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Meditations on the History of ART
by Marcia Kupfer

ART stands for "assisted reproductive technologies." I discovered this when my husband and I confronted the hard fact of our secondary infertility. Perhaps it is because I am an art historian that the invention of another referent for "art," already so charged with meaning, captured my attention. The new usage, albeit peculiar to the medical profession, seems as much an extension as a jarring displacement of the word's conventional semantic range. Whether originally intended to do so or not, ART puns on notions of creativity and skill, ingenuity and artifice through which we humans act upon and transform the "found" order of things in the everyday world. The acronym cleverly plays on the tension between the colloquially opposed categories "art" and "science." Closely related terms in Latin for describing knowledge, ars and scientia have come to represent antithetical branches of learning or fields of endeavor. Self-consciously or unconsciously, ART positions the practice of medicine somewhere in-between, unmasking the pretensions of ars medicae, the healing arts, to science or, vice versa, masking the aspirations of scientific control to art. The age-old debate over the artist's proper task could just as well be applied to the physician: improve on or compete with nature, respect or challenge it?; find harmony with nature or bend "her" to "man's" will?
     Artists and the coterie of specialists who govern art's institutions, like physicians and ethicists, exploit and advance reproductive technologies on which they seek, at the same time, to impose limits. Old master and impressionist paintings are copied in the medium of ceramic tile for a Japanese art collection; motifs from Edo screens and Ming Dynasty scrolls unfurl on fancy scarves in museum boutiques; details of altarpieces surface on Christmas cards, miniatures from illuminated manuscripts in date-books. The digital imaging processes of the Cyberspace Age turn all objects virtually into a genre of clip-art. As numerous commentators have observed countless times, reproduction begs questions of authenticity, place-value and ultimately ownership. Images, excerpted like genetic material from more complex entities, give life to the consumer products by which we measure the success of our seasons. Extracted, interjected, transferred, reconfigured as so many different identities...exactly what in "art" belongs to whom?
     Armand and I had easily conceived our son Ira, born in August 1990, but our concerted attempts to conceive again proved unsuccessful. By early 1994 we had embarked on a course of medical treatment that included cycle after cycle of intra-uterine insemination (IUI) and then of in-vitro fertilization (IVF). After years in which art had constituted my object, my body became an object of ART. I "worked on" medieval churches and their paintings. Now I was worked on - probed, analyzed, interpreted. Once, I did achieve pregnancy, only to suffer a miscarriage at ten weeks. My response to this blow was to persist with yet another annual round of expensive, high-tech interventions, each of which failed. The more I tried, the greater my exasperation and sense of defeat. I knew, as I turned forty-one, that my prospects for becoming pregnant were dwindling (in direct proportion to our savings). Slowly, and with great reluctance, I began to give my body permission to claim victory. ART, in my case at least, could not prevail against the power of nature. Yet under no circumstances did my evolving acceptance of the inability to conceive mean acquiescence: on the subject of another baby for our family, biology was not going to have the last word.
     What makes my story worth telling is not some uncanny insight I have gleaned from a painful journey. Its tropes of willful, almost obsessive, determination and profound despair are all too familiar to women who have suffered infertility. Rather, I undertake this risky literary venture on account of the form in which my self-reflection takes shape. Fragments of recollected experience crystallize in terms of images that I have encountered in my research as an historian of medieval art. Images from the distant past are so deeply burrowed into the recesses of my consciousness that, fantastically transfigured, they sometimes invade my dreams. There, in sleep, I marvel, the amazed spectator of wondrous new artworks from a world long since vanished. While historians today examine how being embedded in a particular cultural moment may color their own (or their predecessors') interpretation of the past, I find myself performing the inverse operation. Thus study of the Middle Ages, spilling over into the disparate arenas of my life, becomes a prism through which I revisit my infertility. The writing of history weaves the life and times of others into art. Turning my practice as a historian to my own life, I offer the following bricolage of iconography, anecdote and critique.

The Cult of the Clinics

Fig. 1.

From the window of her cell, Saint Radegund expels a demon from the possessed woman Leubile, miniature painted c. 1100, Poitiers, Bibliotheque municipale, MS. 250 (Life of Saint Radegund), fol. 35r.

Fig. 2.

Saint Radegund cures Bella, from the same manuscript, fol. 34r.

     My first encounter with ART occurred in June 1993 on a trip to Norfolk, Virginia where I had an early morning appointment to examine twelfth-century sculpture in the collection of the Chrysler Museum. I spent the night at a pleasant Bed and Breakfast near the museum. The next day, I met two women conversing over coffee and blueberry muffins. With the same blase nonchalance one might remark on the local weather, they were comparing their husbands' sperm counts. They had traveled here from Istanbul in order to undergo IVF at a well-known clinic also within walking distance from the B & B. Their husbands, having completed that part of the protocol for which their presence was necessary, had just returned home (they had important jobs). Another cup of decaf, more vital statistics: how many follicles their ovaries had produced, how many eggs retrieved, how many fertilized, how many times the embryos had divided so far, their grades. Both women were anxiously awaiting embryo transfers: how many would be put back in the womb, how many frozen for later use? The proprietor-hostess replenished the tray of muffins...she knew the routines. What planet had I landed on? But it was not so much the unfamiliar talk or its incongruous setting that disturbed me as the eery feeling of its personal relevance.
     At once unsettled and intrigued, I began to ask questions. Armand and I were having unexpected difficulty conceiving a second child. Testing indicated a "male factor," I confided. Armand's urologist suggested that the problem could easily be corrected by a minor surgical procedure. We would then have to wait about three months to see whether motility and count would improve. Don't bank on it, my breakfast company warned; the same procedure had been performed on their husbands but turned out to have little or no impact on sperm quality. So I listened intently as each woman described her couple's medical history, their infertility work-up, their daily regimen of injections, ultrasounds and blood-levels, the number of attempts at IVF in Norfolk and elsewhere. The price-tag? Approximately $10,000 per trial - not including fertility drugs (add some $2,000) or lab "extras" like the micro-manipulation required to inject a single sperm directly into an egg (intra-cytoplasmic sperm injection, or ICSI, another $3,000). I began to feel slightly nauseous and left for the museum, my head spinning. Although I had come to Norfolk to look at miscellaneous stone carvings scavenged from the distant past, I now stared aghast at my future.
     Several months later, under pressure of my thirty-ninth birthday and disheartened by the predictable failure of the surgery, Armand and I decided to advance a notch in the hierarchy of resort. Well-meaning urologists and gynecologists were competent in their own respective spheres but I needed advice of a higher order; most of all, I wanted results. We then did what people seeking relief from physical ills have done since time out of mind. Leaving behind the village soothsayer and empiric, we heeded the irresistible call of the pilgrimage roads and made our way towards the shrines that reported the greatest numbers of miracles.
     Where would we find the mightiest wonder-workers? Fortunately, shrine clergy carefully tracked the successes of their resident luminaries. Saints not performing to standard, not maintaining respectable quotas of cures and punitive strikes, would eventually lose their luster. They could be humiliated, their bones dumped unceremoniously onto the sanctuary pavement. Should they still refuse to come to their senses, they might even be abandoned by their custodians. Saints had to keep up, or face obsolescence. Inventio, the ritual finding of new relics, kept old patrons in line, motivating them to tackle each scourge and every bout of pestilence. Competition has historically proved a powerful incentive. If saints put out for their sanctuaries, surely ART doctors would do the same for theirs. I had faith in the system. Armand and I completed the requisite battery of diagnostic tests at the end of 1993 and began treatment in early 1994 at a clinic in the Washington D.C. area where we lived. The slight variation in pregnancy rates elsewhere did not seem to justify the considerably greater expense of travel and disruption to our daily life. In the end, pragmatic constraints make most pilgrimage (like politics) a local affair.
     Since male factor infertility in our case had an unknown etiology and since Armand had in fact fathered our son four years before, we decided to try a few IUI cycles on the off-chance that perhaps sperm quality had not really changed all that much in the intervening period. While pursuing this low-tech procedure, I would boost my fertility with the cheap, easy-to-take pill, Clomid. Perhaps we might "get away" with this less aggressive, more economical approach. A few thousand dollars later, however, we graduated in June 1994 to IVF with ICSI. The fears stirred in Norfolk the previous June had come to pass.
     At the time of my experience with ART, IVF had a success rate of around twenty percent under the very best circumstances. Couples in which the female was well under thirty-five and had good ovarian function and the male, punchy sperm might have a decent shot at a baby through IVF or one its variants. The more eggs harvested and fertilized, the more embryos developed, the greater the chance of achieving a pregnancy (eventually). The particulars of our secondary infertility, however, made for a grim prognosis. Two obstacles combined to present an intractable case: the fact that I was approaching forty handicapped the treatment of male infertility. Women in my age group could expect to produce fewer eggs under ovarian stimulation, not all of optimum quality. Then, in order to maximize fertilization, the retrieved eggs would be subjected to the technique of ICSI. Probably not all the eggs would be fertilized and, of those fertilized, not all would necessarily progress further into multi-cell embryos. But the real blind-spot in the IVF process followed embryo transfer. What fostered or impeded implantation was anyone's guess.
     Taking into account these variables, IVF increased our chances of achieving pregnancy from zero to around sixteen percent. The chance, however, of actually having a live birth decreased to around thirteen percent, since miscarriage (as in natural conception in my age group) remained a possibility. According to my rough calculations, Armand and I had at least as much chance of a successful outcome as did the infirm who congregated around the tombs of medieval saints. If anything, holy bodies reposing in their reliquaries had a better clinical record. ART indeed improved the hand that nature had dealt to some couples, but the desired result, a baby, was still a distant prospect. Yet we desperately hoped for a miracle. Every other couple I met on the fertility circuit prayed that they, too, might rank amongst the chosen on the right side of the statistical curve. There were no unbelievers.
     The negative pregnancy test, accompanied by the very negative balance on our bank statement, jolted me back to the late twentieth century. "Now what?," I asked the medical director of the clinic, fighting back tears.
     Unsurprisingly, he recommended a second attempt; we should look at the first cycle as a trial run.
     "But it's so expensive, basically we'd be gambling away another $15,000."
     "You know," he replied, "children are an enormous financial responsibility; maybe you can't afford a second one."
     Taken aback by the doctor's caustic remark, I pretended not to register its weird logic. Instead, I pursued a rather different line of inquiry. "Since the main impediment in our case is sperm quality, what if we tried IUI cycles using donor sperm?" Indeed, the clinic's specialist in male infertility had from the start proposed both this method and adoption as alternatives to IVF. "Wouldn't I have a better shot at becoming pregnant than by repeating IVF?" I persisted.
     "Yes," he brushed me off. Little did I know then that to refuse the newly invented remedy for male infertility was tantamount to heresy.

The Wheel of Urines

Fig. 3.

Wheel of Urines, miniature painted c. 1420, London, Wellcome Institute Library, MS. 49 (Wellcome Apocalypse), fol. 42r.

     My birthday came and went, forty years too quickly spent. Forty is a magic number. The Judeo-Christian tradition appoints it the ultimate figure of liminality, a term anthropologists use to describe the transitional phase in rites of passage. Before attaining a new status within the community, an initiate undergoes a dynamic process of change during which he or she is set socially apart and often remains physically confined to a discrete sphere of existence. This interim stage of separation, which follows exclusion or withdrawal from society and precedes re-integration on different terms, may be fraught with uncertainty, even danger. The interval between conception and birth, forty weeks, yields the archetypal measure of suspended transformation; the developing fetus embodies the ambiguous state of abeyance between non-being and full identity.
     God caused it to rain upon the earth forty days and nights, cleansing "his" creation of every breathing thing outside Noah's ark. Over time the flood waters subsided and finally, "...on the first day of the tenth month, the mountain peaks appeared. At the end of forty days Noah opened the porthole he had made in the ark...(Gen. 8:5-6)." [After nine months, the womb opened and a new world came forth, head first.] The Hebrews wandered for forty years in the desert until a generation that had never known slavery crossed into the promised land, a people reborn. Jesus fasted in the wilderness for forty days before assuming his ministry. The Levitical injunctions (12:1-5) designate the period of a woman's postpartum purification as forty or eighty days depending on whether the infant is male or female.
     Along the continuum of a woman's reproductive life, forty is the age that ART specialists have designated as the benchmark in the inexorable decline of natural fertility. A single point thus stands for the transitional years in which the mature female body, no longer in its prime but not yet depleted, marks time before finally reaching menopause. Why forty rather than thirty-eight or thirty-nine? An arbitrary cut-off based on science, or on the convenience of a figure now so culturally diffuse that its ancient symbolic charge goes unnoticed?
     Magic has its uses. When my biological clock sounded its alarm, a way opened in the marital union for recourse to donor sperm. Unorthodox though it was, Armand and I decided to proceed by technologically reversing course. We returned to Clomid and artificial insemination but now enlisted the assistance of a few surrogate cells picked out from a list of numbers. It was a difficult and emotionally wrenching choice for us both. The sense that we were somehow going against the professional grain only made it more stressful. During one procedure, a nurse held up the vial of sperm, read the number on the label and asked,"Is this the man we want?" I responded that I did not regard the bodily fluid in the tube as a man. Odd, I thought. Although the practitioner was accustomed to dissociating genetic material from the women who donate eggs or provide surrogate wombs, she glibly conflated sperm with the male person who was its source. Yet her words spoke nonetheless pointedly to my residual feelings of guilt. Had insemination with donor sperm demoted me to a less-than-faithful wife? I felt ashamed.
     Five cycles brought us to mid-January 1995. Meanwhile, on January 1, our medical insurance policy changed. We had switched health plans so as to take maximum advantage of a new Maryland law. The state that underwrote Armand's employee benefits now mandated full insurance coverage of three IVF attempts per couple per lifetime. If the IUI cycles proved unsuccessful, we would have the option of trying IVF at a different clinic, one which our managed care provider authorized. True, our insurance would not cover injectable fertility drugs or the then still "experimental" technique of ICSI. But at out-of-pocket costs of "only" $5,000 per trial, as opposed to $15,000, IVF seemed like a bargain.
     Soon after the last IUI, we went for our first consultation at the pre-approved clinic, associated with a major hospital in downtown D.C. Since the hospital pharmacy had a limited stock of the fertility drug Pergonal, in high demand and short supply everywhere, we purchased a few boxes in the event we decided to "cycle." (In conversational ART-speak, "cycle" is a verb as well as a noun, just as ICSI is both a verb and an adjective, as in "to ICSI" the eggs, or "ICSIed" eggs). Two weeks later, however, I found myself going to the clinic not for IVF but, with no menstrual period in sight, for a pregnancy test. It turned out positive. At last! Relieved and thrilled, I returned the unopened boxes of Pergonal.
     The weekly count-down to which I had so long looked forward had begun. Forty, thirty-nine, thirty-eight... thirty-four...ultrasound at the clinic...thirty-two, first OB appointment, thirty, twenty-nine... And then, late one Saturday afternoon, blood everywhere, dreams awash in an unmerciful gush of bright red waste. When the emergency room staff confirmed the miscarriage, Armand wept. The absence of his genes in the fetus I carried had in no way diminished his profound sense of loss. Numb with grief, I continued to count the weeks. How many would it take for my body to heal so that I could resume my place on the fertility treadmill?
     June 1995. Two years after my initial contact with ART at Norfolk and we were still at ground zero. I had proved I could become pregnant with IUI and donor sperm. Should we return to this method or go forward with IVF? The physician on whom we now relied persuaded me (skeptical though I was) that my age warranted the most aggressive approach possible. I had, after all, crossed the threshold into the over-forty category. In any case, I had taken Clomid many more times than he believed was advisable (a risk of cancer increased with sustained use). As long as I would have to take injectable fertility drugs like Pergonal or Metrodin, why not do an IVF cycle for which we had the insurance coverage? To ICSI or not to ICSI? That was my question. He adamantly and persuasively argued that our best chances for fertilization lay in using the ICSI technique with Armand's sperm, rather than in combining my eggs with donor sperm in a "natural" IVF cycle.
     The start date of an ART cycle is closely correlated with the onset of the menstrual period. My short-lived pregnancy had ended with an unwanted flow of blood. Now the regular monthly event I dreaded most was the signal I eagerly awaited. I kept watch for the red flag that meant I could now try again. Maybe this time we would get lucky. The fertility circuit converts endings into new beginnings, a source of comfort and, at least for me, a compelling force for repetition.
     At the appropriate point in the cycle, Armand began twice daily to give me intramuscular injections in the hip. There was evening and there was morning, the first day of many in which a powerful fertility drug surged in my veins. The pharmaceutical contained reproductive hormones that control the ovaries (organs also called gonads) so as to stimulate the growth of the follicles, or cellular pockets, in which the eggs develop. These hormones were extracted and purified from the urine of post-menopausal women, who happen to secrete high amounts of natural gonadotropins. During the era of my involvement in IVF, the necessary hormones were not yet manufactured synthetically through recombinant DNA technology. Urine was the only source for the industrial production of human menopausal gonadotropin (hMG) preparations like Pergonal or Metrodin. Clearly the historical preoccupation with urine, the medieval physician's main diagnostic tool, had paid off.
     ART, it thus turns out, is a recycling program. Hormones recovered from the excreta of older women enhance the fecundity of younger women. When a girl becomes nubile she bleeds from her vulva, and when menstruation ceases the by-products of her former capacity for reproduction are expelled through the same orifice. From blood to urine, and with injections of hMG, back to blood. As medieval people had known all along, female effluvia are life-giving substances. Women supply the blood, the very matter, from which they first concoct the fetus in their oven-wombs and then the breast milk, twice-cooked, for nursing the baby after birth. Even the superfluous blood released in menstruation can play an important role in procreation. Beatrice de Planissoles, a noblewoman who lived during the late thirteenth- and early fourteenth century in the southern French village of Montaillou, took special precautions to ensure the viability of her daughter's marriage. She kept cloth that had been soaked with the girl's first menstrual blood, a precious elixir, so that one day she might remove some to mix into the drink of her son-in-law, thereby guaranteeing his marital fidelity. I doubt Beatrice would be surprised to learn that ingredients distilled from her own urine might prove useful in the generation of her grandchildren.
     Especially interesting to me, however, is the purported role of nuns in the manufacture of Pergonal, the oldest hMG preparation on the market. In the late 1950s and early 1960s, the Instituto Farmacologico Serono in Rome (a subsidiary of the Swiss pharmaceutical firm Ares-Serono) obtained eighty thousand liters of urine from post-menopausal nuns and other women in rural Italian communities for the extraction of reproductive hormones. Why the selection of cloistered women as "naturally" the most suitable or expedient source of urine? And what lies behind their donation to Serono: a love of science, an exchange of gifts? The nuns' contribution to the production of a highly purified fertility drug, however ironic, makes perfect sense to a historian of medieval culture. The more radically that holy women of the thirteenth and fourteenth centuries sealed off their bodily cavities, the more miraculous their bodily exudings. The sweat and saliva of starving virgins cured infirmities, and their divinely induced lactation provided sustenance. Surely it seems only a matter of time before a pharmaceutical company tapped into convents for urine from female bodies practiced in renunciation and transformed by charity. Who else but older women vowed to chastity could possibly eliminate waste that might heal the infertility of younger women? The Serono program merely extended a deeply ingrained tradition of spirituality, not to mention ancient principles of sympathetic magic, in a new direction. Did technology reactivate a cultural memory, long dormant perhaps, but never totally eradicated?



Fig. 4.

A barber surgeon bleeds a woman, woodcut in I-Eeronymus Brunschwig, Liber pestilentialis de venenis epidimie. Das Buch der Vergifit der Pestilentz, printed by Johann (Reinhard) Gruninger, Strasbourg, 1500, fol. XXVv.

    In giving over my body to ART I became a member of an order, the demanding protocols of IVF a rule that set me apart from the work-a-day world of ordinary folk. I opened my Book of Hours at 5:30 a.m. with the meticulous ritual of injection. First Armand and I had to mix the precise amount Pergonal or Metrodin powder with sterile solution. I snapped open the glass ampules containing each substance. Armand did the needlework, drawing up the solution into a syringe, infusing it into a vial of powder, again drawing up the now dissolved medicine, infusing the liquid into several more amps of powder. Armand replaced the thick mixing needle with a long, thin and equally terrifying one. While he removed residual air bubbles by flicking the side of the syringe, I pointed to a spot just slightly to the back of my hip. Armand aimed and lunged. I gritted my teeth against the pain that began my day.
     By 6:00 a.m. I was out the door, headed towards the metro and the clinic for monitoring. At 6:45 the waiting room was already crowded with women. Each of us wondered in silence about the follicles proliferating in our ovaries. No chatty coffee klotch and no blueberry muffins here. The ultrasound technician brought the shadowy image of my ovaries onto the screen and I waited with baited breath as she counted and measured the bulbous black blobs, each of which potentially concealed an egg. The more follicles, the more eggs, the better our chances... Then on to the lab technician for "blood work" so that hormone levels could be ascertained. Another line to attend. Which technician would draw my blood today? Some were so adept that I hardly felt the needle, others so heavy-handed that thirty seconds seemed an eternity. Back on the metro. When I finally sat down to my work around 9:00, I was exhausted. Between 3:00 and 5:00 p.m. I waited for the nurse to phone with instructions based on the physician's review of the data. 6:00 p.m., vespers: Armand and I repeated the injection ritual, thus concluding the office of IVF for the day. So we continued until, in the fullness of time, the follicles abounded and grew fat and my blood was saturated with the stuff of their ripening.
     Finally the evening came for Armand to inject me with a different pharmaceutical preparation. It contained human chorionic gonadotropin (hCG), the hormone secreted by the placenta during pregnancy. Bringing the eggs inside the follicles to maturity, the hCG would trigger ovulation twelve hours later. The scheduling of the injection therefore had to be precisely coordinated with the next phase of the IVF cycle, egg retrieval. Using an ultrasound-guided needle, the physician had to aspirate the eggs just before the follicles naturally ruptured, or the eggs would be released and "lost," the cycle ruined. Time was of the essence.
     Now "our" clinic was associated with a hospital, and egg retrievals were performed - of all places - in the maternity ward. The elevator doors opened to a view of the nursery full of beautiful newborns. Was this supposed to be inspiring? No, convenience and efficiency dictated the set up: women in labor and women in the IVF program could to some extent share the same medical equipment and staff. The juxtaposition of the "coulds" and the "could nots," however, always struck me as more than a little cruel. True, successful ART patients might find themselves returning here in nine months but the vast majority of us would never make it to the delivery room. Indeed, by the time I got to this point in my second IVF cycle, after having miscarried some eight weeks earlier, I could not even bear the sight of pregnant women. The longing, the frustration, and oh yes the envy were just too overwhelming. I had to avert my eyes from bellies and babies; had to shut the openings through which I felt most vulnerable and, like female saints of yore, close myself in to gain some semblance of control over my life.
     Armand and I were led into one of the birthing rooms where the anesthesiologist administered an epidural. Five years before I had an epidural during labor with our son. Now I belonged to the other group, from whom nature withheld the fruit of the womb. I was wheeled into a room down the hall. My doctor and his assistants were ready for the routine procedure, the technicians in place in the adjoining IVF laboratory ready to receive the eggs. Then the unthinkable happened. A woman in labor with twins was rushed into the adjacent delivery room; the obstetrical staff needed the one and only ultrasound machine on the floor. We would just have to wait. The eggs in which I invested my shattered hopes for another chance at pregnancy might be lost. My doctor, clearly irritated by the predicament in which we found ourselves, was as helpless as I was motionless.
     "You do understand, don't you, that in there it's a matter of live babies," he reasoned. "These, well, are just eggs."
     "Doctor," I managed to reply, "this is a big hospital. Isn't there somewhere another ultrasound machine we could use."
     "No. Not one of the right sort."
     "I hate to bring this up, but" [given the hefty fees patients and some insurance companies shell out for IVF - a thought I kept to myself] "don't you think you might buy another machine... I mean, couldn't there be two ultrasound machines..."
     "Well maybe now. This never happened before."
     I listened, intent upon the sounds coming through the door that connected the IVF procedure and delivery rooms. Voices were coaching, she was pushing and screaming and pushing and screaming. At last, applause accompanied a baby's cries. The ultrasound machine, no longer needed since the second baby was on its way, was freed for our use. Twenty minutes to the twelfth hour. The team worked fast. The follicles were intact; the eggs were still there! The harvest went forward. Meanwhile, in the next room, the second baby was born to another round of applause. Drifting into the nether regions of my darkest despair, I knew in a flash the utter futility of all my extraordinary efforts at pregnancy.
     "Why those tears?" one of the nurses asked me. "You just got six eggs."
     The specialist in ICSI went to work on my eggs and Armand's sperm. In twenty-four hours we would hear from the IVF coordinator about fertilization and thereafter about embryo transfer. Two days after the retrieval, Armand and I returned to the maternity ward for phase three of the cycle. A nurse, freshening up one of the birthing rooms just vacated, carried out congratulatory balloons and flowers. Not for us; we had three embryos. At least this time I would not have to compete for an ultrasound machine, as the transfer required none. We were all in a lighter mood. As the embryos were pipelined into my uterus the doctor joked about his recollections of the art history course he had taken from the legendary professor Horste W. Janson, whom I knew only through the famously lucrative textbook he had authored. I had to refrain from laughing in the hope that the embryos would settle into the plush uterine lining prepared to receive them. Finishing touches on a work of performance ART, the collective enterprise of anonymous master craftsmen in the lab and of countless invisible women whose secretions made possible my own. A postmodern story familiar to every medievalist.
     Two weeks later, I went back to the lab for a blood test that would determine whether or not implantation had occurred. Positive for pregnancy or negative? The six excruciating hours I waited by the phone for the results capped an excruciating fourteen days of wondering if the embryos were still there, of imagining cell division, of hoping... Finally the phone rang. "I'm very sorry," the IVF coordinator apologized, "it's negative. Stop taking the progesterone and you'll get your period within a couple of days. The doctor will call you and you can come in for a post-cycle consult." Why hadn't those embryos implanted? Maybe this or that movement in the recovery room had disturbed them; maybe I shifted my position too much in the first twenty-four hours; maybe I doubted too much. Maybe if I had a more positive attitude... I momentarily buried my sorrow in order to pick up Ira from his pre-kindergarten class. Tearing out the school door into the June sun, he rescued me from the crowd of all those moms pregnant two and three times over. I would not be one of them.
     From blood to urine and back to blood. Thousands of dollars' worth down the sewer, I thought, as I flushed the toilet. Women's monthly bleeding is a calendrical system, an involuntary periodic flow that keeps time in accordance with the moon. No wonder, then, that the voluntary letting of blood to restore humoral equilibrium was aligned with heavenly bodies whose movement divided day from night and one month from another. Zodiac Man may claim to represent a universal medical standard for the practice of phlebotomy. In fact, however, his is but a mirror image of the power that Nature vested in the rhythms of female bleeding. How to appropriate the power of woman's fertility is a matter for Culture to answer. Gazing into the sky, I could only rail against my fate. I was locked in a cosmic struggle. And I was losing.
     Why did the IVF cycle fail? The postmortem conference with our doctor provided no information. What else was there to do but repeat the procedure; we had coverage for two more attempts. We looked at the calendar trying to predict when my next period would begin so as to get a sense of when we might cycle again. We would then make our summer plans. During my two years in ART I had grown accustomed to scheduling my professional activities and family vacations around my menstrual periods, count-down for all fertility therapy. My body may have held me captive to its reproductive tides, but I was a willing and docile hostage. At our clinic, two physicians performed IVF on an alternating basis: each cycled his patients every other month. In July our doctor would not be available. We made the calculations accordingly.
     The success or failure of our late August/ September cycle was determined, as it turned out, on the first day of Rosh HaShannah, the Jewish New Year. What a coincidence. On the birthday of (Adam's) Creation, we in synagogues everywhere recall three barren women of the Bible: Sarah, Rachel and especially Hannah (1 Samuel 1-2:11), whose prayer sets forth the holiday's central themes. God remembered them and they conceived. Infertility overcome is the founding story of the Days of Awe, which open the harvest season at the head of the agricultural year. Divine judgment looms over the process of reaping what one has sowed, an annual reckoning that takes as its sign the mastery of women's bleeding. We attended a service for young children with our son. The rabbi initiated a collective celebration of congregants' various accomplishments. "Families that had a new baby in the past year, come up to the bima (pulpit)," she called out. Peninnah's piercing words. From the depths of bitterness and resentment, I poured out my grieving soul. What would be the results of the blood test I had taken early that morning? In the late afternoon, the IVF coordinator phoned, "I'm sorry, Marcia, it's negative." My bleeding was not to end.
     Some days later, I turned forty-two. "But," said the mother of Ira's kindergarten friend as we walked home from the local elementary school, "you look really young; I thought you were in your early thirties." "Tell that to my ovaries," I cracked. We had insurance coverage for one last cycle, which we completed to no avail in November/ December. By the end of 1995, we had been bled dry. Emotionally and physically drained, I had reduced my life to follicles projected on a screen.

 The Kindness of Strangers


© British Library - further reproduction prohibited
Fig. 6.

An infant, swaddled and abandoned at a city gate, historiated initial, c. 1360-75, London, British Library, MS. Royal 6E VII (Omne bonum Encyclopedia), fol. 104.

    During the five months in which Armand and I organized our lives around our last two attempts at IVF, we also began seriously to explore adoption as a way to build our family. I began to ask myself what it was I really wanted, to become pregnant at all cost or to have a live baby? I began to decouple the two goals, for it slowly dawned on me that if I endlessly pursued the first, the second might well go unrealized. To let go of trying to conceive would be tough;1 not to cradle another baby of my own would be unbearable. Our resources were finite and we were not getting any younger. I might ultimately have to choose between chasing a desire to give birth a second time and looking beyond to the fulfilment that, I knew for me, lay in a lifelong bond between parent and child.
     The "dead time" between cycles, built into the alternating schedule of the physicians in the IVF program at the clinic, allowed me to prepare the ground for adoption. Individually and as a couple, Armand and I examined our feelings. Would adoption be right for us? We took a series of seminars sponsored by FACE (Families Adopting Children Everywhere). I researched and gathered information. We networked through our many friends, neighbors, colleagues and relatives who had adopted their children. We did not shirk from asking ourselves and others hard questions. Investigation of the pragmatic aspects of adoption and personal reflection on the issues that adoption would raise in the specific context of our family blended together in an integral learning process.
     We attended "open houses" offered on a regular basis by many adoption agencies in the Washington Metropolitan area. I compared the business of ART, a purely capitalistic venture, to the adoption industry, subject to more government regulation but market-driven nonetheless. Strangely (or perhaps not), the medical and legal solutions available to infertile couples seemed keyed into a common index of value, as if professionals in both fields shared pricing guidelines and mutually adjusted their fees. How else could IVF and adoption, involving radically dissimilar operations and expertise, so consistently parallel one another in their cost to the consumer? Clearly the commensurability of the two services depended, in the final analysis, on the product that we dreamed they would deliver.
     If fertility clinics tended to sell themselves by pitching statistics in too free-wheeling a manner, agency presentations could also be problematic. Often, as the highlight of such evenings, newly adoptive couples displayed their babies and toddlers. Innocently intended to encourage prospective couples ("yes, there is a baby at the end of the tunnel"), the practice seemed unnecessarily exploitative. What were we desperate folk supposed to feel? To what position did the showroom scenario reduce us? Were we shopping? Was this supposed to assure us that yes, our children too would be healthy and free of defects? Why did "special needs" cases, if they came up at all, get swept under the rug, a trivial concern, a rare occurrence?
     We could not escape the opportunism to which the "free-enterprise" treatment of infertility in the United States is prone. Yet, by the same token, I had to admit that I favored the flexibility which came with it. We in America could take advantage of more options than allowed, say, to our European counterparts, who face nearly insurmountable obstacles should they wish to adopt. ART may indeed be more cheaply available in Europe, historically obsessed with bloodlines. But should ART fail, tortuous bureaucracies make domestic adoption practically impossible, where it is not altogether illegal, and immigration laws, xenophobic in the extreme, severely restrict international adoption.
     Armand and I decided on an international adoption, preferably from China. Collecting the requisite original documents for notarization, certification and authentication at the county, state and national levels proved laborious. We needed official papers in French and English from three countries (Belgium, where Armand was born and raised; Canada, where I happened to be born; the U.S. where we lived), two states (New York, Maryland), one colony (the District of Columbia), and God knows how many counties (Westchester, Montgomery, Anne Arundel, Prince George's etc.). We built a comfortable working relationship with a small agency in D.C. that respected our wish for as young an infant as possible and agreed to advocate in China on behalf of our interests. I had originally considered a larger, better-known agency based in another state, but had been put off by the director who regarded adoption as an exercise in charity. Confusing the strict, administrative process in Beijing with God's Will, he expected prospective couples to accept selflessly and without question whatever awaited them.
     He was not alone. Far too many adoption providers, I discovered, tacitly assume that infertile couples (not unlike lepers in the twelfth and thirteenth centuries) must be prepared to heed a divine calling for which their misfortune sets them apart. I did not have a vocation for perpetual penance, however. Adoption surely ought not be construed as a week-end excursion to the mall; does that mean infertile couples should be targeted as a venue for would-be do-gooders? Adoption entails choices - whether or not, for example, to assume the responsibility of parenting a child with special needs - that do not arise in giving birth, which presents a fait accompli. Such decisions belonged to Armand and me, not God. As a patient in the fertility clinic, I followed protocols to the letter. As a client of an adoption agency, I wanted to call the shots. Taking an assertive stance felt wonderful.
     Best of all, by turning my mind away from my ovaries, I gave my heart a chance to open and grow. Something was stirring. Had a seed been planted there? I felt an excitement, enthusiasm, and optimism I never did during IVF. To accept and trust these feelings was another matter however. My full and unwavering commitment to adoption evolved only gradually, in fits and starts, over the course of many months. While completing the legwork for an international adoption, we concurrently proceeded with the remaining IVF cycles for which we had insurance coverage. My strategy, unconventional it is true (and to some adoption agencies unacceptable), was to play one path against the other in the belief that I could use the tension between the two to my advantage. Thus I went forward with IVF no longer dreading that, for all the years of hoping and yearning, I would come out with nothing; my life did not depend on a positive pregnancy test. By the same token, I contemplated adoption without losing sight of the authenticity of my own feelings and the integrity of my own needs; I refused to let the religious or humanitarian agenda of others dictate my course of action.
     On the dreary December afternoon that we learned the negative outcome of our last attempt at IVF, Armand and I (longstanding afficionados of Chinese cinema) went to see the recently released film of Zhang Yimou. I had nearly finished processing all the requisite documents and had received our INS clearance. We resolved to take care of the outstanding details by the end of the year. A couple of days later I spoke by telephone with an old friend. I filled her in on the failure of the last cycle.
     "We're moving ahead with our plans to adopt a baby girl from China. I hope we'll have an assignment sometime in the spring or summer."
     "You can't be serious about going through with this! Why can't you accept things the way they are? You have a son, he's five and a half. Time moves on and you're going backwards. It would be different if you got pregnant..." Her reaction took me by surprise.
     "If ART had worked, and I had become pregnant, you would be happy for me. So I'm not sure I understand...why is it okay for me to have a baby naturally (of course, my sense of "natural" in matters of procreation had long ago exploded) but not through adoption, which would be to "go backwards?" What would be different if I got pregnant? Well I am not going to get pregnant; for whatever reason, I just can't conceive. Can't I resist the finality of biology? Did my only recourse lay in ART?"
     My friend's incomprehensible position and lack of support awakened my fighting spirit. I kept replaying the conversation in my mind until I suddenly became aware of resounding questions that, strange as it may seem, I had never consciously articulated, let alone attempted to ponder. Why in fact had I been so invested in becoming pregnant? What was at stake for me? What does pregnancy mean in our culture? Why is biological motherhood valued above all? The critical act of framing my personal issues in relation to unexamined social prescriptions marked a pivotal moment in my embrace of adoption. I shall forever remain grateful to my friend for bringing me to the place from which I could finally let go and move on.
     A lecture engagement in January 1996 took me to London and Paris. As I revisited familiar urban vistas, cafes, and boutiques (irresistible as always), I imagined the pleasure I would derive from future jaunts around town with my son and daughter. The sailboats at Luxembourg Gardens, hot chocolate at Angelina's, the bird market, ice cream at Berthillon. I tried to picture her as a teenager and as a young adult. Would she enjoy peering into windows at Lolita Lempika's or casing the shops around the Place Victoire as much as I do? The short months of pregnancy and newborn care seemed a tiny fragment of the life I wanted to be part of.
     Within days of returning home, however, my resolve weakened inexplicably. My menstrual period threw me into a crisis of conviction. I had not exhausted all of ART. Maybe if I did a Pergonal or Metrodin IUI cycle with donor sperm, I could get pregnant. I called the clinic. Could I cycle? Yes. I would need to come in early the next morning for a baseline ultrasound of my ovaries, order the donor sperm and get the doctor's prescription for the fertility drugs. Escape from controlling habits of mind was not as easy as I had believed. As Michel Foucault had rightly observed, the body is the prisoner of the soul. As soon as I put down the phone, I felt terrible. Traitor. I was abandoning the baby whose quickening in my heart I had just recently begun to feel more and more strongly. Should I really do this cycle? I vacillated. No, I couldn't go through with it. But wait, the dossier had just gone off to Beijing; it would take at least three months for the Chinese administration to act on it. I could still play one path against the other. I woke the following morning, put myself on automatic pilot and went to the clinic. Later that afternoon, the nurse phoned to inform me that specimens from the donor I ordered were not available. "Did we want to select another from the list?" Thank God, a sign! "No," I answered, "It's too complicated, let's forget it." What relief I felt as I hung up the phone. Peace at last?
     Four weeks went by. At night I lay in bed imagining the circumstances of my future daughter's birth and subsequent abandonment. I knew that I would never have more than a general idea of the reasons leading to her separation from her biological family and integration into ours. Family planning policies in China and the culturally entrenched need for a male heir created a devastating mix; was she a second- or third-born daughter? Or perhaps the birth mother was unwed and had no means of supporting herself and a child? How soon after the infant's birth would she be abandoned? How would it be done? When would she be found? Would the birth parents leave a token or a note? How long would it be before authorities in Beijing assigned us a child and grant permission to complete the adoption in China?
     Far more distressing questions haunted my sleep and woke me before dawn. Would the birth mother make the decision and carry it out herself, or would she be unduly pressured? Would her husband or mother-in-law take the child from her by force? What if, on the contrary, she coldly turned her back and walked away? (Let's not kid ourselves, this does happen and not only in China.) I tried to enter the birth mother's state of mind. How could I possibly fathom her feelings of grief and guilt? Would she suffer abiding pain and bitterness? Would time bring healing and acceptance? Would she ever know for certain whether her baby survived? Would she ever wonder about me? World's apart, we would forever be unknowingly joined, by cruel and arbitrary imperatives, in the life of a child whom she had conceived and I would raise. ART, through its fertility drugs, had connected me to the bodies of anonymous women across time, adoption, through its double bond of love and loss, across space.
     Then my period appeared, and I was again besieged by the same gnawing doubts as four weeks before. Should I cycle? But what if I actually did get pregnant? I wouldn't be able to go to China! And if I miscarried again? I would lose everything. Despite the fact that I was on the verge of not wanting anymore to become pregnant, I did make the early morning trip to the clinic for the requisite baseline ultrasound. I got as far as the waiting room and left. My heart was not there.... it belonged to a little girl who, though I did not know it at the time, had in truth been born that very day. I never returned to the clinic. I had enough of ART.
     The planets had shifted their alignment in my favor and a new, brighter star rose on the horizon. Spring had come to Washington. As I walked back and forth between our home and the Friendship Heights Metro station, I passed a large house on Western Avenue that had recently been sold and spruced up. Plaques reading "Mother Theresa's Infant Home" and "Missionaries of Charity" were posted on either side of the front door. Had a foundling hospital been opened here? Curious, I decided to bring over the maternity clothes I had been saving all these years but would now no longer be needing. A young Indian nun, clad in the white cotton sari of the order, greeted me at the door and invited me into the foyer as I explained my purpose.
     "Could you, I mean your organization, use some maternity clothes; they are in excellent condition?"
     "Oh yes, we have someone here now," she replied. I asked her about their mission in Chevy Chase D.C.
      "This house is for pregnant girls, women, who can't stay with their families, which are hostile to them, and so have nowhere to go. We support them through the pregnancy."
      "Do some choose to put their babies up for adoption?"
     "All the babies are adopted through Catholic Charities," and she proceeded to enumerate the sectarian requirements for adoptive couples.
     "But what happens if someone decides during the course of pregnancy that she wants to keep her baby..."
     "Well, then she has to leave."
     "Pardon me?" Maybe I hadn't heard correctly...
     "All the women who stay here have to put their babies up for adoption."
     Dumbfounded, I handed her the bag of clothes and bid goodby. Quite a peculiar profession of charity, I thought; something seemed, well, not quite kosher (or, as the French say, "pas très catholique"). Adoption through Catholic Charities is as expensive as through any other non-profit venue; adoptive couples pay the birth mother's medical expenses, costs associated with her pregnancy (like maternity clothes and counseling), agency social workers for their home study, and all the legal fees involved. The overhead for the one or two residents of the Chevy Chase "shelter" was for all intents and purposes absorbed by adoptive couples. The women needing the most support were, presumably, those who wanted to parent in the face of disapproving, angry families. I wondered where they were supposed to go: return home? (The nun neglected to tell me, I have since learned, that the Missionaries of Charity operate another house in the District for women who do indeed choose to keep their babies. The two groups of expectant mothers are therefore segregated, a policy that, it seems reasonable to speculate, prevents the decisions of some from impinging on the resolve of others.)
     Where exactly did charity come into the picture? In the ritual gesture I had just performed, of course. Did I do any differently than the abbot of Cluny who once a year washed the feet of twelve paupers in humble imitation of Christ serving the apostles? The religious orders distributed food and clothing to the poor at funerals and anniversaries on behalf of deceased benefactors; it was their job to convert the material wealth of rich donors into heavenly treasure for the same. Money-laundering, medieval style. My modern feminist re-staging of St. Martin, or St. Giles, or St. Francis clothing the beggar - the archetypal demonstration of mercy in medieval hagiography - had come right off the painted walls of the churches I studied. Ah, so that's how images work.


Fig. 7.

Saint Giles clothing a beggar, wall painting c. 1200, in the crypt of the Collegiate Church of Saint-Aignan-sur-Cher.

     Whether my maternity clothes provided needed assistance to anyone is doubtful. The act of giving them away, however, had important symbolic value. It represented a definitive break with my procreative body and put closure on the reproductive phase of my life. (Similarly, in the saint's life, the gift of a garment signifies more than an ascetic renunciation of worldly goods and carnal pleasures; it epitomizes the shedding of high social rank and all fleshly ties to kin, including the responsibility for dynastic propagation.) By the end of June 1996, I had lost track of my menstrual cycle: I had forgotten the date of my last period, and was surprised when it came. For the first time in over three years, I was free.

1.  I owe the section heading to John Boswell, The Kindness of Strangers. The Abandonment of Children in Western Europe from Late Antiquity to the Renaissance (New York, 1988).

   Genealogies and Generations


Fig. 8. Lineage of Adam and Eve, miniature painted by Stephanus Garsia Placidus, third-quarter of the eleventh century, Paris, Bibliotheque Nationale, MS. lat 8878 (Beatus of St. Sever), fol. 5v.

     On the sultry Monday morning of September 2nd, Armand and I look out from our hotel window at the futuristic city-scape of Shanghai. We would soon meet our daughter for the first time. According to official records, she was found in a suburb far to the north of the city on March 6th ; a birth date of March 3rd is presumed. Orphanage staff had named her Wang (the patronym assigned to all their 1996 foundlings) Li Bei; her characters literally mean "energy treasure." Since receiving our assignment some two weeks before, I have been spinning a mental tapestry of prized and priceless qualities. Sketchy outlines of a spirited temperament emerge in the foreground: dynamism, vibrant power, vitality in vast abundance. I stare at a black and white image of her in a photocopy of a fax transmission made from a photocopy of an undated photograph. I try to glean the proverbial thousand words. A lifetime of deciphering images has not equipped me to see through a glass this darkly. I think of Ira, barely six, now with my parents in New York. He had understood. When I first brought home the documents from the agency and showed Ira the picture of his new sister, he kissed it. Still, I have no clue.
     Everything has led up to this day, but when the interpreter from the Shanghai Adoption Administration accompanies us to the Children's Welfare Institute on Pu Yu Road I feel unprepared. Into the garden courtyard, through the double doors of the building, up the stairs and down the hall to a small living room where Armand and I, petrified with anxiety, wait in silence. The director of the orphanage brings our six-month old baby and places her in my arms. The moment for which I had ached is now. Language ceases. My body takes over; it alone knows what to do. I am in the midst of a purely physical event, like giving birth or being born. Gradually my mind registers the sounds of applause and picture-taking. Armand holds the baby. The director wants to know what we will call her. "Gabrielle Libei," I stammer. "Gabrielle Libei Rose," Armand adds, "after my mother." Both our children now bore Americanized forms of the Yiddish names of Armand's parents, survivors of Auschwitz and Ravensbruck, who had passed away only shortly before Ira's birth. The handing down of names from the dead to the living signaled the continuity of the generations. As the director assumed custody of the baby for the last time, we brought our visit to a close. The next morning we would begin finalizing the adoption.
     On the way back to our hotel, the interpreter laid out the week's schedule. Was it 4:00 or 5:00 p.m. already? Armand and I strolled along the Bund by the Huangpu River. Kites and balloons danced overhead, loaded barges crept along. Behind us stood nineteenth-century buildings that had belonged to the foreign concessions during the period of Western colonial domination. Ahead in the distance, the Pudong TV and Radio Tower soared into the sky to reclaim the city. Neither one of us could speak about our experience at the orphanage. We were too stunned.
     Less than twenty-four hours later we were playing with the baby in the privacy of our hotel room. Gabrielle laughed a full belly laugh that rolled over her plump little body and flooded mine. In that instant of recognition, I became hers forever. Something in the ring of her laughter, her sparkling eyes and the grasp of her tiny hand curled round my finger told me that I had found all I had been searching for. She was my very own. Moment by moment, day by day, physical intimacy sealed our deepening attachment. I got to know my baby not in a hospital maternity ward but while exploring the bustle of Shanghai and the gardens of Suzhou. Everywhere people responded to her loveliness and congratulated us. I was especially moved by how much the staff of the Shanghai Adoption Administration and Children's Welfare Institute cared for her. They showered her with beautiful gifts - mementos of the city (including a miniature crystal replica of the TV Tower), a childhood memory album, a cup emblazoned with her baby picture. When finally we flew home, it was Rosh HaShannah. Gabrielle lay sleeping against my chest, and sometimes suckled the tip of my nose. I tasted the sweetness of the New Year. Such great good fortune I had not imagined could be mine.
     I watch my children grow, delighting in the person each is. I thrill to both. To say more would be to trivialize the somatic intensity of my passion for them. That passion springs not from conception and birthing, nor from sharing a gene pool, but from the maternal relationship to which I assent and which I renew every waking and sleeping minute until it is time for my name to be passed on. The years I spent consumed with and by reproductive technologies seem now strangely unreal. How could I have been so driven? To what purpose? Yet, I wonder... Perhaps the experience of ART helped me to see beyond nature. Needles, probes and monitors demystified procreation, revealing it for the mechanics that it is. The real story lies in how humans translate the single mode of generation common to the species, a biological phenomenon, into the culturally diverse structures that make family a social artifact.


Fig. 5.

Vein/ Zodiac Man, miniature from the Wellcome Apocalypse, fol. 4 1 r.


Marcia Kupfer is an historian of medieval art. She has been awarded major fellowships from the Institute for Advanced Study at Princeton, the National Endowment of the Humanities and the Fulbright Program.

Her numerous scholarly publications include a book, Romanesque Wall Painting in Central France: the Politics of Narrative (Yale University Press, 1993) and articles in academic journals (Art Bulletin, Speculum, Word & Image). She has just completed a monograph on images, burial practices and healing rituals in a medieval parish and is currently writing a general book on Romanesque art.

Email: makupfer@erols.com

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