In Box

The Islamic Republic of Baby-Making

How the supreme leader's revolutionary acceptance of 
cutting-edge fertility treatments 
is changing lives in Iran -- and unsettling the deeply conservative 
Sunni Middle East.

On a sultry evening last fall, a private fertility clinic in the southern Iranian city of Shiraz was so busy that the harried receptionist struggled to accommodate all the women seeking its services. On a mantelpiece rested a framed fatwa from Ayatollah Ali Khamenei providing religious sanction for sperm and egg donations -- placed there, perhaps, to reassure these women that they had the supreme leader's approval for what they were about to do. Many had traveled long distances from smaller towns to reach the clinic, and the packed waiting area was abuzz with conversation, as women swapped stories about treatment, drugs, and their shared struggles to conceive a child.

"I couldn't afford this five years ago, but I've saved up now and am ready to try," said one 30-year-old woman seated in the waiting room.

While the world's attention has been focused on Iran's nuclear program, the country has been quietly working on a different sort of breakout capacity. The Islamic Republic -- governed by its strict mullahs, who've managed to botch progress in fields ranging from domestic manufacturing to airport construction -- has unexpectedly transformed itself into the fertility treatment capital of the Muslim Middle East. Iran now boasts more than 70 clinics nationwide, which attract childless couples, Sunni and Shiite alike, from throughout the region. This initiative has raised challenges to traditional views on parenthood and marriage and has helped chip away at taboos about sexual health -- even as it has left some of Iran's conservative Sunni neighbors aghast.

"Doctors in the Gulf are horrified by the way the Iranians have allowed this," says Soraya Tremayne, an Oxford University professor and an expert on fertility in Iran. "They say, 'We would never allow this among us.'"

For generations of Iranians, infertility was once a marriage-unraveling, soul-decaying trauma. It was memorialized in films like Dariush Mehrjui's Leila, in which a conniving mother bullies her son into taking a second wife when his first fails to conceive. The first wife, ashamed of her infertility and still in love with her husband, goes along with the plan, but the emotional strain destroys their marriage and the husband is ultimately left with a child, but bitterly alone. The film screened just a few years before Khamenei's 1999 fatwa and was a major hit, resonating with the multitude of Iranian women and men facing the prospect of a childless marriage and the intolerable alternative of polygamy.

IRAN, LIKE OTHER MIDDLE EASTERN COUNTRIES, has an extremely high infertility rate. More than 20 percent of Iranian couples cannot conceive, according to a study conducted by one of the country's leading fertility clinics, compared with the global rate of between 8 and 12 percent. Experts believe this is due to the prevalence of consanguineous marriages, or those between cousins. Male infertility is "the hidden story of the Middle East," says Marcia Inhorn, a Yale University medical anthropologist and a specialist on assisted reproduction in the region. Couple that with a shocking, multidecade decline in the average number of children born per woman, and it means that fertility treatment is needed in Iran more than ever.

Still, the pressure on a married couple -- and particularly the woman -- to produce children remains intense.

"We live in an Eastern society, and having children remains a very significant thing in our culture," says Sara Fallahi, a physician who practices in one of Shiraz's three fertility clinics. "Even for this generation that's getting married later and wanting smaller families, most still definitely want one child."

Iran's first in vitro fertilization (IVF) clinic opened up in Yazd, a desert city in central Iran, more than 20 years ago. It immediately found itself inundated with clients. By the mid-2000s, it was so popular that lines stretched out the door. Couples who had traveled from rural areas would camp outside in hopes of getting an appointment. More clinics soon opened in Tehran and across the country.

IVF quickly gained acceptance in other parts of the Middle East, but physicians ran into religious restrictions prohibiting more advanced forms of fertility treatment. Standard IVF involves fertilizing an egg with sperm in a laboratory and then returning the embryo into the womb, a process requiring that both the egg and sperm of the respective partners be viable, which is not always the case. The next step in treating infertility requires a third party -- that is, an egg or sperm donor from outside the couple. In Islam, the ethics of such treatment are murky: Patients initially worried they might be committing adultery or that children born of such unions would be illegitimate.

But childless couples continued to demand a way to conceive. In Iran, medical specialists set about finding a religious solution, seeking the support of sympathetic mujtahids* (clerics qualified to read and interpret the Quran). The Shiite tradition of reinterpreting Islamic law was central to the clerics' willingness to go along -- in stark contrast to Sunni jurisprudence's focus on scholarly consensus and literal readings of the Quran, which has meant few fresh legal rulings on modern matters. Although, to Westerners, Iran's Shiite clerics might appear reactionary, they are downright revolutionary when it comes to bioethics. In recent years, they have handed down fatwas allowing everything from stem-cell research to cloning.

Their edicts did necessitate some Quranic contortions, however. The religiously acceptable solutions offered at first, like temporary marriage between an egg donor and the fertile male partner, proved too complicated, requiring a married donor to endure a flurry of divorces and remarriages. And some clerics who disagree with Khamenei's fatwa still advocate temporary marriage as a way of avoiding the adulterous implications of third-party donations. But this approach is easier for husbands, who can contract a temporary marriage with a female egg donor without needing to divorce the infertile wife; for a fertile wife to be able to receive sperm from a donor, she must divorce her husband, wait a religiously mandated three months before marrying the sperm donor, then divorce him, and finally remarry her original husband.

Iranian clerics' willingness to issue innovative religious rulings coincided with a changing political and demographic climate that also spurred fertility treatments. In the wake of the 1979 revolution, the country embarked on a quest to boost population, but by the late 1980s and early 1990s, as Iran struggled to rebuild in the aftermath of its devastating war with Iraq and with the baby boom in full effect, many questioned whether the country's economy, schools, and cities could handle the population growth. So the authorities reversed course, implementing a set of policies that gently persuaded traditional Iranians to have fewer children.

According to Oxford's Tremayne, authorities carefully avoided words like "reduction" and "control" and instead proposed "regulation of the family," emphasizing that the policy was intended not only to reduce family size but also to enable infertile couples to have families. The bargain worked, as traditionalists embraced the government's anti-natal policies and Iran's fertility treatment centers multiplied. By promoting contraception and vasectomies, among other strategies, and withdrawing state subsidies after the second child, Iran managed to reduce its population growth rate from 3.8 percent in 1986 to 1.5 percent in 1996. But it may have worked too well: Today, Iran finds itself below the replacement rate of 2.1 children per woman.

In 1999, Khamenei issued his landmark fatwa making third-party sperm and egg donation permissible. "Both the egg donor and the infertile mother must abide by the religious codes regarding parenting," the ayatollah decreed, setting out the various conditions that made the act permissible before God. Through Khamenei's edict, the Islamic Republic had made clear at the highest level that the state was ready to sanction Iranians' efforts to make babies -- whatever it took.

TODAY, THE ERA WHEN INFERTILITY WAS discussed in hushed tones is giving way to a lively culture of intervention and openness. Women chat openly about IVF on state television, couples recommend specialists and trade stories on Internet message boards, and practitioners have begun pushing insurance companies to cover treatment. And the state runs subsidized clinics, so the cost for treatment is lower than almost anywhere else in the world: A full course of IVF, including drugs, runs the equivalent of just $1,500, according to Fallahi.

Khamenei's fatwa was revolutionary for Shiite Muslims everywhere, and it cleared the way for many clinics in Lebanon, which has a significant Shiite population, to follow suit. But according to Yale's Inhorn, Sunnis are also responding to the ruling, with some infertile couples from the Arab world heading to Tehran clinics that employ Arabic interpreters. Sunni countries like Egypt, Turkey, and the United Arab Emirates practice classic IVF widely, but offer no treatment options for men and women who require third-party reproductive assistance to conceive.

"Some Sunni couples have been able to wrap their minds around egg donation," says Inhorn. "They can tell themselves, 'Well, at least there's one fatwa that says it's OK. Some branch of Islam says so.' This makes them more at ease."

Still, Fallahi, the physician, says that anxious clients at her clinic in Shiraz often raise the question of religious approval. "They want to be sure what they're doing is not haram," or forbidden by Islamic law, she says. Parliament legalized embryo donation in 2003, providing some legal backing to the supreme leader's religious ruling. Fallahi stresses, however, that Khamenei's edict is the opinion of one marja, or source of emulation, and that not all ayatollahs agree. "We tell people that parliament has approved this, but that they need to check with the marja they follow to see if he gives permission."

In some ways, fertility treatment may be the rare area where the Iranian regime has moved forward before society is ready. Although legislators approved embryo donation, they overruled Khamenei on sperm donation, banning the procedure in 2003. As a result, the practice was pushed underground, and those clinics that quietly offer the treatment are vulnerable to prosecution. Sara Bamdad, a researcher in Shiraz who conducted a survey on public attitudes about assisted reproduction, found that only 34 percent of respondents approved of egg donation. "Lawmakers should be thinking about the future and what is going to happen to these children when they're older," says Bamdad. "If a society can't accept a child that's born of assisted reproduction, then there'll be so many problems in the future."

IRAN'S LEGAL SYSTEM HAS YET TO CATCH UP with the implications of third-party fertility treatments. Under Iran's Islamic family law, babies born of sperm or egg donation fall into the legal category of adopted children and stepchildren, who are not permitted to inherit property from non-biological parents. Couples thus must find alternative ways to put aside assets to provide for these kids, and the rights and responsibilities of biological parents (the egg or sperm donors, who are meant to remain confidential but whose identities are sometimes disclosed in practice) remain unclear.

But if religious rulings are still murky, the baby-making revolution may be gently removing cultural taboos around other areas of sexual health. The Avicenna Infertility Clinic in Tehran, the country's most prominent fertility treatment center, has recently opened a health clinic that treats sexual dysfunction and sexually transmitted diseases.

Tremayne recounts visiting a fertility clinic where a large room full of men and women sat watching a video transmission of a surgery to fertilize a woman's egg on a giant television screen. "Our intention is to create a new culture so that people understand how babies are conceived and how infertility can be treated," a doctor told Tremayne. Scenes like this are part of a broader effort to educate the public, and while it may take years for infertility to lose its stigma in Iranian culture, the discussion of bodies and their biological functions and failings may be gradually helping Iranian men and women share responsibility for what has for centuries been the profound nang, or dishonor, laid at the feet of women.

The pursuit of cutting-edge baby-making has launched a process that could ultimately change what it means to be married and infertile, what it means to be a parent, even what it means to be kin in the Islamic Republic. As Iran struggles with the collision between its people's evolving values and the tenets of Islamic law, its success with fertility treatment suggests that it just may be possible to reconcile these competing pressures. But whether it will catch on in the Sunni Middle East is an open question.

"Iran is surging ahead using [these technologies] in all their forms," Tremayne says, "going places where the Sunni countries in the region cannot follow."

Additional reporting was contributed from Shiraz, Iran.

*Correction: The print version of this article in the January/February 2014 issue incorrectly spelled mujtahid as mujahid. (Return to reading.)

Illustration by Jon Han

In Box

Trial by Fire

What crises lie in wait for Janet Yellen?

Each of the last three chairs of the U.S. Federal Reserve faced daunting challenges soon after assuming leadership of the world's most powerful central bank. It will be no different for Janet Yellen, the highly talented and respected incoming chair. How she reacts to the set of known challenges, let alone the unanticipated ones, will impact the well-being of every American and huge swaths of the global economy.

Back in 1979, Paul Volcker came to the Fed with a mandate to snap the United States out of a debilitating period of low growth and high inflation (or "stagflation"). Shortly after taking office, he did more than raise interest rates; he embarked on a multiyear policy effort that ended up underpinning a three-decade period that took inflation from public enemy No. 1 to essentially a nonissue.

Success was far from obvious in Volcker's early days, however, and it would not have materialized without his now-legendary steadfastness and conviction. With sky-high interest rates throwing the economy into recession, he faced enormous political pressures to abandon course, including from Jimmy Carter, the president who appointed him but then seemed surprised by the consequences of the monetary policies he pursued. Volcker made multiple brave calls along a difficult path. With the Fed-induced recession contributing to Carter's bruising loss to Ronald Reagan in the 1980 election, you can still find Democrats today who blame Volcker for giving the election to Republicans-and for laying the groundwork for what came next.

Alan Greenspan, Volcker's successor, faced his own moment of truth. Just months into his tenure, he had to deal with a sudden and dramatic financial market collapse. On Oct. 19, 1987 (what came to be known as Black Monday), the Dow Jones industrial average plummeted some 22 percent for no apparent reason-an unprecedented drop that threw global markets into disarray. Greenspan's boldness in aggressively injecting emergency liquidity contained the damage and, in the process, safeguarded the integrity of the global financial system.

Fast-forward to September 2008. Just 31 months after Ben Bernanke took the reins from Greenspan, he found himself facing a fearful situation: the disorderly bankruptcy of an influential broker-dealer (Lehman Brothers), the near collapse of a massive insurance company (AIG), a potential depositor run on a large money market fund (the Reserve Fund), and a host of nightmarish cascading financial dislocations. Thrown into urgent crisis management, the new chair stepped up to battle a financial crisis that was on the verge of tipping the global economy into another Great Depression.

Bernanke was forced to do more than just come up with innovative Fed instruments to slow the metastasizing market failures that were sucking liquidity out of virtually every major economic interaction worldwide. Together with Treasury Secretary Hank Paulson, he marched up to Capitol Hill to convince skeptical lawmakers to approve a massive bailout package-with a calm, decisive persuasion of which only a scholar of his stature would have been capable.

How Janet Yellen would deal with these types of challenges no one yet knows for sure. But she had better be ready. It would not surprise me one bit if she finds herself the fourth consecutive head of the Federal Reserve to face a serious crisis soon into her tenure.

Yellen takes over a Fed that is playing an unusually broad role in supporting markets and the global economy. The institution finds itself deep in experimental mode, using largely untested tools-be it purchasing tens of billions worth of bonds a month, keeping interest rates artificially floored, or seeking to influence private-sector behavior by venturing ever deeper into "forward policy guidance" (basically, orchestrated communication to markets about the Fed's intentions).

There are few historical parallels, analytical models, and policy playbooks to guide her. Indeed, there isn't even a common and detailed understanding among academics of how the Fed has really influenced economic prospects and the functioning of markets since the global financial crisis. Meanwhile, financial investors are delighted to have the continuous support of the Fed's wide-open wallet, which has driven asset prices to rise to historical records, despite unusually sluggish fundamentals.

It's not quite a poisoned chalice, but Yellen is taking over a Federal Reserve that has ended up, mostly inadvertently, underwriting a series of consequential and unusual disconnects. Under her guidance, the Fed will need to find a way to better reconcile booming financial asset prices with the unfortunate realities of what is now being labeled "secular stagnation"-an unusually prolonged period of low growth and high unemployment. The central bank will also have to find a way to reconcile its steadfast commitment to supporting the domestic economy with the disruption that causes for other countries. After all, with the United States both supplying the global reserve currency and hosting the world's deepest financial markets, what the Fed does has enormous consequences for the flow of international capital in and out of other countries. Those countries have felt the Fed's largesse, and many will find their capacity to cope challenged when the taps begin to close.

Yet the Fed under Yellen will need to find a way to transition the economy from artificial growth to genuine private-sector-led growth. It must gradually reduce its direct involvement in the markets and do so without causing disorder that undermines economic growth. Bernanke has already signaled the route ahead: namely, a gradual retreat from monthly bond purchases in favor of great reliance on forward policy guidance.

There may be no imminent crises like the ones Volcker, Greenspan, and Bernanke faced. Yet the situation Yellen inherits is arguably more complicated and fluid. Indeed, it may well constitute one of the most complex challenges ever faced by a central bank. If that weren't enough, the Fed's tool kit is ill-equipped for the task at hand, and the institution is hampered by political polarization and congressional dysfunction.

No one knows for sure how much time the Fed has before it must deal with the unintended consequences of its experimental policies. It could be months; it could be years. Much depends on whether Bernanke has actually bought enough time for U.S. household balance sheets to heal and for the economy to pick back up robustly.

But Yellen can't wait to find out. She needs to deliver on four interrelated fronts early on in her tenure. First, as the benefits of the Fed's unconventional stimulus decline, as they inevitably will, she must avoid exposing the fragility of a recovery still hampered by inadequate infrastructure and demand, unresolved pockets of excessive indebtedness, and long-term unemployment.

Second, with many equities and corporate bonds flirting with bubble-ish levels, she must work with other agencies to ensure that recent progress in banking regulation and supervision has materially reduced the threat of destabilizing market incidents.

Third, she must find a way of breaking the unhealthy co-dependency that has developed between markets and the Fed. Markets cannot function well in the long term on the assumption that they will always have the Fed to support them, and the Fed cannot always rely on artificially boosting financial assets to promote growth and jobs.

And fourth, she must clearly communicate Fed policy in a world that has become extremely sensitive to every word, signal, and whisper emanating from the world's most powerful financial institution.

What is undeniable, even at this early stage, is that the to-do list awaiting Janet Yellen when she enters the Fed is as daunting as those that ended up facing her three predecessors. And we have no idea what challenges and crises the world could soon throw her way. She brings enormous talent and experience to the Fed chair, but she'll need some good luck too.

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