Exploring the Multiplicity of Embodied Agency in Colombian Assisted Reproduction

Abstract

Analyses of assisted reproductive technologies have demonstrated how objectification and agency can coexist in infertility centres. How objectification creates opportunities for empowerment, however, has not yet been explored. In analysing women’s narratives of assisted conception in Colombian infertility clinics, I demonstrate the complexity in women’s embodied experiences of various objectifying stages of assisted conception and argue that their experiences produced multiple forms of embodied agency. Women used diagnostic procedures to learn about their bodies and infertility complications, which augmented their authority over their bodies and treatment. They drew upon their embodied knowledge to reduce treatment anxieties, while sensations such as pain were made purposeful, and hence meaningful, as women strove to reconfigure the significance of the embodied sensations of conception in a context of medicalized reproduction. In these narratives, we see that lived bodies are productive agents of social change, generating meanings and working to reshape dominant social understandings.

Keywords

agency assisted reproductive technologies embodiment infertility objectification women’s bodies

Introduction

Medical practice has been criticized for its objectification and control of women’s bodies due to their deviation from the male standard and role in preserving society through childbirth (Turner, 1987: 88). Some scholars have specifically argued that medicalized reproductive practices, such as assisted conception, remove women’s agency through the objectification of their bodies and the surveillance of their reproductive systems. Such processes, they argue, reduce women to fragmented parts as their bodies are manipulated by medical experts and technologies (cf. Gupta and Richters, 2008; Perrotta, 2008; Sharp, 2000). Contrary to this depiction of the docile, fragmented woman devoid of subjectivity, Thompson (2005; see also Cussins, 1998) has argued that objectification is not antithetical to agency and personhood. In her research on assisted reproduction in the United States, she demonstrates that objectification is not always reductive and ‘in opposition to the presence or goals of the subject’ (i.e., a take-home-baby), rather ‘patients can manifest agency (and so enact their subjectivity) through their objectification’ (Thompson, 2005: 179). Thompson’s research suggests that objectification can both empower and make agentic. The question remains, how are individuals empowered in an agentic manner through the medical gaze (Foucault, 1973).

In this article, I explore the multiple ways objectification is embodied by women undergoing various stages of assisted conception processes in Bogota, Colombia, what this objectification actually does and how it manifests as agency. Through these analytical approaches, I aim to heed Timmermans and Almeling’s (2009) call for empirical studies of objectification in medical practice, while addressing the question: how does assisted conception simultaneously objectify and empower? Through empirical examples, I show that agency can manifest through the body, adding to our growing understanding of what constitutes agentival activity (cf. Madhok et al., 2013). Furthermore, these examples depict the multiplicity of embodied agency as they manifest in situations of bodily objectification.¹

Objectification, Embodiment and Agency

Thompson (2005) has argued that we must question the oversimplified notion that objectification results in the loss of agency and alienation, a perception based in the Cartesian dualism or the separation of mind and body which shapes dominant understandings of modern biomedical practice (Shaw, 2012). In her seminal work, Thompson (2005: 179) explains that ‘infertility clinics are…instructive places to look for the possible coexistence of objectification, agency, and subjectivity’, given the diverse ways that patients (especially women) are objectified ‘usually under the authority and expertise’ of medical professionals and patients’ personal investments in undergoing infertility treatment. The vested interests of patients in pursuing assisted conception makes them active agents that embrace objectification in their hopes for treatment success.

Thompson (2005: 181; Cussins 1998: 168–169) adopts a broad definition of agency that goes beyond physical action, describing agency as a woman’s ability to ‘change’ or alter her conception of self so she may participate in the objectification of her body during certain moments and reject it during others. Agency here then is a means of self-adaptability. This broad understanding of agency corresponds with Madhok’s (2013: 106) call for scholars to consider agency not only as overt action and resistance but also as critical reflections, motivations, desires and ethical practices. In broadening our definition of agency, it allows compatibility between objectification and agency to be recognized in the narratives of Thompson’s participants.

Other scholars exploring patients’ lived experiences of assisted conception have also detailed the co-constitutive nature of agency and objectifying medical practice. In particular, scholars have noted how undergoing infertility treatment has transformed women in agentic ways. Franklin (1997: 165), for instance, claims that ‘despite its costs and pains’, the women she interviewed felt IVF had ‘“made something of them” as women’. They understood the physical, as well as emotional and financial, demands of treatment as a form of ‘enablement through technological assistance’ (Franklin, 1997: 165). For these women, this technology and its demands on the body was a means to pursue particular desires. The invasive experience of infertility treatment, combined with the way infertility makes some women feel their bodies have failed them or their gender identity (narratives that reproduce dominant medical discourse and patriarchal norms), has also been seen to empower women to resist certain aspects of medical practice (Becker, 2000). Becker (2000) argues that through reflecting on these invasive and disembodying processes, and undergoing lengthy self-education, over time women became more active in their treatment as they developed a sense of confidence, and in some cases took an assertive (even aggressive) role. What these authors show is that agency is not represented by a single moment of choice or action. Rather women may come to feel empowered through many overlapping moments of their treatment journey, some of which are objectifying, others which are liberating. Agency, in other words, develops progressively.

Greil (2002) adopts a different approach to agency in his exploration of the commonly narrated body as machine metaphor – a dominant biomedical analogy of the body made up of replaceable parts – embraced by women undergoing infertility treatment in the United States. He considers that through separating the faulty body part (e.g., ovaries, uterus, eggs, etc.) from the self, women may be preserving their sense of self, a self (in its entirety) who is not faulty or defective. Thus, the physical as well as verbal objectification of individual body parts may function as a means to maintain one’s integrity. However, as Millbank’s (2017: 102) research demonstrates, women’s embodied experiences of infertility treatment are often complex: ‘the machine is part of them and part of them is in the machine’. In other words, their bodies function as a machine, allowing non-functioning body parts to be bypassed or fixed, but their body parts also function, in a sense, outside of their bodies specifically in regards to embryology. The machine metaphor, therefore, may both provide a sense of bodily integrity and a heightened sense of disembodiment or fragmentation.

Despite the ambiguity surrounding this metaphor that Millbank acknowledges, Greil (2002) argues that engaging the body as machine metaphor permits women to logically seek biomedical intervention to ‘fix’ their fertility problem (or bypass the malfunctioning body part). By entering a situation where they have little control and are ‘expected to be passive’, these women aim to regain control over their bodies (Greil, 2002: 109). This argument is reiterated by Thompson’s (2005) observation that women actively embrace objectification to overcome infertility. Here, then, agreeing to undergo invasive treatment (and even take a passive role) is a form of agency as it is through bodily objectification that these women may obtain their goal of having a child. Agency here then is both a choice to be objectified and taking a (at least partially) passive position.

These examples demonstrate that in the context of assisted conception, agency takes many forms. To understand the multiplicity of agency and to avoid contributing to the image of the vulnerable and stigmatized infertile woman, Dierickx (2020: 2) urges us to explore the complexities within experiences of infertility. As Millbank’s (2017) research exemplifies, the complexity of women’s narratives describing experiences of assisted conception (with their many mixed metaphors, contradictions, incomplete statements) are connected to the complexity of the body and its entanglements with entities that transcend its physical form. These include the specific subject of her research, extra embryos, but also legal, cultural and clinical frameworks (i.e., broader contexts), which do not necessarily reflect, but still influence, women’s lived experiences. Embodied experiences and the meanings attributed to them, as Howson and Ingles (2001: 302) argue, are shaped by, but never completely determined by, social constructs. The disjunctures between women’s lived experiences and broader social constructs contribute to the complexity of their experiences and their struggles to make sense of the new realities created by assisted conception.

As scholars, we should embrace not only complexity and multiplicity within subjective experiences, but also in the ways that we analyse such experiences. Perler and Schurr (2020), for instance, urge us to think beyond bioavailability and biovalue when analysing gamete donation. Rather, they argue, we must think of other, more complex entanglements, such as wider logics of care (Mol, 2008), which are situated within specific socio-political contexts. As they demonstrate, care in a context of egg donation and inequality may not only involve that of the couple wanting a child but also care for the donor’s loved ones: by giving a part of her body (i.e., being bioavailable), the donor is using her body as a means to create a happy family, not for the commissioning couple, but for herself. When we consider the complexity of this context, we can understand the donor’s actions as agentic and meaningful, rather than her situation as one of mere exploitation. Moreover, through this analytical process, it also becomes evident that the donor’s body can function as a social force that works to transform other forces and broader situations (Yang, 2015).

When analysing the complexity of lived experience and the body in this way, we can see how agency, in various forms, can be enacted through the body. In what follows, I aim to explore how agency manifests during different moments of objectification in high-tech infertility treatment. I will draw on data from 10 months of ethnographic research in two infertility centres in Bogota, Colombia, and interview transcripts from 87 in-depth interviews with women (or couples) undergoing assisted conception (Shaw, 2018, 2019). All women whose narratives are presented in the following analysis identified as heterosexual and all but one were married. These women held a variety of professional and administrative posts, apart from one who was voluntarily unemployed, and lived middle to upper-class lifestyles, a necessity to be able to afford the relatively high costs of Assisted Reproductive Technologies (ARTs) in Colombia (see Shaw, 2019). Their experiences using ARTs varied greatly, some of them having only undergone one cycle, while others had undergone various cycles and used donor materials. The characteristics of these women reflect the larger group of women who participated in this study, but in most cases, those whose narratives follow I interviewed more than once and had the opportunity to accompany through a longer portion of their treatment journey. Through the analysis of these data, I first demonstrate that women’s embodied experiences of the various objectifying processes that accompany assisted conception were complex. Second, in exploring the complexities within women’s experiences of objectification, I show how their experiences produced productive and reflexive reactions that often created new understandings of their bodies, their infertility and ways of conceiving. Through experiencing the discomforts and disruptions that accompany assisted conception, women pragmatically gave meaning to the medical processes they were enduring and worked to transform dominant understandings of conception. In these women’s narratives, we see how objectification can produce multiple forms of embodied agency.

Agentic Objectification

Franklin (1997) describes assisted conception as a way of life due to the demands it places on women, and the way it may come to take over their lives. High-tech infertility treatments such as IVF and intracytoplasmic sperm injection entail various treatment stages that have to be administered on a strict schedule. The majority of these stages directly involve the use of technologies that are controlled by the doctor and allow for the surveillance and manipulation of the woman’s body. Even when the doctor is not present, such as when injecting hormones, the woman’s body, in particular her ovaries and the follicles growing inside her, is still the object of concern from the medical perspective. In what follows, I focus on three aspects of assisted conception: visual diagnosis and ovarian monitoring, hormone stimulation and the embryo transfer. I will not discuss the ova removal or the fertilization process, as the former is performed while the woman is anesthetized and the latter takes place behind the closed doors of the laboratory away from the purview of the woman.

Note that medical staff who participated in this study recognized the significance and multiplicity of treatment experiences in regards to emotional and psychological anguish and social concerns. Yet the bodily sensations of ARTs often went unmentioned, and thus were overlooked. Dr. Herrera,² a co-owner of an infertility centre, for instance explained, ‘The treatment process is not physically as invasive as an operation, for instance, but emotionally and socially it is more invasive’. She continued by acknowledging that each couple’s doubts, concerns, questions and emotions about infertility and treatment, and the role each partner plays in the treatment process are unique: ‘The possibilities are endless’. Dr. Herrera, like other medical staff, emphasized the various social and psychological implications and understandings of infertility and undergoing ARTs, but she hardly mentioned the bodily experience. When considering physical implications, medical personnel’s emphasis usually pertained to potential pain, which they saw as minimal (complications not withstanding). For the staff, there is little room for variation in women’s bodily experiences. Moreover, how the doctor observes and manipulates the body is not understood as multiple. Rather, practice is at least believed to be standardized, creating a nearly singular bodily experience of ARTs and thus one which is less significant to the medical staff than that of the emotional/psychological sensations of treatment. Despite this, medical staff did not only engage with women as objects but rather understood that their overall health and social situation could interfere with treatment success.

Visual Diagnosis and Monitoring

Ultrasound, specifically the transvaginal ultrasound, is fundamental for infertility treatment. The technology is used during every treatment stage, penetrating the body both physically through entering the vaginal canal and visually (Gupta and Richters, 2008: 240). It permits the fertility expert to gaze inside the woman’s body during diagnosis and surveillance of ovarian follicle development, to locate these follicles during ova extraction, to guide the embryos to their ideal location during the transfer and finally (hopefully) to detect a developing embryo weeks later. Despite the objectifying nature of the ultrasound, through engagement with the technology and the doctor, women often experienced ultrasound monitoring as strange, and even troubling, but also as a means to reinforce bodily recognition or a means of knowledge production.

During interviews, most of the women described the transvaginal ultrasound as a peculiar, new experience:

The experience of the ultrasound was very odd and a bit disturbing. It was strange having something inside me, while someone [the doctor] described to me the health of my body parts – my uterus, fallopian tubes, ovaries – while pointing them out on the screen. (Adriana, actress, 44 years old)

Adriana’s description of this experience as ‘odd’, ‘disturbing’ and ‘strange’ while simultaneously emphasizing an acute awareness of her body point to the multiplicity of this embodied experience – showing that this moment was both fragmenting and alienating, while also unifying. At the same time, as Dr. Mabel was separating Adriana’s reproductive organs from herself – showing them on a screen and telling Adriana her ovaries look like those of a young woman – Adriana was seeing her organs as fragmented, recognizing this as ‘odd’ and reasserting (to herself) that these are her. In order for this to happen, Adriana’s body needed to be both fragmented and seen as whole, while also seen from both the doctor’s and her perspective. Adriana would not have embodied this reassertion of herself without this complexity of beings (i.e. herself as fragmented and whole, and the doctor).

Other women, such as Selina, experienced the examination as very informative, with the wand inside of them facilitating the doctor’s explanation of the anatomy of their reproductive organs. Selina, a 27-year-old educator, was intrigued by the depiction of her organs on the screen in front of her and mentioned being curious about the ‘functioning of my body’. Although Selina emphasized the functioning of her body, not her individual organs, she found hearing about their individual purposes and how they contribute to her infertility complications to be a valuable learning experience. For Selina, the fragmenting nature of the ultrasound provided her with a different way to view and learn about herself and her troubles conceiving.

Many women found it difficult to find the words to express their ultrasound experience beyond being strange or informative, a difficulty scholars have acknowledged in embodiment studies (e.g., Csordas, 1994; Jackson, 1983). My observation of women’s behaviour during these examinations is, however, suggestive. Women’s facial expressions were often contorted or scrunched, expressions that I interpret may have been signs of confusion or curiosity about what was depicted on the screen given some women’s narratives about their experiences. When asked directly, only one woman described the transvaginal ultrasound as painful. Pain was a topic women discussed openly in relation to hormone injections, their discomfort following the ova removal or when recalling their experiences of the embryo transfer. Thus, it is unlikely that most women’s facial expressions during the transvaginal ultrasound were related to discomforts that they were unwilling to express verbally. Confusion, however, is consistent with the women’s narratives of the examination being an odd experience that allowed them to see their bodies from an angle they had not experienced before, which contributed to some women’s curiosity. Women often asked the doctor questions during the examination, engaging with him or her to understand what they were seeing and experiencing better. As Waskul and Vannini (2006: 7) explain, ‘in communicative action the body comes to be’. Through the women’s engagement with the doctors, they retained their presence and actively participated in the process, while furthering their understanding of their body and infertility diagnosis.

The doctors themselves often used the ultrasound’s sophistication to foster further engagement with the women during transvaginal examinations:

During an examination of Fatima’s uterus, Dr. Diaz discovered an abnormality. He zoomed in and then used the computer mouse to draw a circle around a white looking object, allowing the object to become clearly visible to the untrained eyes of Fatima and myself. Turning to Fatima, he explained, ‘The object is a myoma, which needs to be removed before you can start ovarian stimulation’. The screen on the wall in front of the examination chair allowed Fatima to see the highlighted image clearly. At a click of the mouse, the myoma was displayed from another angle. Dr. Diaz explained that he was assessing its size and determining how difficult it would be to remove. (Fieldnotes; corporate lawyer, 42 years old)

The ultrasound allowed Dr. Diaz to explain the abnormality he discovered in Fatima’s uterus more effectively. He highlighted the myoma not for his own benefit, as he was aware of the appearance of a myoma, but for Fatima and myself so that we could more easily observe the growth inside Fatima’s uterus. Despite the detached appearance of Fatima’s organs and the emphasis Dr. Diaz was placing specifically on the myoma, he was also engaging with Fatima as he tried to make her understand through a visual representation of her divided body what needed to be removed.

In these examples, we see that the women’s engagement with the doctor prevented the ultrasound from being experienced as merely objectifying. Through their communication, the women avoided being reduced to body-objects (Mol and Law, 2004). Furthermore, the engagement of the women with the doctor and the technology (often through the mediation of the doctor) are what enacted new understandings of the body and infertility as women (and often the doctor, too) came to see their bodies from the inside (as well as the outside) in new ways.

The numerous ultrasounds required during high-tech infertility treatment seemed to diminish women’s perception of the procedure as odd, disturbing and at times alienating or a means to learn about themselves and their infertility as treatment progressed. For many women, by the time they reached the stage of ovarian stimulation and the intense monitoring involved, the process became normalized. Having become accustomed to the ultrasound, the women frequently appeared to go routinely through the process of undressing, donning the robe, placing their feet in the stirrups, permitting the doctor to monitor their reproductive organs and finally re-dressing and leaving. Even when the procedure became routine, however, women’s bodily experiences were still connected, if only vaguely, to notions of treatment success or failure that accompany follicular monitoring. The women attached meaning to these numerous transvaginal ultrasound examinations, as they determine when ovarian hormone stimulation ends and if the ova removal will be scheduled. Thus, these experiences become embodied as markers of treatment progression or failure. Furthermore, for women questioning the quality of their eggs, the ultrasound was entwined with their ability to use their own gametes or their need for donor materials.

Ovarian Stimulation and Embodied Discomforts

After diagnosis and a treatment regimen is established, women begin ovarian stimulation through hormone injections. The hormones stimulate the ovaries to produce multiple ova, which are closely monitored via transvaginal ultrasound and later removed from the anesthetized woman’s body during a surgical procedure to finally be fertilized in the laboratory. Unlike other treatment stages, the doctor does not directly manage the administration of hormones; however, these injections permit the doctor to better control the timing of ovulation for the ova removal. After the prescription was written, ovarian stimulation became an interaction between the woman and the nurse(s), and the woman and her body. Women often experienced ovarian stimulation as being ‘saturated’ with hormones, to use Samara’s description (administrative assistant, 33 years old), indicating that their embodied experiences went beyond the doctors’ description of mere physical discomfort, and were intertwined with their wider concerns about treatment success, the physical pain that reverberated throughout their bodies, the colico (physical and emotional discomforts caused by augmented hormone levels) treatment caused and the meanings attributed to these bodily sensations.

Fear

Most women undergoing their first round of treatment lacked experience administering injections and worried about injecting themselves. While receiving instructions from the nurses about how to inject the hormones, women’s expressions often showed signs of concern:

Following a consultation, the woman sits down at the reception desk and hands the nurse a prescription. The nurse reads it and then explains to the woman that she can take home the Lupron^© [hormone] but she should inform the clinic when she starts injecting it after the beginning of her next menstrual cycle. The nurse fetches the medication from the back room. Upon returning she explains how to administer the injection, demonstrating how to read the syringe and verify the dosage, and where on the abdomen to apply the medication and how to clean the area. Noticing the woman looks anxious, the nurse explains a second time, this time referring to the instruction guide. Taking the medication and syringes the woman laughs nervously and says she is scared. The nurse tells her not to worry and to call with any questions. (Fieldnotes)

This description was typical for women beginning hormone stimulation. Although they often verbally and physically expressed their concerns to the medical staff, they were still encouraged to administer the injections on their own, reiterating the role they must take during this stage, a role that makes them responsible for treatment success or failure (Throsby, 2002: 64). The pressure of this responsibility was often embodied as further concern or anxiety, as most women feared not the physical act of injecting the hormones, but the consequences of administering the injections incorrectly.³

To counter this anxiety and fear, some women actively sought out the daily assistance of a nurse to receive the injections. For instance, Reanna explained she would be at the clinic every morning at 10 a.m. for the next 10 days or so to receive the injections: ‘I have to be muy juiciosa [very diligent], because, God willing, the treatment will work this time’ (administrative assistant, 34 years old). Reanna was not necessarily choosing to come to the clinic for the injections because she was scared of administering them herself, but because she worried that doing so incorrectly would result in another failed treatment.⁴ In reflecting on numerous surgeries, two failed artificial inseminations, and one failed IVF cycle (previous procedures in which she injected the hormones herself), she intended to do everything possible for the current cycle to be successful. Reanna had embodied a sense of security in seeking the help of someone else, a trained nurse, to administer the injections for her. Reanna may have been choosing what some would interpret as the reduction of her autonomy and further objectification instead of taking the initiative to inject the hormones on her own, but for Reanna, this was a strategic act, a sort of responsive agency, informed by previous bodily experiences, meant to reduce her fears and increase her chance of pregnancy. In practice, Reanna’s embrace of objectification redistributed (at least partially) her responsibility for treatment success as she incorporated others into this phase of the treatment process.

Most women could not attend the clinic daily to receive injections due to other obligations and the unreasonable time it usually takes to drive to the clinic given Bogota’s hectic traffic, but this did not prevent them from seeking additional assistance to reduce the fear and anxiety that accompanied hormone stimulation. Waskul and Vannini (2006: 8) explain that ‘embodied people mindfully resolve pragmatic problems with intention and purpose’ given their broader social context and resources available to them. To overcome the anxiety attached to incorrectly administering injections, women telephoned nurses to verify the dosage, where and when to apply the injection and for how many days. Others visited pharmacies to have the injections administered ‘properly’. Although women could manage this part of the treatment process on their own, their lack of experience in and confidence about administering injections, and their fear that doing so incorrectly would decrease the likelihood of treatment success, caused some to seek further medical assistance. In relinquishing their physical control over injecting hormones on their own, these women redistributed their responsibility for treatment success and converted the fear and anxiety they embodied into a sense of reassurance, a pragmatic action that did not diminish their consciousness of the body, as Leder (1990) has suggested, but rather transformed a negative embodied sensation into a more bearable one.

Pain

Nearly all the women in this study complained about the hormone injections and physical pain the injections caused them. Larissa, recalling her experience, explained she had 18 injections in her abdomen and countless more in her buttocks, painful experiences that she must have expressed verbally to her husband, as he snickered at her remark, and then commented, ‘she complained a lot, but the injections did appear to hurt’ (veterinarian technician, 26 years old; mechanic, 27 years old). Julia foresaw the pain she would experience when the clinic administrator confirmed she would have to administer 10 hormone injections in the buttocks over the next few days. Julia commented, ‘Faltaré la cola’ (literally, I will be without buttocks, figuratively, I will be unable to sit down [due to the pain]; pharmaceutical sales associate, 36 years old). Larissa’s and Julia’s narratives concerning hormone injections depict more than localized physical pain; rather, they show that this pain was embodied as complaints and irritation or an inability to perform a common task such as sitting. The physical pains women experienced emanated from particular parts of their bodies to affect other aspects of their lives.

Physical pain also manifested as heightened awareness of one’s body. Women came to differentiate between different severities of pain depending on the specific hormone being used and where on the body it had to be injected, in the buttocks or the abdomen. Iris specifically mentioned the severe pain of the ones in her buttocks and the difficulty she was having sitting, while the ones in her abdomen were painful but did not affect other parts of her life (financial advisor, 32 years old). Nicola differentiated between the hormone type and the applicator, commenting that the one the nurse had just administered hurts as it has lots of liquid and has to be administered slowly, while the ones that click and are quickly injected are not as painful (business executive, 40 years old).

Benjamin and Ha’elyon (2002) claim pain becomes a part of IVF, part of what a woman is willing to endure for the possibility of having a child. Iris’s narrative reflects this embodied notion of endurance: ‘I was not able to sit for two days because of the injections, but I did it with love…we see a child in our future, concentrating on our end goal, the end success, helps us get through this’ (financial advisor, 32 year old). The pain Iris experienced with the injections was localized on her body, but its significance was entangled in her (and her husband’s) desire for a child and the reality that they would only conceive using ARTs. In connecting this localized pain to the wider desire for a child, Iris’s pain was transformed into perseverance. In other words, the pain she experienced was meaningful and purposeful (Fannin, 2019), connected to their overall attempt to have a family. Asad (2000: 49) contends that being able to respond perceptually and emotionally to internal and external causes of pain and use the painful experience in purposeful ways within specific social relations makes it agentic. Thus, experiencing pain in this instance involves embodying the significance of that pain within its surrounding context – one’s desire for a child – which creates a form of embodied agency.

Colico

In addition to pain, women discussed physical and emotional discomforts. They differentiated between pain from the injections and other discomforts related to the hormones’ effects on the body. Women described their bodies as ‘full’ or ‘saturated’ with hormones and equated this to prolonged or augmented premenstrual syndromes, or what they called colico. Colico manifests as body aches, abdominal cramping, the inability to eat or sleep and being overly emotional. I often saw women sitting in the waiting area, rubbing their stomachs, not in a caressing fashion as, for instance, pregnant women do, but rather out of discomfort. The nurses’ greetings to arriving patients commonly included asking how the woman was handling colico that day.

In addition to these physical discomforts, women often experienced added anxiety, depression or augmented emotional sensations. Adriana, for instance, claimed her body being full of hormones was causing her to ‘go crazy’. She wanted to cry about everything and fight with everyone. She gave the example of being at a funeral for a friend’s mother and crying as though it was her own mother’s death she was mourning (actress, 44 years old). For Adriana, the hormones saturated both her body and emotions, they saturated her in her entirety, causing her to behave in ways uncharacteristic of herself – experiencing a sense of otherness due to the chemical manipulation of her body. Despite suggesting a bodily infiltration and a sense of embodying otherness, this statement also suggests Adriana became self-aware of her mind/body connection in a more profound way than usual as she reflected on how the hormones were connected to her emotions and behaviours. Her lack of control also functioned as a means for gaining another kind of control – a kind of reflexive agency.

Despite the discomforts and, for some, sense of otherness of colico, its sensations were linked to the growth of ovas: colico was simultaneously a disturbing side effect of hormone stimulation and a sign of positive treatment progression. The understanding of colico, therefore, is more complex and slightly distinct to that of pain, as colico is embodied as a sign of continued treatment success. Both have to be endured for pregnancy to be possible, but the meanings attributed to these sensations alter the way they are associated with wider treatment goals.

Embodying Potential Conception

The embryo transfer follows the ova removal and fertilization process. Medically speaking the embryo transfer is a minor procedure that involves the use of a speculum, a catheter being pushed through the cervix, and embryos being injected into the uterus, a process made visible via ultrasound imaging. During the procedure, doctors are primarily concerned with the woman’s cervix and their ability to inject the embryos into her uterus, as well as the likelihood that the embryos will implant. Their attention, therefore, is primarily on the embryos and a fraction of the woman’s body, not the woman herself, though they do engage with the woman as they try to ease her tension and discomfort. Despite the apparent simplicity of the procedure, it is filled with anxiety and hope for both the medical professionals and the woman/couple, as it is the last medical intervention in the conception process and the moment when nature resumes its control. For the woman, the embryo transfer also entails further pain and discomfort, but also a desire to savour the moment of potential conception.

When I asked women about the embryo transfer, most first recalled the simplicity of the procedure, but then remembered the discomfort of having the catheter inserted. Angelica stated, ‘It [the embryo transfer] was horrible’. The insertion of the catheter through her cervix caused her horrendous pain that persisted after its removal (voluntarily unemployed, 35 years old). Larissa, likewise, recalled it as the worst part of the entire treatment because of the pain (veterinarian technician, 26 years old). As the catheter was inserted, the women I observed scrunched their faces, gritted their teeth and/or squeezed their eyes shut from the agony, even though the doctor had instructed them to relax. Verbally, however, women declared they were fine during the transfer or directly following it. For instance, Jimena, who had undergone two previous IVF cycles, after having the catheter removed and while lying on the hospital bed for the approximate hour that is intended to assist implantation, repeatedly scrunched her face, due to what I can only assume was pain (unlike the ultrasound, women directly reported they experienced this procedure as painful after the fact), while holding her breath and touching her abdomen. When I asked if she felt all right, each time she took a deep breath and said, ‘I am fine’ (paediatric orthodontist, 42 years old). Despite Jimena appearing to be in pain, she made an effort to endure it without complaint as she focused on the embryos that had been injected on the stilled ultrasound monitor. Similar to the discomfort caused by the hormone injections, I interpret Jimena’s actions as a means to bear the pain that accompanies assisted conception. Such pain is embodied as part of the process these women must endure to have a child. However, unlike the hormone injections, the embryo transfer is the final stage of a complex treatment regime, the stage in which conception is intended to take place. Conception is not socially imagined as a painful process. Thus, this bodily experience has to be reconfigured for this conception process to be made meaningful.

In a similar vein, the embryo transfer lacks intimacy as Iris and Fernando explained talking more to one another than to me, ‘We do not want to think of conception as a scientific process, when it should be a loving, pleasurable, and enjoyable process, not one that happens in a clinic. But this is what we have to do if we want a child’ (financial advisor, 32 years old; financial advisor, 34 years old). Natural conception is not understood as a painful, scientific procedure, but a sensation of compassion and pleasure. Rather than focusing on the pain and sterile, medicalized environment, women strove to embody the wider significance – creating a child – of their bodily sensations (Zeiler, 2010) and reconfigured the meanings of creating a child in the context of assisted conception (Silva and Machado, 2010: 629).

This reconfiguration is partially facilitated by the ultrasound that visually shows the embryos inside the woman’s uterus once they are injected. Most women stared intently at the ultrasound monitor when the fertility specialist injected the embryos. Once injected, a nurse would pause the monitor allowing the embryos to be continuously watched while the doctor concluded the procedure and the woman waited to be informed to leave. While watching the screen, women often touched their abdomen connecting the embryos’ visual presence floating on the monitor and their physical place inside the woman’s uterus, an embodied experience vastly different from natural attempts to conceive. This connected visual/bodily experience helped women transform the meanings attributed to the painful, sterile, cold reality of medicalized conception, as they embodied the sensations of what might be their closest experience of pregnancy. In giving meaning to these bodily sensations that are dissociated with natural conception, women’s embodied experiences work to reconfigure the dominant understandings of conception in the context of assisted reproduction.

Discussion

Although medical interventions may objectify the body, this does not imply a docile body, devoid of agency (Thompson, 2005); rather as these findings have demonstrated objectification may also empower and make agentic in multiple ways. Women’s narratives indicated that their embodied experiences of assisted conception, processes in which their bodies were analysed (and experienced) as fragmented and whole and observed from both the inside and from without, were multiple and complex. Their experiences were entangled within their desire to have a child and previous infertility interventions, the uncertainties and confusion that accompany intricate treatment regimens and their wider social context. However, it is not only their experiences of objectification that were multiple, but how they reacted to and utilized these embodied experiences of objectification in productive ways were also multiple. In other words, women’s experiences of objectification enacted various types of embodied agency.

During diagnostic and monitoring interventions, women’s agency manifested through new means to learn about their bodies and their infertility complication, processes that were facilitated by the visualizing mechanisms of the technology and discussion with medical professionals. Although, at times, the ultrasound produced experiences of fragmentation, it also provided new ways of engaging with and visualizing their bodies, creating knowledge producing processes. These experiences assisted women to better understand the functioning of their bodies and overall reproductive capacities, which increased their authority over their bodies and selves, while also increasing their conceptualization of how ARTs could overcome their particular infertility complication(s).

Embodied agency also manifested as active responses to undesirable sensations of treatment interventions. For instance, in Reanna pragmatically relinquishing her control over hormone injections, allowing others to manipulate her body due to the fear of failure and embodied knowledge (Lippman, 1999: 259) about previously failed treatment cycles, she took ownership of and altered her negative sensations of hormone injections (i.e. fear and anxiety), while refashioning the sensations into more bearable ones (i.e. partial reassurance). Here invited objectification functioned as a means of responsive agency – utilizing embodied knowledge and available resources to alter or transform a current situation or experience. Moreover, in seeking further medical assistance, Reanna also let go of responsibilities for treatment failure related to hormone injections redistributing such responsibility to others involved in her treatment cycle. As suggested by Greil’s (2002) research, sometimes through relinquishing control we actually gain other forms of control.

Reflecting on notions of the self and treatment processes demonstrates another form of embodied agency. Reflective embodied agency connects current bodily and emotional or cognitive changes to previously formed images of one’s self, thus altering the experience through self-awareness. Adriana, for example, demonstrated reflective agency as she connected her body’s saturation with hormones with her experience of emotional otherness. Through reflexively responding to her heightened awareness of her mind–body connection, she regained a sense of self. This was also evident in the ways that women recognized their individualized organs on the ultrasound monitor as themselves.

Benjamin and Ha’elyon (2002) claim that women in their study detached themselves from their bodies during painful IVF procedures. This contradicts how women in this study appeared to give meaning to pain experienced during hormone injections and the embryo transfer through the ways that they connected their pain with the wider treatment process and their ultimate goal of having a child. Painful experiences, like the sterile environment of the medical facility, are not commonly associated with conception, but they became significant parts of women’s attempts to conceive and were experiences to be endured. As Iris’s narrative emphasizes, regardless of undergoing assisted reproduction, women still wanted to embody conception as they had always imagined they would, in a loving, pleasurable embrace. In giving meaning to pain and the medical procedures involved in the conception processes, women actively made their embodied experiences purposeful within the context of assisted conception (Asad, 2000). This meaning making was partly facilitated through knowing that embryos had been injected into the woman’s uterus and the embryos’ visual representation on the stilled ultrasound screen. By focusing on the embryos that (literally) embodied the potential for conception, and which were finally physically embodied within the woman’s womb, and the wider significance of the embryo transfer – an attempt at conception – women’s bodily sensations, however distant from non-medicalized conception, were made meaningful. Again, we see how women’s embodied experiences were intertwined with the ultrasound, and their wider understandings of conception and desires for a child, dynamic relationships that gave meaning and purpose to the medical processes being endured. Furthermore, in actively producing meaning through their bodies, women worked at reconfiguring the significance of conceiving in the context of assisted conception.

In the many ways that assisted conception objectifies woman’s body, it also creates the potential for such objectification to be embodied in multiple agentic forms. Objectification produces bodily knowledge and new forms of bodily recognition. It is embodied as responsive and reflexive agency. Bodily objectification also becomes empowering in the ways that meanings are produced through the body and the ways it constantly adapts the body (its interpretation, wholeness/fragmentation, enactment) to reach specific goals. The various ways in which objectification empowers women indicates the multiplicity of embodied agency. In breaking down these various manifestations of embodied agency into analytical categories, I aim not to simplify our understanding of agency, but rather to demonstrate how agency’s enactment is multiple and complex, elicited from objectifying experiences in diverse ways and at various times during treatment processes.

In recognizing the multiple agentic ways women respond to objectification, we must also consider the specific context in which such agentic acts manifest. Gupta and Richters (2008: 247) explain that the experience of ‘objectification through reproductive technologies depends on several factors, which vary across the world and in individual cases’, including the social and structural constraints that shape women’s lives and the cultural meanings ascribed on the body. The nature of the highly competitive private medical system in which ARTs are provided in Colombia where doctors often invest their own finances in their clinics and are highly dependent on the recommendations of their patients/clients (Shaw, 2019) may create a more equal power dynamic between patient/client and doctor and help facilitate more labour-intensive care than that found in other locales. Furthermore, the women who participated in this study all lived middle or upper-class lives, the majority were well-educated and most had supportive husbands and/or extended families. As our social positions and cultural understandings of medical practice are entangled with our embodied experiences (Blackman, 2010), these likely contributed to women’s agency when undergoing invasive medical procedures or when engaging with highly skilled doctors. The configuration of these factors contributes to the labour-intensive care that women often receive at these private facilities, which (at least partially) facilitates women’s active participation in, and even ability to alter, treatment processes. Finally, unlike in Thompson’s (2005) study where some women had concluded their use of ARTs or had recently experienced treatment failure – an experience she claims alters the relationship between patient as subject and patient as object – most of the women whose narratives are presented here were still undergoing treatment (either their initial treatment or were in the midst of a subsequent treatment after coping with previous treatment failure) when they were interviewed. Finding meaning in and responding agentially to objectifying procedures may have been a coping mechanism to help overcome the difficulties they were experiencing to continue with treatment.

Following Timmermans and Almeling’s (2009: 26) practical question: ‘how does objectification throughout a diagnostic trajectory affect “compliance” with treatment?’, I ask what does analysing the empowering effects of objectification mean for women’s engagement with medical intervention; that is, what does it do in practice. Mol (2002) explains that how people experience healthcare interventions, how they embody and give meaning to them, also involves practical responses; it is, thus, integral to the ways they will approach additional or new medical interventions in the future. For instance, finding hormone injections bearable because they are intertwined with the wider desire to have a child, compared to being overwhelmed by meaningless pain that interrupts one’s life, will affect how women approach their next IVF cycle or whether they approach it at all. This may also have consequences for what interventions women approach in the future. Furthermore, in recognizing that objectification can also empower women in idiosyncratic ways, we should also consider what this may mean in practice. For instance, in asking women to inject hormones on their own, they become responsible for their treatment and treatment outcomes, factors which may place further burdens on them. Having the ability to invite further objectification, as Reanna did, may help women alleviate doubts they have about the treatment, their bodies, their own intervention in the process as well as their responsibility for treatment success or failure. Healthcare professionals can help facilitate the distribution of treatment responsibilities by being empathetic and supportive when patients ask for more information or assistance in managing treatment processes that are designed to be handled independently. Further distributing the responsibility for treatment outcomes is not only integral to individuals seeking infertility treatment but is a practice that could help empower patients undergoing various medical interventions.

Taranilla (2017: 110) argues that assisted conception encourages individual creation of powerful imaginaries and makes us reconsider our procreative nature. As I have shown, assisted conception also pushes us to reconsider the connections between objectification and agency, and the multiple ways bodily objectification can enact agency that is lived through bodies. In considering these nuanced ways that agency manifests in the body, we expand our understanding of what agency is, reemphasizing that individuals negotiate constraining factors through multiple means, as well as contribute to analyses of what agency does (Madhok et al., 2013). Like bodies themselves, embodied agency is complex and multiple, shaping the ways women experience their health and their engagement with medical interventions. Furthermore, as Yang (2015: 101) explains, bodies and their experiences ‘function in their own right’ in ways that may differ from how wider society imagines. As women construct new meanings of conception through their bodily experiences, experiences that do not correspond with dominant understandings of conception, and create their own image of what conception is, they reshape (ever so slightly) our conceptualizations of reproduction. In seeing agency as produced through the body, then, we see how bodies can be agents of social change.

Footnotes

Acknowledgements

I am indebted to the couples and medical staff who generously participated in this study. I would also like to thank the anonymous reviewers who challenged me to further develop my argument and reformulate my ideas, and Gill Haddow, Patricia Jeffery and Erich Hellmer for carefully reading and providing feedback on early drafts of this article. This study was supported by two postgraduate grants from the University of Edinburgh.

ORCID iD

Malissa Kay Shaw

Notes

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