and AR.	The AR professional community elsewhere also uses marketing strategies. In London, for example, there is The Fertility Show, which is similar to Expo Fertilidad. However, this needs to be studied and compared in greater detail.
History	AR is putting together its own “scrapbook” of memories with its stars, heroes, victims, villains, and highlighting moments independent from gynecology.	Although there are continuous references to the same founding moments in AR’s history (e.g., the work of Steptoe and Edwards), more comparative studies on this topic are needed to see how each setting writes its own story with its local elements.

Note. AR = assisted reproduction; ICSI = intracytoplasmic sperm injection.

3.2. Conclusion

In this article, I analyzed AR’s ongoing professionalization process with the purpose of exploring whether AR was consolidating into an independent field within medicine. It is an article on medical specialization in action. Throughout, I pointed at specific moments in which AR was gaining cognitive, normative, and evaluative consolidation, structure and independence, leading me to suggest that AR not only has reached full professionalization but also might eventually separate from gynecology and become an independent specialty within medicine. But probably more important than that, I suggest that the work done by andrologists and biologists could eventually feed into this field in a more egalitarian way. What consequences might all this have for the biomedical study of reproduction and the treatment of (in)fertility?

Due to the epistemological composition of AR, both men and embryos are looked at in more detail. The strength andrology has gained due to AR could give men an opportunity to have a more active and important role in reproduction. While traditional gynecology commonly only focused on the female role within reproduction, AR is offering the possibility to have a more integrated view, particularly if it incorporates andrology as a central area of expertise. Likewise, since AR incorporates biologists, embryos are also being paid closer attention. This could end up in a more complex understanding of reproduction and infertility, one that includes women, men, and embryos. Since we are talking about specialization in action, there is still need for further research into this, both locally and comparatively.

Footnotes

Acknowledgements

I thank Professor Adam Hedgecoe, Pedro Garcia Moreno E, and Beth Reddy for their time and valuable comments in all the different drafts of this article. I am also grateful to the editors and reviewers for their suggestions.

Author’s Note

Sandra P. González-Santos is responsible for the conception of the article, developing the ideas, and writing the first and subsequent drafts. She has no competing interests to declare. She has no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, no other relationships or activities that could appear to have influenced the submitted work. All views expressed are her own.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Mexican Council for Science and Technology, CONACYT (Grant Nos. 205923, 229302).

Author Biography

Sandra P. González-Santos is a postdoctoral researcher at the Philosophy of Science Postgraduate program at the Universidad Nacional Autónoma de México (UNAM). Her research focuses on the many ways people make sense of contemporary biotechnologies and the diverse processes by which technology and society co-construct each other.

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