Abstract
Abstract
Despite the centrality of the role of embryologists in in vitro fertilization (IVF), there is relatively little literature on the nature of their work. In this article, we draw on results from a large ethnographic study on the emerging IVF industry in South Africa and reproductive travel in sub-Saharan Africa (SSA), where IVF clinics and embryologists are scarce. Drawing on qualitative interviews with 11 embryologists, who work(ed) in SSA, we illustrate how their care practices are produced through the interaction of people and things. We emphasize the importance of context in shaping their practices, including the shortage of embryologists, the need to set up ‘first’ clinics in their respective countries, the paucity of trained counsellors in clinics and the mobility of IVF staff. The embryologists we interviewed performed multiple tasks on top of their laboratory work, including entrepreneurial tasks, advocacy, training, development of regulations, mentoring and patient counselling. They enacted care in several ways, towards gametes and embryos, patients, clinics and the profession. These multiple tasks and care practices make for dynamic and fulfilling careers of the interviewed embryologists but also stretch their capacities. They also raise questions about their contribution to the scarcity of embryological work in SSA. If access to IVF is to be achieved in the SSA region, more embryologists need to be trained and retained.
Lay summary
Embryologists play a central role in IVF. Yet, there is limited knowledge about the nature of their work. We examine the work of embryologists in SSA, where IVF clinics and embryologists are scarce. Based on qualitative interviews conducted with 12 embryologists, we illustrate the multiple tasks they perform on top of their laboratory work: entrepreneurial tasks, advocacy, training, development of regulations, mentoring and patient counselling. Context is important in shaping these practices. This includes the shortage of embryologists in the SSA region, the need to set up ‘first’ clinics in their respective countries, the lack of trained counsellors in clinics and the mobility of IVF staff. These multiple tasks, while professionally fulfilling, raise questions about their contribution to the scarcity of embryological work in SSA, which contributes to the limited access to IVF in this region.
Introduction
Embryologists are vital to in vitro fertilization (IVF) success, yet there is relatively little literature on the nature of their work. The authors of one editorial suggest that ‘the embryologist has always been considered a highly skilled “artisan of life”, extensively trained to master sensitive microscale procedures where the margin for error is close to zero’, and note their various roles other than technical (Rienzi & Fauser 2021). A summary of the ‘modern’ embryologists’ work suggests that they undertake a multiplicity of tasks – not only as technical experts but also as managers, researchers, collaborators, scholars, communicators and mentors (Choucair et al. 2021). The importance of one or another role may depend on their specific position and experience, but ‘embryologists’ efficacy behind the scenes reflects positively on the success of the fertility clinic’ (Choucair et al. 2021). Hence, although invisible and ‘behind the scenes’ (Choucair et al. 2022, Choucair et al. 2023), the work of embryologists is intense, collaborative and stressful. One study of embryologists found that 59% of UK and 62% of US embryologists reported high ‘burnout’, stress and occupational challenges (Murphy et al. 2023).
Little is known about the roles and experiences of embryologists in IVF clinics in the global south. Some anthropologists have reported on embryologists’ transnational mobility, as embryology was – and still is – a scarce expertise in many places in the global south, while the demand for IVF is constantly growing (Hörbst & Gerrits 2016a,b, Simpson 2016, Franklin & Inhorn 2025). Hörbst & Gerrits (2016a) showed how, in Uganda and Ghana, these ‘transnational arrangements affect the local appropriation of laboratory procedures, protocols, and practices in various way’ (p. 69), and González-Santos (2014) delved into the relationship between clinicians and embryologists, where the latter – referred to as ‘biologists’ in the Mexican context – felt not ‘as much taken into account as much as they should’ (p. 39).
Efforts to define the role, status and training needs of embryologists are ongoing (Alegretti et al. 2015, Kovačič et al. 2015, Richings 2015). In looking at the role of embryologists in ensuring quality care, Kathryn Go describes them as ‘the most valuable and critical asset of an assisted reproduction technique laboratory’ and notes that ‘through their hands, safe conduct of patients’ gametes and embryos is achieved’ (Go 2015). She highlights the combination of technical skills – ‘the craft’ of embryology – with various administrative or regulatory compliance activities and lists a long range of responsibilities within clinics. These include the preparation and quality testing of materials and labware; preparation of gametes for transfers; cryopreservation and thawing procedures; embryo transfers; sperm manipulation, preparation and storage; training of new embryologists; biopsies; and retrospective data analysis. In addition, they are responsible for the maintenance of the laboratory, including instruments, equipment, supplies and temperature; record-keeping of all treatment cycles; education of clinical staff and patients about procedures; compliance work with accreditation authorities; and reporting of clinical data (Go 2015). Above all, embryologists carry a unique responsibility for the ‘moral objects’ of human embryos (Ehrich et al. 2008) demanding meticulous attention and risk avoidance in their work. At any point, they can succeed or fail through technical mishap, neglect or carelessness.
The care-work and emotional labour undertaken by embryologists – to care for embryos, oocytes and sperm, and patients – is highlighted in a study in New Zealand on the work of ‘biological scientists’ in human embryology and assisted reproduction. In this study, the tasks of medical scientists and embryologists are divided into a five-fold ‘object of care’: clients, reproductive material, the scientific and bureaucratic system that underpinned their work, the quality of the team dynamics and each scientist’s own internal state or ‘fitness to work’ (Fitzgerald et al. 2013). In New Zealand, these scientists were strongly encouraged to make personal contact with their clients to convey results and explain procedures, rather than to work anonymously in a remote laboratory with decontextualized reproductive material (Fitzgerald et al. 2013); this explains their engagement with and commitment to care for patients in the first place. Furthermore, the emphasis on the other four objects of care was related to the idea that they were working with ‘precious’ material, referring in particular to oocytes and embryos; mistakes with such irreplaceable material were simply not an option (Fitzgerald et al. 2013). Other than taking care of these materials, embryologists took care of the scientific and bureaucratic processes underpinning the practice of the clinic, laboratory team dynamics and their own internal state of mind. They also undertook many aspects of the emotional labour considered important to high-quality patient-centred care: counselling patients, conveying bad news, trying to impart hope and managing ‘difficult’ patients (Fitzgerald et al. 2013).
In this article, we likewise consider the work of embryologists through the lens of care, building upon and expanding the understandings of the work of embryologists as care-work. However, in a slightly different approach to the above categorization (Fitzgerald et al. 2013), we suggest care is enacted and co-produced through the interaction of people and things, an approach used in science and technology studies and material semiotics (Mol 2002, Mol et al. 2010, Park & Fitzgerald 2011, Pols 2012). This approach considers how people and material objects shape each other through relationships, which gain meaning as they are situated in practices and vary in different contexts. Instead of only describing how embryologists care, we consider how embryologists and the practices of their work enact care and are mutually shaped in the process. This allows us to consider how tasks, technologies and people – patients and other staff – together enact care within an IVF clinic. The approach, captured in ethnographic descriptions of IVF clinics, highlights the ontological choreography of multiple actors and technologies in the provision of care (Thompson 2005, Whittaker 2015).
Context
Across sub-Saharan Africa (SSA), there is a shortage and maldistribution of IVF clinics. It is estimated that 1500 assisted reproduction cycles per million infertile people are required in SSA to meet present needs, but in 2020, only 87 cycles per million took place (Afferri et al. 2022). The International Federation of Fertility Societies identified some 210 clinics in SSA, the majority in South Africa (40), Nigeria (96), Ghana (18) and Kenya (11) (Allan et al. 2019, Dyer et al. 2020, Horton et al. 2022). Almost all clinics offering IVF in SSA are private clinics, and as a result, ARTs are not affordable for most people experiencing fertility problems in these countries (Dyer & Patel 2012, Dyer et al. 2013, Dyer et al. 2017, Botha et al. 2018). Only a few initiatives of publicly funded IVF in SSA countries (Nigeria, Mali and Uganda) have been reported (Mutumba-Nakalembe 2023 Whittaker & Gerrits 2023); in South Africa, only three public academic clinics offer a limited number of subsidized IVF cycles (Hammarberg & Kirkman 2013, Asemota & Klatsky 2015, Botha et al. 2018). Expanding IVF care across the continent is difficult, given the limited number of clinical and laboratory staff with the necessary expertise. In particular, there exist a shortage of embryologists, challenges in providing training for them and difficulties in retaining experienced staff due to a ‘brain drain’ to other countries.
Training options for embryologists differ across countries. In South Africa, stringent selection and training for embryologists is observed (A Whittaker & T Gerrits, personal communication). Medical biological scientists can enrol in any of 12 different training programmes (such as genetic counselling, medical physics or microbiology) at seven different universities with medical faculties or can train at any one of six SANAS (Health Professions Council of South Africa)-accredited medical institutes or diagnostic laboratories. However, reproductive biology training is provided at only two institutions. Medical scientists with a four-year degree in science may enrol in a 24-month prescribed evidence-based internship in reproductive biology at one of two authorized academic ART laboratories (under the auspices of the Medical and Dental Board). Clinical technologists complete a two-year training in basic sciences at one of three universities of technology, then specialize in reproductive biology at various authorized ART laboratories. Certification of Independent Practice by the Health Professions Council of South Africa as a clinical embryologist is needed to practise as an embryologist. Overall, at the time the study took place, the numbers of people training were small; within public institutions, there were only nine new biological scientists being trained in reproductive biology at two hospitals (Steve Biko Hospital and Tygerberg Hospital) connected, respectively, with the University of Pretoria and the University of Stellenbosch (A Whittaker & T Gerrits, personal communication).
In this article, we draw on our work on the emerging IVF industry in SSA, during which we observed the multiple tasks and work of embryologists that supplement their laboratory-technical tasks. Below, we first present the motivations of embryologists in SSA. We show their high level of engagement and commitment, noting the diversity of their roles and tasks (Choucair et al. 2021). As we illustrate, the roles of embryologists are complex and may include work not undertaken in some other settings around the world. In the clinics we observed and in other interviews, embryologists were highly valued by fertility specialists and considered crucial members of the care team for patients and regularly consulted for their expertise. Care-work enacted by embryologists in SSA includes human reproductive materials, patients, running the laboratory, the profession and data. We argue that this care-work, in concert with their technologies, is crucial to achieve the main goal of clinics in providing effective and (high) quality infertility care. Finally, we explore aspects of care-work relevant to infertility care within SSA. We describe aspects of the work of embryologists not mentioned in the previous literature, including fundraising by embryologists and their roles in establishing ‘first’ clinics, mobile work as ‘fly-in fly-out’ (FIFO) staff, combined professional backgrounds and advocacy work where there may be little or no government financial support for IVF, nor legislation or professional guidelines in place.
Methods
We draw on qualitative fieldwork and interviews conducted as part of a large ethnographic study on the emerging IVF industry in SSA. The qualitative methodology fitted the exploratory aims of the broader study and enabled us to combine different means of data collection, such as semi-structured interviews (SSIs), observations and conversations. In this ethnographic study, we interviewed 117 informants (including patients, clinicians, embryologists, nurses, counsellors and donors) from January 2022 to February 2023. This included key informants from across SSA (mainly South Africa, but also Uganda, Mozambique, Namibia, Tanzania, Ethiopia, Cameroon, Zambia and Ghana) and observations during visits to three public and six private clinics in South Africa – Pretoria, Johannesburg, Mbombela and Cape Town (in September and October 2022).
In this article, we draw on SSIs with 11 embryologists who work or previously worked in fertility clinics in South Africa, Namibia, Ethiopia, Uganda, Zimbabwe, Kenya and Zambia. Thirteen embryologists were approached for an interview, of whom 11 agreed, one declined, and one did not respond. The conduct of SSIs is a valid way to gain insights into people’s accounts – their views and experiences (Green & Thorogood 2018). Informants were recruited through direct approaches to fertility clinics and personal networks of the study team. As hardly anything is known about the role of embryologists in SSA and no database exists, we opted for a combination of convenience and maximum variation sampling, attempting to include embryologists working in different contexts, positions and clinics to explore their different views and experiences (Green & Thorogood 2018). We spoke with six male and five female embryologists, all working in different clinics; nine of them (had) worked in private clinics and three in public clinics; their work experience varied substantially, from around 40 years to a couple of years.
The SSIs, using a SSI-guide (presented in the Appendix, see section on Supplementary materials given at the end of the article.), lasted on average approximately one hour and were conducted in person during visits to clinics or via Zoom throughout 2022 and 2023. All participants gave signed informed consent. Participants were asked to describe their work and comment on their motivation to do this work and its challenges, describe their roles and tasks in the clinic, reflect on what they felt might improve access to ARTs in SSA and consider the future of IVF in the region. For the current article, we used insights gained about their motivation and variety in roles (see also Franklin & Inhorn 2025). All interviews except one were recorded and transcribed (in one case, when the informant declined to be tape-recorded, notes were taken manually). One interviewee asked for the interview guide before the interview took place and answered the questions in written form; this document was shared with the researchers during the interview.
Interviews were thematically coded (inductively) by the two first authors and then compared across the sample to note similar and contrasting opinions. As is common practice in social science, we provided all participants with pseudonyms (rather than numbers) to emphasize their personhood. Given that the community of embryologists is very small, we have not provided further data on the background and ages of informants to protect their anonymity. Ethical clearance was granted by Monash University (MUHREC 27166), the University of the Witwatersrand (M210546) and participating clinics. All names in this article are pseudonyms.
Findings
Motivations to work in embryology
You know I must be honest with you, there were many times that I really wanted to get out of it because in the beginning it’s long hours, it is irregular hours. In the days when we started out we would have aspirated in the morning and then in vitro culture the eggs and strictly 4 o’clock in the afternoon – you were not allowed to do fertilisation before 4 o’clock. So that being a Monday, a Saturday, or a Sunday, 7 days a week. That is how we used to work. So the hours were very difficult for me but then at that time it just so happened that every time that I wanted to get away or do something else my road just got deeper and deeper into this’… as much as I at times tried to get out of it my roads always lead into deeper things, more, yeah, and that’s why I’m still here.
When asking our embryology informants working in SSA IVF clinics to describe what their jobs entail and what an average day looks like, many first emphasized that ‘no day is the same’, given the enormous diversity of their tasks. In attempting to describe a ‘typical day’, one embryologist in an academic training clinic in South Africa explained in a written description:
Started work at 06:30 h with mail over breakfast and pre-reading intern reports, followed by evaluation of embryos progress in the embryoscope at 07:00 h; conducted morning meetings to discuss previous procedures, current embryo development and the day’s ART tasks; then undertook administration and in-person talks with interns at 08:00 h; followed by tasks related to the work program including dealing with financials/disposables/equipment/repairs at 11:00 h. At 12:00 h had to troubleshoot a lab event and problem-solve, then had lunch [during which time processed more emails]. By 02:00 h undertook some research work as well as professional association activities and database entry. Went home at 04:50 h and then at 06:00 h was involved in an African Federation Fertility Society – Webinar.
That is why I say I am actually in a very nice position here because I am an embryologist by registration, I still do embryology, I do what I love, I love working with sperm. And then also, I mean, the shipments and the donor sperm and I mean – when I started doing this I never thought I would choose a donor for a patient.
These multiple daily tasks and responsibilities were described as rewarding by all our informants, though also extremely challenging, given the extended hours of work each day and over weekends. Most described good relationships with the fertility specialists and other clinical staff, recognition of their importance to the workings of the clinic and autonomy in their scientific work (reinforced in our interviews with fertility specialists).
Ja, so for me it is difficult. Sometimes I get to work and I think ‘I’m done, I can’t be a mom and do this and have a husband that has a difficult job.’ But then I love the research side, and then there is just a new research question or this new thing popping up – and there are so many questions in this field! So from a research perspective, it is an amazing field to be in. (Octavia)
Some embryologists had a personal motivation for their involvement, such as seeing close relatives or friends suffer from infertility or not being able to conceive themselves. The latter was the case for embryologist Sam (Zimbabwe): ‘I mean I'm more than motivated, you know … that my child is an IVF baby and that’s why I was motivated, yeah; so I mean I couldn’t get any bigger motivation’. Octavia’s own experience of motherhood increased her motivation to continue working in the field: ‘And then I had my own child and for me it changed there … I realised this is what people want and this is why they are there’. For Billy, a family connection to the IVF industry in Uganda inspired him to gain an advanced degree qualification in embryology.
In addition, a number of embryologists undertake various forms of advocacy work, such as with government policies and institutions to improve funding for infertility treatment, to ease barriers to the importation of equipment and medication, or to improve access for patients. Embryologists were highly motivated because of their pioneering role in introducing fertility care in their country, as embryologist Erik (Ethiopia) explained: ‘The government, they didn’t give it any attention, the health professionals didn’t know about it too’. He noted the social stigma experienced by infertile people in Ethiopia, especially women, who he said had little recourse to biomedical treatment; here, polygamy, witchcraft or holy water were used to overcome infertility, and ‘women becoming nuns in convents and divorce’. In addition to working in embryology, Erik had become a fundraiser for a public infertility unit and saw himself as an advocate whose mission was ‘opening the eyes’ of health professionals and policymakers to the burden of infertility.
Sam was the only embryologist who mentioned that his involvement in embryology was partly financially motivated, although the profession attracts a relatively high salary, especially in the private sector, this also makes retention of embryologists in the public sector difficult. Erik, for example, referred to the different salary levels for expert IVF staff in the public sector in Ethiopia: ‘I think gynecologists were paid, like US $2000, and the embryologists, it’s like, not more than US $500 in a month, which is big money, actually’. Some embryologists intimated that they had moved into the private sector because of better conditions, pay and experience, contributing to shortages of embryologists in the public sector of SSA countries.
Caring for reproductive materials
The primary role of embryologists, recognized in the laboratory, is the responsibility for human reproductive materials. As noted above, the sense of care derives from the clinical work – the work of making a baby – and the work in preserving the materials of potential human beings through handling, testing, vitrifying, transporting and thawing with care. There is enormous responsibility invested in the embryologist; at any point, they can succeed or fail through technical mishap, neglect or carelessness. The laboratory work must be precise, documented and double-checked, all under time pressures. There is great emphasis on the efficient use of laboratory materials and time due to the demand for cost-efficiency and specific biological chronology – time periods required for fertilization, embryo development and transfers.
Several embryologists emphasized that they handle human embryos, which are – according to one interviewee – ‘not objects’. One argued that embryologists need to take care not to become disassociated from the embryo and to be aware of the special status of the embryos in the work they do. She illustrated this by recalling an event early in her career, when she had grown several embryos for one patient, and the clinician-in-charge had asked her to throw away three of those. She bluntly refused to do so – they were ‘perfectly good embryos’.
So what we used to do a few years back, the clinics give patients a flask, a thermos flask, and you fill it with [a medium] and you put your sperm or eggs in there and you travel it up and down. So with sperm I am fine with patients to do that, but now with eggs and embryos it is starting to get a bit risky. So [a shipping company] is close by and I always tell patients to contact them and let them bring their shipper and we pack the shipper or they pack the shipper – it is at an additional cost, I know, but at least we know it is safe; the shipper is upright. And I mean sperm is one thing, but if your embryo, that’s your last embryo and now you are walking around with it in a flask!
The technologies themselves figure in this care, as the ‘flask’ is not considered ‘safe enough’ for oocytes. Having appropriate, up-to-date, clean equipment, materials and space is paramount, and it is with pride that embryologists displayed to us their newest equipment, impeccable systems of record-keeping, effective systems for identifying material, checklists and workspaces. The technologies are both symbolically and pragmatically extensions of embryology care – they are the exclusive domain of the embryologist and the means through which material is tested, counted, fertilized and stored and through which vigilance and protection are enacted.
In recognition of the preciousness of the materials they are working with, some embryologists also referred to their dependence on higher powers, beyond technology, to be successful (Whittaker & Gerrits 2023). Praying at crucial moments, such as trying to find a healthy spermatozoon in a testicular biopsy or during ICSI fertilization, can be considered a practice of care undertaken in hope to increase the chance of success. For Sam, treatment failures were the most difficult of all: ‘Especially in the first year or two, you know it was really difficult when you failed, either you failed to fertilize the eggs or the embryos end – virtually no pregnancy’. Although he now feels he is experienced enough that he is capable of resolving most situations that confront him, he continues to call on God and says His support is still ‘dearly needed’.
Enacting care with patients
Embryologists may be thought of as technicians working in laboratory settings – dressed in white coats, wearing hair caps and gloves for hygienic purposes, distanced from the people they are working with and whose gametes they are handling with care. This does not reflect the situation of the embryologists we spoke with, who were all involved in emotional labour as part of their jobs, which was also observed by Fitzgerald et al. (2013). All of those interviewed directly interacted with and cared for their patients outside the laboratory, and this seemed to be an essential and rewarding part of their job. These interactions differed depending on the kind and size of the clinic(s) in which they worked, their particular professional background, including training additional to embryology, and the position they held in the clinic.
I think, you know I try to just, I try to involve them as much as I can so that in the end they will realise that I cannot guarantee them a baby, but I can guarantee them that I will walk the road with them. And I think having the first interview, … I have about half and an hour interview with them explaining to them what we’re going to do, how they can expect to feel, what they can expect in terms of feedback, when they should be coming back, what we’re going to do with the embryo transfer, what will happen to their remaining embryos and in my way I try to familiarise them with very unfamiliar circumstances, and also try to at least put them in control in a situation where they don’t have control over anything …
The patients first of all, I mean it’s varied. You have the highly educated ones who come to you after they have done all their research on the internet or whatever and then you have those who have no idea what they are even doing. So our way was really to break it down to them at their level. You know I explained the concept of a seed and the soil, why does the seed germinate and others don’t germinate… This is what you are going to go into, this is what you should expect and these are the success rates. If you are not successful we can do this again. These are your options. So we used to have very good dialogues and we would discuss options, you know.
(The patients) become so anxious as to (say things like) ‘yesterday you said I had nine eggs, now today you say only five have been fertilized, now tomorrow only three are developing, what is happening? Will I – you know we can’t do anything about the stress that these people are under, or we can’t take it away. It’s part of the whole thing, but you can definitely limit the period that they have to cope with it on a daily basis but by at least talking to them, explaining to them what the real situation is.
If somebody really was post-menopausal, you know there was no point in wasting time selling them what you don’t have (IVF with her own eggs), but we freely talked about the concept of egg donation, egg sharing, surrogacy, but breaking it in a way that they could digest. For instance, somebody would say ‘Hey, but if another woman carries my baby then that’s not my baby’, and then we explain the genetics but at the level that they understand.
It is a huge responsibility, but I do look at it very scientifically. I never help a patient choose a donor if they say they have no selection criteria. So you need to give me three or four selection criteria, we need to have something, so I try and approach it as scientifically as possible with as little emotional connection to it as possible.
Embryologists are also heavily involved in clinic policies and ethical considerations surrounding the use of third-party material. In South Africa, sperm donation is allowed to be anonymous, but elsewhere in SSA countries where our informants worked, little or no regulation existed. This means that clinics determine the ethical considerations and conditions under which third-party material is used (cf. Hörbst & Gerrits 2016a). For example, in Zimbabwe, although third-party donation is currently anonymous at their clinic, embryologist Sam is concerned that in the future, direct-to-consumer DNA testing may result in donor-conceived children tracing their family background: ‘I am worried for 20 years to come or so’. For that reason, to be able to care for such requests in the future, he keeps track of donors’ names and other details. At the time of the interview, this was a handwritten file; subsequently, a digital donor record system was installed at the clinic.
Providing information on the procedures around shipping donor gametes and embryos is another task of one South Africa-based embryologist, although the actual shipping is organized by companies that provide specialized IVF courier services. This also involves direct communication with patients, to explain the options and procedures. Although the clinic is not legally responsible for these courier tasks and the risks involved, such as the materials not being carried properly and therefore arriving damaged, Octavia had to have conversations with patients about this.
Caring for the clinic
Due to the paucity of infertility clinics across the SSA region, several embryologists were involved in work as ‘pioneers’ lobbying for funding and investment to build ‘first’ clinics (both public and private), getting them running and offering a variety of treatments (including egg and sperm donation), or expanding to other countries. We consider this as ‘caring for the clinic’. This was time-consuming work that was additional to actual laboratory work – caring for ‘precious’ materials – and caring for patients.
Setting up a clinic involves several steps: budgeting; finding investors or engaging in some form of crowdfunding; finding a proper building and adapting it to fit the requirements of an IVF clinic and laboratory; recruiting and training staff; purchasing equipment and arranging permissions for its import; getting medication approved, ordered and stored; guaranteeing backup of medication; logistics to ensure adequate supplies of culture medium; and so forth. In these steps, embryologists were confronted with various hurdles and challenges. One embryologist had undertaken such work in several countries and was often called in to troubleshoot laboratories with poor success rates to try to identify and fix the problem.
Convincing other people, either policymakers in the public health service sector or private investors, to support the establishment of a clinic was the first hurdle they had to take. International professional contacts – experts they met during training abroad or at international conferences – were important for this. Erik, for example, collaborated with an Ethiopian university to convince some government officials and university professors to establish a public IVF clinic in a wing of an existing hospital. In the absence of financial support from the government, he then facilitated liaison with a US university clinic, which led to support for the IVF clinic for a period of five years. To staff the clinic, three gynaecologists working in the hospital and interested in infertility were recruited and sent to Taiwan for short IVF training courses and to Egypt for on-the-job training; embryologists were sent to India for a six-week course. Erik then assisted with getting approval for medication and culture media, all newly introduced products in Ethiopia, which had to be approved by the Ethiopian Drug Administration. The bureaucratic hurdles in getting approvals were manifold; at the time of the interview (October 2022), they were still in process. The public IVF clinic started functioning in 2021, more than two years after Erik proposed the clinic.
Meanwhile, Erik had found another investor – a private company – prepared to invest in a private IVF clinic in Tigray Province. This company uses money from private investors who want to invest in health, led by a UK citizen originally from Ethiopia who understood the problem. With this investor, Erik was able to convince the government hospital in Tigray Province to build a new storey on top of the existing women’s hospital – ‘they preferred it not to be a solo IVF clinic, because it’s like, people don’t like it, it will be like, discriminatory’. Due to hostilities in the province, this clinic was not used when this interview was conducted – ‘it’s sitting there. Everything is there, the equipment. It’s idle now’. So, while Erik spent much time in setting up IVF clinics in Ethiopia, he has returned to a third country to work as an embryologist.
Other embryologists reflected on similar challenges in setting up and expanding IVF clinics in SSA. Billy, who has lived and worked for a long time in Uganda as an embryologist, well remembers the efforts it took to get IVF introduced and the system working. Over the years, he invested time and effort in organizing IVF logistics. He arranged to purchase equipment, second-hand, from a European IVF centre that was closing, and had to convince the government that this was not just ‘the West dumping their used stuff’. Some large scientific equipment suppliers did not yet have agencies/offices in SSA, and they even had to buy instruments like a small microscope in Dubai, which was the nearest agency. Billy mentions that they were quite privileged from the start, ‘despite only purchasing and importing culture media, really buying a small quantity of stock for a limited number of patients’. He noted the support he received from ‘friends from Brussels who kind of lobbied for us’, which enabled them to establish relationships when going to conferences and allowed them to buy smaller quantities: ‘And, when their numbers were increasing over time (the companies) started taking us more seriously and they could ship (larger quantities)’.
When they (government officials) don’t know these kinds of things, equipment and all, they tend to classify them as they want that attracts a whole huge duty. So it took us some kind of diplomacy dealing with key stakeholders in the ministries of health, and some government officials, some of whom had been our patients, to lobby. So once those kinds of people did speak on our behalf, yeah for some countries especially Uganda we had the favour of having a lot of the duties on some of these things lifted. So that helped us.
Other embryologists had similar stories of their work setting up clinics, lobbying for funds, approaching investors and negotiating with government agencies. These roles are far beyond those typically associated with embryologists but indicate the crucial roles they play in advocating for the expansion of infertility services across SSA.
Transnational mobilities: care-work across borders
The shortage of expertise in embryology in many countries in SSA leads to the movement of clinicians and embryologists to provide services on rotation across the region, ‘flying-in flying-out’ (FIFO) across countries – and even continents – to deliver their lab services in short periods of time, often on a monthly or bimonthly basis (Hörbst & Gerrits 2016a,b, Franklin & Inhorn 2025). This transnational mobility – of patients and staff, gametes and embryos, lab equipment, materials and medication – complicates the functioning of the clinic and laboratory and further extends the care-work of embryologists across borders.
This mobile FIFO work involves travel on a regular basis to other ‘satellite’ clinics or laboratories to deliver laboratory services in countries without embryology staff. This affects the work of embryologists, leading to an increase in ‘batching’, a practice that involves the control and manipulation of women patients’ hormonal cycles so that egg retrieval, fertilization of eggs with sperm and embryo transfer can take place for a cohort of patients within a discrete time period of a few days, making efficient use of the presence of embryologists. Embryologist Billy, for example, has worked on a regular circuit traversing satellite clinics in Uganda, Tanzania and Zambia. The organization of work is influenced by the scarcity/availability of certain expertise –in particular embryologists – and the need for time, material and cost efficiencies. For the embryologist, such work is intensive. Peter, for instance, noted the intensity of his workload during periods working in a satellite clinic in Namibia and elsewhere outside South Africa when he is the only one in the laboratory, ‘so I do everything. Instead of there being two or three people helping there is only one person’.
Caring for the profession
(I) encourage independent evidence based-scientific thinking and life-competencies. So that interns carry on a philosophy of strong self-worth, develop their own capabilities, based on experiences and knowledge where to get answers if in doubt.
Trainees in medical embryology are carefully selected. As one trainer noted, embryologists must be able to carefully handle the precious materials they are going to work with, and not everyone has this capacity. Our interviewees noted that approximately 15 applicants apply annually in South Africa to be trained in medical embryology, usually coming from biological science backgrounds, but of these, only three are accepted due to the limited capacity to train more. The applicants have to spend a day in a lab to watch the realities of the work involved. The embryologists and medical scientists with whom they work during that day will then score the applicant on a number of qualities, before the applicant is invited for an interview. At the interview, we were informed that their motivation for training and the work is an important topic.
Once trained, most embryologists are in such demand that they are lost to public health systems and usually find work in the private sector. Several experienced embryologists in our sample had emigrated for further training opportunities and experience and also, in some cases, to permanently live and work overseas. As a result, across SSA, clinics complained about the difficulties in attracting and retaining embryologists and other medical science staff.
Discussion and conclusions
While working in the IVF laboratory – performing laboratory technical tasks – may be thought of as the embryologists’ primary task, in our study, all embryologists combined various forms of work beyond what is usually considered their conventional ‘role’. This is partly due to the context in which they work. Our exploration of the work of embryologists highlights the importance of context in shaping their practices, interactions and expectations. The shortage of embryologists, the lack of ‘corporate’ multi-centre IVF clinics in South Africa and the region (as may be the case in the US), the paucity or lack of trained counsellors in clinics, the mobilities in IVF staff and patients characteristic in the region and the need to set up ‘first’ clinics in many countries all mean that embryologists’ work extends beyond the technical. Within SSA, their roles often involve tasks beyond what might be expected of an embryologist in a laboratory in the US or Europe. The shortage of embryologists, other clinical staff and counsellors affects practices in SSA clinics, and accordingly, embryologists we interviewed undertook entrepreneurial tasks, advocacy, training, development of regulations and mentoring and patient counselling, on top of laboratory work. Clearly, this varied with the size of the clinic and its stage of development (for example, fundraising was only done by embryologists initiating a clinic). This combination of tasks makes for a dynamic and fulfilling career for those we interviewed but also stretches their capacities. It raises the question of whether their deployment across this range of tasks contributes to the scarcity of embryologists in SSA.
We conceive of the work of embryologists as forms of care-work and suggest that care is enacted (and experienced) in IVF clinics through the sum of tasks, technologies, patients and other staff, which together enact care. This not only suggests the importance of care as a fundamental outcome of the work of all staff and technologies but also suggests the importance of the context, expectations and reception of care. This is a different approach to the traditional view of care in IVF clinics, which tends to view it as part of a job description of a particular staff member and assumes that quality care follows their actions alone. Our approach breaks down divisions between ‘technical’ and ‘clinical’ staff and recognizes the various ways in which care is enacted: towards gametes and embryos, clinics and technologies, the profession, patients and, in SSA, the broader goals of providing access to infertility treatment to patients who need IVF.
The embryologists we interviewed were all involved in various forms of emotional labour and care with patients; they took pride in this and saw this as part of ensuring quality patient care (Fitzgerald et al. 2013). We were initially surprised by this, and this also contrasted with the experience of one embryologist who had worked in the US, where they had no contact with patients. Embryologists we interviewed saw themselves not only as technically adroit but also as responsible for creating families. They found that patient contact motivated their careful handling of the ‘precious’ human reproductive materials with which they worked. However, some of the interviewed embryologists are undertaking tasks, such as counselling or donor selection, for which they are not necessarily trained (although it should be mentioned that one of the interviewees combined specializations – in embryology and psychology – which justified this combination of roles). IVF clinics are strongly recommended to follow internationally accepted guidelines for IVF counselling and the use of donor material and donor selection, as provided by ESHRE and other professional organizations, which include the training of specialists in these fields (https://www.eshre.eu/Guidelines-and-Legal).
In the Global North, the changing work of embryologists is a subject under discussion. This has been prompted by the advent of automated AI and microfluidics, which will change the technical roles of the embryologist away from manual manipulation and towards more data capture, management and analysis (Bori & Meseguer 2021). However, in other ways, our study suggests that the caring role of embryologists with the advent of new technologies may be increased, requiring vigilance over AI decisions and increased need for informed communication with patients.
Recognition of the deep engagement of embryologists in enacting care and contributing to successful IVF in their clinics is essential. In Global South countries such as those in SSA, the context in which embryology is practised poses differing challenges. Given the shortage of embryologists in SSA, their deployment across a range of tasks contributes to the scarcity of embryological work. In SSA countries, access to affordable and effective IVF is required, and there is a pressing need to train more embryologists to cater to the growing need for and use of medically assisted reproductive technologies. Furthermore, models and technologies of low-cost IVF all require the human resources of trained embryologists to ensure quality care and efficacy. If access to IVF is to be achieved in the region, then more embryologists need to be trained and retained.
Study limitations
A major limitation of this study is that only 11 embryologists who are or have been working in SSA have been interviewed, not covering all SSA countries where IVF clinics exist. However, as this study/article is intended to explore the variety of embryologists’ roles and the various forms of enactment of care – and not intending to make generalizations and/or judgements about the functioning of the embryologists in these clinics – this is not considered to be a major problem.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/RAF-24-0025.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.
Funding
This work was supported by the Australian government through an Australian Research Council Discovery Project Grant (DP 200101270).
Author contribution statement
TG and AW conceived the study, conducted the interviews, analysed and interpreted the data and authored the article. LM analysed and interpreted the data and co-authored and edited the article.
Acknowledgements
The authors wish to thank all participants in this research. The authors wish to thank other members of the project team, including Associate Professor Karin Hammarberg (Monash University), Dr Tessa Moll (University of the Witwatersrand) and Cal Volks (Monash University). Ethical clearance was granted by Monash University (MUHREC 27166), the University of the Witwatersrand (M210546) and participating clinics. Signed informed consent was obtained from all informants.
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