- Malin Maili,GOOD, BAD AND TROUBLESOME: INFERTILITY PHYSICIANS= PERCEPTIONS OF WOMEN PATIENTS

GOOD, BAD AND TROUBLESOME: INFERTILITY PHYSICIANS= PERCEPTIONS OF WOMEN PATIENTS

Malin, Maili, STAKES, Health Services Research, Evaluation of Health Services, PO Box 220 FIN- 00531 Helsinki, Finland (correspondence), tel. 358-9-3967 2258 fax. -358-9-3967 2485, E-mail: and Department of Public Health University of Helsinki PO Box 41 FIN- 00014 Helsinki University, Finland

Abstract

This study analyses what kinds of differences and categorisations Finnish infertility specialists draw among their patients. . I studied the process of medical judgments and decision making in infertility care context. Semi-structured theme interviews were conducted with 14 physicians out of the 29 who provided in-vitro fertilisation treatment (IVF) and related technologies in 1993. They defined the Other, the less appropriate in infertility care, according to the gender, social class (genes) and the psychosocial situation of the patient and the parent-to-be. Human reproduction is a strongly gendered social issue, that therefore infertility physicians talked mainly about women. The 'good' woman patient and mother-to-be was stated to be one who is of proper age, of good temper, in a stable heterosexual relationship, not too career oriented and from the middle or lower social classes (compliant and capable of true maternal love). On the other hand, part of the lower classes lack knowledge and willingness to seek infertility treatment. The 'bad and troublesome', less appropriate woman patient and mother-to-be is a wealthy career-focussed woman from the upper social classes, or a lonely single woman. But women with overt mental and social problems, or women with husbands who have these problems were experienced to be the most difficult infertility patients in public clinics. The Other mother was defined as a career-centred woman who is too materialistic and selfish, a lonely woman who is too depressed or a woman with psychosocial problems who is too 'bad' in every sense to be a mother. (236)

Introduction

Medical practices are culturally formed, change in the course of history (Helman 1997:105-6), are discoursively constructed (Foucault 1984), and are realised in material structures. Medical practices are not coherent whole and one unity, instead they varied according to health care provider, his profession and speciality (Mol & Berg 1998), according to the patient's gender (Doyal 1995, Lorber 1997:40-41), social class, ethnicity and healthiness (Annendale 1998). There is multiplicity of medical practices (Mol & Berg 1998). In general, practices of medicine form a symbolic system, expressing some of the basic, underlying values, beliefs and moral concerns of the wider society (Helman 1997:106). Contemporary moral concerns are increasingly being expressed in medical terms and by medical professions (ibid. 1997:106 ).

Assisted reproductive technologies (ARTs: in-vitro fertilisation (IVF) and related technologies that use the couple's own or donated gametes/embryos) belong to the area of body politics, social deployment of human bodies, which is constrained by regulatory controls (Scheper-Huges & Lock 1987, Epstein 1995:4). Reproduction is a highly gendered matter since it is profoundly connected to womanhood. In western cultures issues pertaining children and motherhood raise strong emotions.

Different kinds of Others are supervised by different manners on behalf of those who are in socially dominant positions. To constitute a difference and to control it is 'an act of power', a normative act (Wittig 1990). As powerful medical professionals, infertility doctors are part of the cultural process where the formally morally appropriates are constructed, and thus they take part in defining the embodied gendered Others, the morally less appropriate subjects in infertility care (Spitzack 1992, Schildrick 1996). By defining the Others/differents, physicians form hierarchies and categories among patients (Clarke 1995) according to certain usually idiosyncratic criteria (Annandale 1998) which may affect their treatment manners (Stein 1990). Infertility physicians= perceptions about treatment, patients and the experience of childlessness are connected to cultural assumptions concerning the nature of womanhood, manhood, motherhood, fatherhood and the roles of patient and doctor. Moral categories can be seen to be constructed and maintained discoursively in everyday life context (Goffman 1983). The aim of this study is to analyse Finnish infertility specialists= constructions of the differences among their patients in the context of highly technological infertility treatments offered to patients who are usually quite young, not seriously ill, and where it is socially accepted to want to have a child. The aim is to study what kind of cultural norms drive doctors' medical explanations about infertility patienthood and in turn are driven by them (also Epstein 1995:6).

The object of the physician's determination can be seen to be situated in a web of complex power relations which according to Foucault (1984) inscribe the subject in a discursive and material structure of normality. The body of (a woman) patient in infertility care is understood as a surface of signification, on which the subject is defined by many different variables (class, race, sex, age, nationality, culture) (Braidotti 1992, Lupton 1995). These professional definitions and practices also affect the material embodied body's sense of herself (Toombs 1993). In this study the bodily object and subject of determination is an infertility patient, usually a woman.

Reproductive medical discourses are culturally powerful since they in particular include mythical stories and metaphorical meanings concerning the birth of a baby, the knowledge of the Origin of subjectivity (Doane 1990, Simonsuuri 1996:12). Many times myths are stories about coming from somewhere to somebody: they include the elements of separation, transition and incorporation (van Gennep 1960, Turner 1967). The way of expressing myths are symbolic and therefore metaphorical reflecting people's unconsciousness (Simonsuuri 1996:39-41, 55). Metaphors communicate culturally strong attitudes toward somebody or something which may even be harmful to some people like women and people of colour. Metaphorical myths are not static, whereas they change in the course of history. (Sontag 1978, 1989, Simonsuuri 1996:20-21). Therefore, it is interesting to study what kinds of metaphorical inscriptions infertility physicians conceptually constructed among their patients.

The first human baby born with help of the IVF technique was born in England in 1978 (Steptoe & Edwards 1978), and the first IVF baby in Finland was born in 1984. In Finland the annual number of IVF babies born was 357 in 1992 and 1484 in 1998 when about 60 000 babies are born annually (representing 2.5% of babies born in 1998), and the number of clinics has increased from 13 in 1992 to 20 in 1998 (Gissler 2000). In the Finnish health care system, services are available to all in need at public clinics for small fees. In the private clinics services are available to those who can afford them, although the universal national health insurance reimburses a part of the treatment price in the private sector. The public and private clinics have treated about the same number of IVF patients in the =90s (Gissler 2000). But people going to public clinics have to wait some months to one year for infertility treatment, when they can have investigations and treatments immediately in a private clinic (Malin Silverio & Hemminki 1996). Thus, the patient may self-select where they go for help with their fertility problem. Usually the first contact is in a private clinic with a gynaecologist or in a health centre with a general practitioner who may refer the patient to a public clinic. People may also directly contact the specialised infertility clinics

Subjects and methods

I did this study by conducting semi-structured theme interviews with physicians who provided IVF and other infertility treatment in 1993. Physicians were identified by calling all Finnish infertility clinics and asking the names of practising IVF physicians. I listed the physicians' names (n=29) in alphabetical order according to cities, and selected every other physician for interviewing (n=15). One of these physicians refused the interview because of his workload. The interviews happened in their work rooms during working hours, and they were tape-recorded and transcribed. The average duration of the interview was 2.5 hours - the longest lasted 4.25 hours and the shortest 1.25 hours. The major interview themes concerned doctors' personal work histories, the history of IVF in Finland, aspects of the IVF treatment procedure, psychosocial aspects of the patients undergoing IVF and general social questions concerning the ARTs.

There were equal numbers of female and male physicians, half of whom worked in private clinics and half in public clinics. All were specialised at least as obstetricians and gynaecologists. Six were younger than 40 years old, eight were over 40 years old (the range was 35-54 years of age). Three physicians had only one year of work experience in giving IVF treatment, three had one to three years of experience and eight had over four years of experience. The physicians worked full-time in nine IVF clinics, and four of them also worked at the same time in private and public clinics. Altogether the interviewed physicians represented 11 different IVF clinics (see Malin Silverio & Hemminki 1996 for more information) at a time when there were six public and eight private clinics giving IVF and other infertility treatments (Gissler 2000). There was no regulative legislation in place either in 1993 or at the time of writing this article. In private infertility clinics interviewed infertility specialists worked exclusively in infertility care, whereas in the gynaecological department of public hospitals the doctors also provided other gynaecological care. A great number of the patients they have met have severe infertility problems, and many end up having IVF treatments after less invasive technologies have failed. Interviewed physicians talked mainly about IVF done with the couple=s own gametes

Some discussion of my position in the study field may clarify my perspective, legitimate my interpretations and situate my knowledge formation in its context (Haraway 1991, Wolf 1996). As the interviewer I was a 30-year-old female sociologist who told the physicians that I was preparing my doctoral thesis on IVF practice and its social implications. It was not common for them to be interviewed by social scientists. The physicians stood in a clear hierarchial position above me since they were older and had high status as established infertility specialists. Some younger physicians who had little work experience were in the beginning of the interviews somewhat insecure and nervous. Physicians working in other parts of Finland were more open in their opinions than were physicians in southern Finland, which is the most densely populated part of the country. Non-southern physicians openly expressed their worries and discussed the troublesome ethical questions concerning infertility care.

My general impression was that it was relatively easy to interview the physicians. They seemed to be quite homogenous in their opinions and willingness to present their attitudes in the interviews. Eleven doctors were friendly and somewhat remote teachers of a young sociologist, patiently and profoundly explaining all the details of the treatment. However, two doctors who worked in the same clinic were openly aggressive when interviewed. One of them expressed her mistrust of the interviewer openly and questioned the whole study and its methodology. Some seemed to be somewhat frustrated to have to talk with me about larger social questions such as why people want to have children. Overall, physicians= perceptions as communicated to me could be interpreted to be 'legitimative talk' in regard to physicians= work and in some sense represented for me their own =family sociological thoughts' (see also, Armstrong 1984).

The interviews were analysed thematically. First, from every interview predetermined themes and themes which arose from the material itself were picked out. Then all the physicians' discussions around each theme were put together, and different dimensions of each theme were considered. Every dimension of the themes was listed while paying attention to contradictory statements and what was not said (Huberman & Miles 1994, Seale & Silverman 1997). In this study I examined the following themes: any talk concerning gamete donors, the significance of the patient's psyche for the treatments and talk about IVF patients (typical, those difficult to meet, to whom do not want to give treatment, gender differences, selection etc.). One physician's talk about a certain topic could include various dimensions, even contradictory elements, which is considered to be part of the nature of human opinion (Clandin & Connolly 1994). Even the formation of the Other, which is according to Gilman (1985: 20-22) the reflection of person's anxiety in front of the unknown, the classifying categories of the Other may be many and contradictory. Thus, the results of the study are multivoiced an multi-layered (Richardson 1995).

Results

The Good

Infertility physicians stated the criteria for having IVF or other infertility care to apply almost only to the woman. The age of the woman was paramount since the success of IVF depends to a large extent on the age of the woman as on her ability to conceive in general. Only women under 38 years of age can attend public clinics, while there was no age restriction in private clinics. But the physicians also stated the social significance of the age of the mother; it is not good for the mother to be too old when the child is a teenager (not considered to be the case for fathers). However, one physician said he could consider in theory giving treatment to a post-menopausal woman with donated eggs.

In general physicians did not want to treat either lesbian or single women. A heterosexual relationship was the first precondition for having IVF, as it is in Britain (Steinberg 1997:82). In the following statement one can see 1) how the importance of the heterosexual pair relationship is constructed, 2) how physician expressed negative stereotypes of women and 3) the physician's identification of himself as 'a giver of a child' to the couple, not to the woman.

=... We treat a couple, I don=t treat a woman who comes to me to ask for insemination in order to have a child like buying a doll from the shopping centre, so we treat a couple, it is necessary.... I give a child to the family... I don=t give a doll to the woman= (man, private clinic, H6 page 23, italics added)

Accordingly, various physicians did not accept a single woman having a child with the help of AID (artificial insemination by donated semen) because she feels lonely. In that case the woman was seen to be using the child to meet her needs. This may indicate a moral ideal where nobody is allowed to be used as a means to achieve selfish goals. But on the other hand, physicians also admitted that they never really know what happens in the home of the couple, which meant that they cannot be sure that a woman has a male partner, and therefore even single and/or lonely women may have AID. One woman physician even said in a negative sense that women can be so clever that they can get AID without a partner. This opinion clearly represents a negative stereotype of women.

Additionally, the physicians in private clinics said in a positive sense that nobody really knows what happens between a doctor and patient, i.e. treatment of older, lesbian and single women may be possible without official approval. But again one man physician said that he could very well imagine using AID to help a single but educated career woman who has not had time to meet a 'good man'. Thus AID will replace the missing proper male partner or lack of time to find a partner, and women are not obliged to search restaurants and bars some man with whom to have sex in order to become pregnant. AID will help women to avoid being like prostitutes or will help them to avoid manipulating a man in order to have a child without his permission. This above image of women may not fit the cultural image of a good mother, who is supposed to sacrifice her own needs, be loving, nurturing and caring. (Bassin et al. 1994).

The patients from lower social classes were seen to be heroes with less resources who sacrifice all in pursuit of having a child. Thus they were evaluated as good parents-to-be since money is secondary in their life and they literally give up everything for the sake of having a child. Here money has a morally positive meaning in terms of giving all that one has for the sake of procreating. These patients were also described to be more compliant and good patients since they do whatever the physician asks. But on the other hand, physicians assumed that less educated lower-class people and people living in agrarian parts of Finland lack information on (and willingness to participate in) infertility treatment options compared to educated higher-class patients living in urban parts of Finland. In urban areas patients from all social classes were stated to come for IVF treatment in public clinics, which was considered to be good for the sake of social equality. Very wealthy career people were seen to be less good parents-to-be and to be difficult patients. They were experienced as assertive consumers of medical treatment (Calnan & Williams 1996), which many physicians find difficult to deal with (also, Lupton 1997).

=...it has been an interesting point, which may interest you as a sociologist, that those people who are believed to have a lot of money, they calculate every penny and speculate the chances for the success of the treatments in detail. But those people who save money from small wages when they come to have IVF.... Both (of the rich couple) are about 35 years old, have been working 10 to 15 years, don=t have any economical problems, and what is the problem to pay 1100-2200 , for IVF? But they are the ones who are suspicious of starting IVF. And on the other hand there may be a couple who don=t have permanent work and salary, or have very low wages... They come here and put all they=ve got into IVF, they don=t think about a summer cottage, a new car or travelling abroad...= (man, private clinic, H7, p.55, italics added)

This perspective notwithstanding, some said that it is easy to treat upper-class patients since they speak the same language and obviously have the same value system as the physician. Identification with them may be easier and thus communication between the doctor and patient may be less problematic.

The Bad

Some physicians identified with the child-to-be, and they wanted to protect children from having bad parents, primarily from bad mothers, meaning career women, lonely women or woman with psychosocial problems. In general rich and wealthy couples were seen to be calculating, money-oriented and thinking of a child as an achievement in life. The underlying meaning is that the child has a right to be born wanted, loved as she is and to be a primary person in the life of the mother (and the father). Therefore, when ambitious career pursuits and motherhood were combined it was considered to be horrible for the potential child. In this case the physicians were thinking about the quality of life of the unborn child. A self-centred, money- oriented mother was seen as one of the worst fates for a child. One physician said that he tries to question directly the motives of career patients to have a child if they seem not to have time even for treatments.

..There is a man or a woman, who can not get pregnant for some reason, then (one can ask) does she have possibilities to raise a child, e.g. how much trouble will a child mean for her work? This will not give a good start to a child's life .. . even now I have to say to some couples who say that they have too busy a schedule to meet a doctor for infertility treatment, that s/he has this and that meeting at this time and that time, then one has to say: Have you thought a bit when you are so busy that when you have a child who will take a lot of time, how will you handle work and child care at the same time? (man, private clinic, H10, p.25)

... when there are busy career women...when they start trying to have a child at 30 years of age when their career is established, their own flat has been bought... (having a child) doesn=t succeed, then one is over 35 years of age, this kind of career woman is in a terrible hurry to have a child.. When I have followed these women I got impression that to have a child is like an one effort in life... they have to show that they are able to become pregnant and deliver a child.. .They may feel that they are not a true woman without experiencing pregnancy, childbirth and raising a child.... (woman, semiprivate clinic, H9, p.33-34)

A career woman was seen to want a child by any means, as a product among other pursuits in life. Here again appears the main theme about money excluding true maternal love, although half of the labour force in Finland consists of women who work full time. Women's work participation has a long tradition in Finland and is an obvious necessity when the population is so small and living expenditures high (Rantalaiho & Heiskanen 1997). But crucial is here the meaning of the work for the woman, i.e. is it the most important in her life or secondary after the family?

Additionally, a lonely woman is not allowed to use a child as a remedy for her loneliness. A woman's loneliness may indicate psychological problems. But still, many physicians said that it is good that infertility care is available to all despite their social class, since the quality of parenthood does not depend on the social class of the parents.

Contradictory attitudes about women

Usually women were experienced to be active searchers for treatments because infertility was seen to touch them more, and because women are accustomed to using gynaecological services. Men were described as passive followers of women in infertility care, although in the =90s the couple was stated to be the object of treatment, not only the woman as in the =80s. Whit some couples the women were considered to be passive, inactive, waiting like good girls in queue for treatment, whereas the men were considered to be more active in infertility care. Men move to hurry the treatment while women bide their time. Some young men were said to be active subjects in care, calling the doctor about the results of the treatments, and actively asking questions when they were in contact with physician. On the other hand, modern women were also seen to be active, assertive consumers of infertility treatments.

Sometimes women IVF patients were seen as potential abusers of their husbands. Some IVF physicians interviewed the man and woman in a couple separately to ascertain whether the woman is putting pressure on the man. Physicians tried to be sure that women do not pressure their husbands into participating in infertility treatment and using donated sperm. It was said that no physician wants the woman to blame her husband in a family argument that he is not capable of producing a child. By holding separate interviews the physician learns the motives of the couple, and can control the dynamics of the relationship. The statements about women as abusers can be interpreted as expressions of the negative stereotype of the woman (see also, Steinberg 1997:88).

..One has to listen to both members of the couple, I say to the man personally that he can contact me whenever he wants, because a wife easily tends to put pressure on her husband if the infertility depends on the man, and she needs donated sperm (in order to get pregnant) (woman, private clinic, H9)

The woman patient is controlled also in her future use of frozen embryos in that she must still be married with the man who is the father of the embryos, and that it must be the couple's wish to use these embryos, not only the woman's individual wish. Here physicians protect the legal status of the child and the self-determination of the father.

However, women patients were seen also to be in a victim position when their husbands in cases of remarriage want to have a child of their own by any means, even by using donated semen when the woman has children from a previous marriage. In this case the physician may directly question a couple's wish to have a child together. It may be that it is important for some men that others can see his wife's pregnancy and the birth of the new child.

. It (a child) is matter of manhood, his self-esteem... they are not able to continue their family line... I have an AID couple who are remarried, there is a woman who already has 4-5 children from a previous marriage, the children are even small... the new husband has no sperm .. They came to me to ask to use donated sperm, and even when I have asked them that aren=t those 4-5 children enough for you?.. I feel that it is like a must to have a new born, it is like =keep a front together= that the new husband has a child too... (woman, private clinic, H9 p.34)

Additionally, physicians said that recently semen quality has lowered in general, which means that some fertile women have to undergo IVF in order to have a biological child with their husband. Furthermore, some saw it as necessary that the husband comes to the clinic with his wife when she is in treatment in order to know what she is going thorough to be able to support her.

And the most Difficult and Troublesome

But above all, physicians felt most uncomfortable giving infertility treatment to those who have had psychosocial problems: those who were alcoholic, mentally ill, asocial, had a criminal background or even those who were physically handicapped (nobody talked about people with intellectual disabilities). Many of these troublesome people belong to lower social classes and physicians usually meet these patients in public clinics. Physician has too see that patient or her partner has these problems, or somebody has to tell to the physician about patient's life situation (the head physician of the municipality, or past medical records). These people raised the most anxiety among the physicians. They felt these encounters were very difficult and wondered whether they have any right to determine who will reproduce and who will not with the help of IVF, since people without infertility problems reproduce whenever they want. Sometimes in these kinds of problematic situations the head physician of the couple=s municipality calls and refuses to pay for their care because the couple has already abandoned children (or because there is overt public knowledge that the couple has serious alcohol or other social problems). Doctors themselves were most worried about patients' ability to take care of children. Thus, the first option for the infertility physician is to refuse to give infertility care to these kinds of patients. In case of mental problems the infertility specialists may ask for a psychiatric consultation, which means that nothing happens until the psychiatrist gives his opinion on the case. Another means which physicians can use is to delay giving care as long as possible. Some physicians waited for the couple to come to the same solution as the physician, i.e. to not have treatment, and to not try to have a child. Some stated that this type of difficult patient (not socially proper) is likely to drop out of the queue for treatment without the physician doing anything.

These findings are in accordance with those of Silverman (1981), who concluded that the means the doctor can use when not wanting to give treatment (in case of Down children) are those of: 1) patient selection, 2) doing nothing (non-intervention) and 3) delaying giving treatment. With these patient groups physicians used time as a tool of power and control (Fox 1999). Some physicians said directly that IVF demands that the patient be at a certain intellectual level since the procedure is quite complicated. Mentally ill, alcoholic and asocial persons are not purposeful and patient enough for IVF.

In unclear situations my clinical gaze reveals susceptible patients/women.... Of course one can see it (abnormality?) from their behaviour and way of conversation... and when one finds out what actually lies behind the wish to have a child... then I ask to go to psychiatric consultations where the situation is clarified more... Somebody may have had mental problems I can see it in the medical records. It is an extremely difficult situation and one faces these situations constantly...can I say =You are too stupid to be able to participate in IVF, and therefore we won=t treat you?..... these situations are extremely difficult... Sometimes a man has been constantly in prison, and has been released and they come here and say that they want to have a child... these kinds of things happen, and common sense says that it is much more better that they never will have any child. But it is difficult to say this to them. .. Many times its better to delay giving the treatment... And in the case of alcoholism.. One cannot be like God in determining who is treated and who is not, these situations are so difficult...= (woman, public hospital, H13 p.31)

Some physicians even wondered openly if nature works through psychosomatic processes so that these kinds of people have difficulties in getting pregnant, i.e. nature has already decided that it is not good for them to have children. But if the woman was depressed it was not considered to be very pathological; on the contrary, IVF (and a potential child) was seen as a means to help a woman suffering from depression. (Mild) depression was accepted and seen to be understandable result of infertility.

The Finnish criteria for entering IVF were in accordance with those described in Steinberg=s study on IVF in Britain (1997: 81-82). There IVF clinics have clear selection criteria for IVF/GIFT treatment, which include intelligence, sexual orientation and lifestyle as well as age and attitudes towards treatment. The financial status of a couple is an exception, since in the British context it seems to be good if the parents are wealthy, whereas in the Finnish context it was somewhat questioned whether wealthy and career-oriented parents (specifically the woman) have the capacity to love and nurture a child emotionally. The British IVF/GIFT clinics tend to pick =proper= parents (Steinberg 1997:86), but parents= ability to care for children can change during the course of their lives. One can never be sure that one=s life situation (health, material resources, relationships) will remain stable.

Technology and nature

In this study doctors said that modern people with fertility problem have strong faith in technology. Patients believe that there is always available some medico-technical solution for any problem they have, and therefore doctors have to guide them wisely and paternally or maternally. Couples with impaired fertility many times believe the promise of ultimate transcendence of the infertility problem through technology (also, Davis-Floyd 1990). But many physicians stated that very seldom does a pregnancy start as a couple plans. Nature is always full of surprises and uncertainties, even the physician must be humble before nature and the limits of medicine. One physician even wonders how conception ever happens naturally, since the process is so complicated and failures can occur at every stage (compare to, Franklin 1992). Many said that one has to be humble in front of nature and human reproduction processes, since they include a lot of unknowable issues. IVF physicians said that they only help nature when they take part in the conception process (see also, Franklin 1997:10-11,96,103). Nature was always considered to be party to successful conception, either naturally or with the help of IVF.

Woman=s nature

The body-mind dichotomy as part of the epistemology of biomedicine (Kirmayer 1988, Helman 1997:101) was not supported by all interviewed physicians. Instead the majority admitted that psyche and soma (particularly those of women) are interwoven in reproduction. Nature was seen to be full of surprises and many times beyond the reach of technological control. Many suspected that the woman=s stress due to the infertility experience and due to the treatments may affect the success of treatments but rejected the idea that it causes the infertility. However although they almost unanimously refuted the belief that certain psychological characteristics cause infertility in women, some wondered if bad tempered women will ever conceive. (The impact of a man=s stress on his fertility was mentioned only once, in one anecdote in which a man lost his whole family in a car accident and consequently stopped producing sperm). Some said that the psyche may affect care also through cancellation of the treatment, meaning that the couple cannot stand the tension involved in treatment.

Thus a woman's nature was directly stated to affect the success of infertility treatment and even sometimes the capacity to conceive in general. If the woman was judged to be too tense, or bad tempered, she was not expected to become either pregnant easily or to be successful in IVF.

-What do you think, do psychological factors affect fertility?

- It has not been investigated properly.. but I got the impression when treating these couples, I feel that it does affect it, because I feel that those women with 'too small a hat' (cranky, in a negative mood) never will conceive, those women who have their mouths downward (bad temper, cranky), whose hat is too small and whose forehead has a lot of wrinkles (worried) and those who are very cranky, they will never get pregnant. But those (women) who are very optimistic, they will conceive much easier – I have gotten this kind of impression that they get pregnant easier. (woman semiprivate clinic H9, p.39-40)

The impact of the psyche or stress was described to be seen in spontaneous pregnancy where the woman gives her body to the physician and becomes =regressed= enough in the course of the infertility examination so that she becomes pregnant before any treatment has been given. This is in accordance with the passive sick role position, and with the cultural image of the passive woman (Parsons 1975) and with traditional mother myths (ever patient, passive, loving) (Bassin et al. 1994). Spontaneous pregnancies may happen also after all treatment attempts end and the distress of the treatments disappears, or she may become pregnant in the last IVF attempt when she has almost given up all hope. However, the number of these miracles are few according to the physicians.

. If one is stressed it affects her fertility.. And during these treatment cycles one feels sometimes that some stress is affecting... The implantation of the embryos in the uterus,... Many times it happens that the couple comes for the last IVF attempt, it is clear that this is the last time, and then she becomes pregnant! It is like when the stress has gone and you don=t have to succeed now... And when they have had a long period of childlessness in their past, they get a little cat or dog or adoptive child, and suddenly she becomes pregnant! Or when they stop all treatments, they stop trying, when no diagnosis has been found, and suddenly she recognises that she is pregnant! There has to be some system of stress working at the basic level.= (woman, private clinic, H9 p.40)

Technology usually represents controllability, while nature represents uncontrollability (Honey 1994). Technology is culturally connected with masculine properties whereas nature is connected with the feminine (Ortner 1990, Honey 1994). To use technology is a modern way of coping with and handling problem situations. In the area of reproduction, the use of technology with its masculine associations, has its peculiarities since human reproduction belongs to nature and woman's sphere; hence some culturally interesting tensions are born.

Doctors explained that in modern society people have become accustomed to controlling every aspect of their lives, and when this is not possible - as it is many times in life - they cannot stand the insecurity they face. In the same vein, unsuccessful treatments were felt to be horrible disappointments for people in the =90s. During the early use of IVF in Finland infertile patients in the =80s were said to have had an adventurous mentality in regard to care, they accepted the disappointments better than do couples in the =90s and they had more patience with the treatment. Physicians wondered if people of the '90s are no longer mentally prepared to meet disappointments in life and that they are too anxious to proceed as rapidly as possible in the treatment. According to Franklin's study, among IVF patients (1997:90,96) there is also narrative of hope in which it is hoped that children will be brought into being via scientific progress, with the help of state-of-the-art technology. A narrative of hope conforms both to the conventions of romance, in providing an obstacle to be overcome, as well as the conventions of scientific heroism (ibid. 1997:90).

This may indicate the modern health care consumer's faith in technology as the solution for his health problem (Calnan & Williams 1996 ). This attitude is connected with the entrepreneurial culture even in the area of reproduction where there are various ways to have a child between which one may choose (Strathern 1992:36,38,148; Franklin 1997:96 ). This trend may be particularly true in the case of infertile patients who are young and not usually seriously ill, making them potential competent actors in health care. Additionally they have been shown to be less satisfied with infertility care than is the case with clients of other services (Malin et al. forthcoming ). In physicians' talk this representation of the assertive consumer reached its peak in the form of the ambitious career-oriented woman who wants to have a child, like any other material commodity, with help of ARTs.

Although the physicians stressed the role of nature in reproduction, some still saw IVF technology as a reproductive supertechnology which overcomes nature. Some stressed the possibility of control over a woman's bodily functions through hormone medication which chemically suppresses the woman=s own bodily systems; thus the impact of the woman=s psyche on her metabolic system becomes limited. The success rate of IVF was considered to be the best when compared to other treatments and even when compared to the monthly pregnancy rate for fertile couples (often a 30% pregnancy rate was given). Many said that the success rate for IVF could not be better than that for natural pregnancy. Still there remains one problematic moment in IVF which is the implantation of embryos in the woman's uterus; some physicians wished there was an 'embryo glue' to hold the embryo inside the uterus for a full term. In sum, physicians either naturalised IVF technology in the sense that they represent it as only way of helping nature, or they re-naturalised the process of human reproduction claiming that it is a miracle that conception ever happens naturally.

After the last IVF attempt the feelings of the couple were described by physicians to be those of 1) deep sorrow and disappointment and 2) an emotional relief that they had tried everything possible and that to remain childless is their destiny. But some even continue to call to the physician afterwards when new medical innovations have been invented to find out if this particular method can help them with their infertility. The infertility experience was seen by IVF physicians as human suffering, worth alleviating with any available medical means. IVF was considered to be a good way of coping with infertility when a couple - a woman – has exhausted all treatment options. The couple's successful navigation of the psychological crisis of infertility and the treatment was seen to make them more mature as individuals, as a couple and as parents than they would be without this experience. This psychological crisis meant suffering which made the couple better in a moral sense, more mature, serious and more ideal parents-to-be (also Frank 1993, Charmaz 1999a-b).

The suffering of the couple also legitimates rapid medical intervention: physicians said it to be torture to have queues for IVF. This tradition of valuing suffering has religious connotations, too, making some sense of human suffering in general. Doctors also thought that through the suffering of childlessness the relationship of the couple may strengthen and become more mature than before, but in the worst case the couple may separate. The treatments might even be disrupted due to divorce, resulting from the infertility crisis being too hard to live with.

In physicians' understandings, while suffering from childlessness one has be optimistic in regard to technological treatment, and be compliant, co-operative, motivated and highly committed to the infertility care in order for it to be successful. If one (a woman) is pessimistic, bad tempered, highly worried, very tense, nervous or distressed, success is less likely. Usually suffering is considered to involve seriousness, misery and helplessness. This contradiction is interesting: How can one suffer optimistically? In part, this can be understood in terms of =public gift-giving= (Titmuss 1970, Fox 1995) or impersonal reciprocal exchange (Bauman 1997:92) where the patient gives her gratitude and positiveness to the doctor, in return for medical treatment. Furthermore, this optimistic rhetoric is common and connected to the recent individualistic cultural rhetoric in which everything is seen to depend solely on the individual herself. Consequently if one fails in treatment this =demand for optimism= may indicate that it was the patient=s own fault, she was not optimistic enough to be able to conceive or she did not try hard enough.

People have invented their own uses for IVF, too, as the physicians have seen some couples say they wanted multiple pregnancies so that they could have all the children they wanted. A common risk with successful IVF is multiple pregnancies, which happened in about every fourth IVF-pregnancy in the early 1990s (Gissler 2000). Physicians think that patients do not seem or do not want to understand the medical risks and social burden of caring for many - in many cases - premature babies (who have a risk of being disabled when they are older) (see also, Price 1992a-b), but it may be that they take this risk consciously (also Franklin 1997:110).

'.. when I tell about the risks of IVF, because when you inform (patients) about the care you have to tell about every possible risk, many times I feel that the patients don=t want to hear the risks, because the thing is so important (a wish to have a child)... and when I have told about the risk of having multiple pregnancies, they say to me that it is not a risk at all, that they actually wish to have a multiple pregnancy, it is clearly the wish for many even if they are ashamed to say it openly.= (woman, public clinic, h11)

Discussion

Clinical decision-making is marked by moral discourse (Annendale 1998:274). A physician's medical judgements are grounded in his value judgements about the patient based on the patient's gender, social class, ethnicity, age, physical attractiveness and the type of illness (Lupton 1995:123-124). But physicians' personal judgements are also shaped by their interaction with the patient, and the social attributes of both the physician and patient shape their interaction (Annandale 1998:274) as do their different experiences and perceptions concerning childlessness, infertility and infertility treatments (Toombs 1993). Physician makes the clinical judgements, he has a monopoly on medical knowhow concerning infertility, and he has the power to determine how and whether to proceed in treatment.

Health care personnel has been shown to have models of a =good= or =bad= patient, which they use to make judgements about patient care (Stein 1990). A health care personnel=s unofficial moralistic taxonomy of types of patients has an impact on the ways in which patients are treated (Stein 1990:98). =Good= patients are described to be those who are not culpable for their illness, they respond quickly to treatment, do not question the treatment or doctor=s status and are compliant. Conversely, =bad= patients are those who can be seen as responsible for their illness, they question the treatment, are not compliant, and are too demanding, even hostile and question the authority and competence of the doctor (ibid. 1990:98). Demanding and difficult patients can be those who have a social position similar to that of the doctor and who consequently behave assertively. Additionally, =bad=, difficult patients can be those of less advantageous social position who feel uncomfortable with a higher status doctor and thus behave assertively or noncompliantly (see also, Martin 1987). But ultimately, the patient is dependent on the care provider, the physician - what the Finnish patient can do is file complaints and change doctors.

The IVF specialists determined the Other in infertility treatment – 'the bad', the less appropriate patient and prospective parent - according to the gender, social class and psychosocial situation of the subject. Firstly, the gender of the patient made a difference in infertility care as in reproduction in general. The woman as a patient and a mother-to-be was the main focus of the physicians' talk. The ideal woman patient and mother-to-be was supposed to be of a proper age, living in a stable heterosexual relationship, of good temper, not too work oriented and healthy in the mental and physical senses. 'Bad', less appropriate women patients and mothers-to-be were described to be those who were older, lonely, non-heterosexual women, married women who are too career-centred, cranky pessimistic women, and women with social and mental problems or who has a partner with these problems.

Women were seen both as potential abusers of their partners, putting pressure on their husbands to use AID, and using frozen embryos without his permission, or they were seen as victims of their partners, as when a new husband wants a child so eagerly that he will even request the use of AID when the wife already has children from a previous marriage. Women may be seen to be victims also when the cause of infertility is located solely in her partner, and it is she who undergoes all kinds of treatment. Furthermore, physicians saw women sometimes to be too passive in treatment and on the other hand, sometimes to be too active, neither of which was considered to be a proper quality of a good woman patient.

Secondly, the social class of the patient and the parent-to-be made a difference in the physicians' judgements. Highly money- and work-centred people, who are often from higher social classes, were seen to be difficult patients and improper parents, incapable of loving and nurturing their children. They were seen as people for whom a child may represent one material achievement among other pursuits in their lives and for whom work comes first in life. This type of patient may have a resemblance in a British study on modern infertile patients who according to Franklin (1997) have an entrepreneunial mentality regarding IVF. These couples may be those IVF patients in the 1990s who had high faith in technological solutions and tfor whom it was hard to stand disappointments in treatment.

In contrast, =ordinary couples=, the patients from the lower and middle social classes, were seen to be =poor= heroes (with less resources) sacrificing all in pursuit of having a child. Thus they were evaluated as good patients and parents-to-be since they do whatever the doctor says and they literally give up everything for the sake of having a child. Here money has a morally positive meaning in terms of giving all one has for the sake of having a child. This is a somewhat peculiar characteristic to find in Finnish society and culture, since due to welfare policy the social class differences are not strong and even upper-class physicians are in favour of equality in society (national social insurance system reimburse one part of cost in the private clinic).

But there were some contradictory perceptions in regard to patients= social class, since on the other hand upper-class people were considered to be intellectual and purposeful enough to participate in IVF, and they know more about the treatment possibilities and how to search for care. Lower-class people and people from peripheral parts of Finland were seen as potentially lacking knowledge about treatments and the intelligence to participate in them. Social class was also seen as reflecting the quality of a person's genes. But still, many stated that it is good for the sake of social equity that treatments are available in public clinics to all despite their social class.

When a career and motherhood was combined it was considered to be horrible fate for the child. Furthermore, the bad mother stereotype was that of a lonely woman who wants to use a child as a remedy for her loneliness. Additionally, women who are mentally ill or have serious social problems, with or without a partner, were considered to be bad mothers (and victims of their life situation at the same time). In the psychoanalytical sense a mother is able to give life (delivering a child, letting go) but also to take life away from her child (absorbing it inside her womb, suffocating) (Rich 1981:67, Vegetti Finzi 1996). This is in accordance with the culturally split image of woman, i.e. she is either good or bad, a masochistic 'Madonna mother' or a sadistic stepmother (Vegetti Finzi 1996, Hautamäki 1999). This image of the selfish career woman or desperate lonely woman (or in the worst situation a mentally ill woman with many social problems) may reflect the cultural image of a bad, destructive mother who is capable of killing her children at least emotionally. (The metaphor of the selfish =career mother= is in sharp contradiction with traditional western good mother myths (Phoenix. & Woollett 1991, Bassin et al. 1994)). But physicians favoured as infertility patients neither women who behaved according to a passive traditional woman stereotype nor those who behaved as demanding assertive consumers. Obviously, doctors preferred women patients to display a proper combination of passive and active behaviour in treatment..

Thirdly, psychosocial situation of the patient and parent-to-be made the greatest difference when physicians defined the proper infertility care subject. Social problems like alcoholism and criminality, and serious mental illnesses were seen to exclude a capacity for parenthood and for infertility patienthood. These people belong in many cases to lower social classes. There could be a belief among physicians that these problems may be passed on to their offspring if not by genes but thorough environmental factors. Particularly physicians in public clinics were anxious in front of these kinds of people, they said that physicians have no right to determine who may access infertility care and who may not, but society and a child have rights in regards to the parents= capacity to take care of a child. In private clinics doctors seldom meet these kinds of people. Physicians act in these kinds of situations as protectors of the unborn child and as gate keeper on behalf of society. In the same sense, Finnish infertility physicians join the category of professionals who determine what proper or normal parenthood is and control entry to it (also, Steinberg 1997:88). These physicians' moral judgements may reflect the general importance of a child's Origin which is seen as being endangered if the woman is not an appropriate mother. The mother (yet) knows the origin of the born child (mater semper certa est) and the child's identity will be based on this knowledge and relationship with the mother. The most crucial question here is what kind of woman is allowed to have knowledge of a child's Origin.

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