What it Means to Be a Woman

In Western countries, it has become much more socially acceptable to be childless, and more American women are hitting their 40s without kids, according to the latest census data. By contrast, in many developing countries, women have no careers—just motherhood—to give them their identity. "The notion of child-free living is not considered an acceptable thing for a married couple," says Inhorn. And particularly in Muslim and Hindu areas, she says, adoption "is not an immediate second path."

Legal adoption is "bureaucratically onerous" and often not socially acceptable, says Elizabeth Roberts, assistant professor of anthropology at the University of Michigan, who studied the people of Ecuador. So it's not surprising that even extremely poor people may go into debt trying to conceive. "A family is only a family if there are children, basically," says Roberts. "The biggest stumbling block is money."

Many couples may waste valuable years resorting to "black magic," says Aravinda Guntupalli, a professor at the University of Tübingen in Germany who studied infertility in India. The couples ask so-called sacred people what days they should fast, and they journey to spiritual places. In the tribal area of India where Guntupalli worked, women dry up umbilical cords and sneak them into infertile women's food to try to help them. "They think it creates some fertility juice in the body," she says.

Not surprisingly, infertility treatments are rarely covered by insurance or by government aid. "How do you provide what is clearly a highly technological, sophisticated procedure in a place that doesn't have a lot of money?" says Adamson, a member of the not-for-profit International Committee Monitoring Assisted Reproductive Technologies, a technical adviser to the World Health Organization. Leaders of countries struggling with dirty drinking water, tuberculosis, malaria and AIDS may find IVF expenditures hard to justify.

Infertile couples in developing countries don't publicize the fact that they need help even if they can afford treatment. Children are seen as a gift of the gods, so failure to conceive may be perceived as an indication that someone has sinned or is unworthy. "People aren't willing to go up on [the equivalent of] Oprah Winfrey and say, 'Yes, I'm infertile, and I'm getting treatment'," says Dr. Aniruddha Malpani, an Ob-Gyn who runs the Malpani Infertility Clinic in Mumbai with his wife. "People have actually traveled [for treatment], telling people they're going on holiday," says Inhorn.

Even for couples who do have access to fertility clinics, there are challenges. For example, some cultures consider masturbation evil. Yet it's traditionally the way doctors get semen samples to check a man's sperm count and then to perform IVF. In some cases, doctors can offer condoms that allow a couple to have intercourse and save the sperm. Another cultural hurdle: the Muslim world does not accept egg or sperm donation. "Each child should have a known father and a known mother," explains Inhorn. "Every child must know his own heritage." Adds Adamson: "It's very important to honor and respect the fact that people have these values."