Watching embryos: exploring the geographies of assisted reproduction through encounters with embryo imaging technologies

ABSTRACT

New biomedical imaging technologies, which enable embryologists to observe the development of human embryos, are presenting new possibilities for the lived geographies of assisted reproduction. More specifically, these technologies produce novel visual representations of in vitro embryos that can be shared with fertility patients as a way to involve them in their treatment, and we explore how this imagery circulates in places and relationships beyond the fertility clinic with diverse effects. Drawing on empirical material from interviews with both patients and partners undergoing in vitro fertilisation (IVF) in the UK, this article critically examines how encounters with embryo imagery create spatially and temporally extended as well as intimate relationships between people and a particular kind of reproductive bioinformation. Through this, we advance geographical approaches to embodied encounters with assisted reproductive technologies, biomedicine and bioinformation, as well as social and cultural conceptualisations of the mobilities of extracorporeal embryos and their visual representations. Patients and partners’ engagements with a new form of reproductive bioinformation provide important insights into the making of new reproductive knowledge and experience.

Resumen

Las nuevas tecnologías de imágenes biomédicas, que permiten a los embriólogos observar el desarrollo de los embriones humanos, presentan nuevas posibilidades para las geografías vividas de la reproducción asistida. Más específicamente, estas tecnologías producen representaciones visuales novedosas de embriones in vitro que se pueden compartir con pacientes de fertilidad como una forma de involucrarlos en su tratamiento, y exploramos cómo estas imágenes circulan en lugares y relaciones más allá de la clínica de fertilidad con diversos efectos. Con base en el material empírico de entrevistas con pacientes y parejas que se sometieron a fertilización in vitro (FIV) en el Reino Unido, este artículo examina críticamente cómo los encuentros con imágenes de embriones crean relaciones íntimas y extendidas espacial y temporalmente entre las personas y un tipo particular de bioinformación reproductiva. A través de esto, avanzamos enfoques geográficos para encuentros que se manifiestan con tecnologías de reproducción asistida, biomedicina y bioinformación, así como conceptualizaciones sociales y culturales de las movilidades de embriones extracorpóreos y sus representaciones visuales. Los compromisos de los pacientes y sus parejas con una nueva forma de bioinformación reproductiva brindan información importante sobre la creación de nuevos conocimientos y experiencias reproductivas.

Résumé

Les technologies d’imagerie biomédicale novatrices, qui permettent aux embryologistes d’observer le développement des embryons humains, offrent de nouvelles options à la géographie vécue de la procréation médicalement assistée (PMA). Plus précisément, ces technologies produisent des représentations visuelles inexplorées des embryons in vitro, qui peuvent être partagées avec les patients pour la fertilité afin de les impliquer dans leurs projets de soins. Nous explorons les manières dont ces images circulent dans les lieux et les rapports au-delà des centres de PMA-FIV, avec des effets divers. En s’appuyant sur des données empiriques provenant d’entretiens avec des patients qui suivent un traitement de fertilisation in vitro (FIV) au Royaume-Uni, ainsi qu’avec leurs conjoints, cet article examine de manière critique comment les rencontres avec les photos d’embryons créent entre les personnes et un type particulier de bioinformations de la procréation des rapports qui s’étirent spatialement et temporellement, mais qui sont aussi intimes. Avec tout cela, nous faisons progresser les approches géographiques concernant les rencontres concrètes avec les technologies de procréation médicales assistées, la biomédecine et les bioinformations, ainsi que les conceptualisations sociales et culturelles des mobilités des embryons extra-corporels et de leurs représentations visuelles. Les engagements des patients et de leurs conjoints avec de nouvelles formes de bioinformations de la procréation offrent des perspectives importantes pour la réalisation de connaissances et d’expériences inédites pour la procréation.

KEYWORDS:

• Geographies of reproduction
• assisted reproductive technologies
• embryos
• bioinformation
• biomedical imagery

PALABRAS CLAVE:

• Geografías de la reproducción
• Tecnologías de reproducción asistida
• Embriones
• Bioinformación
• Imágenes biomédicas

MOTS CLEFS:

• Géographie de la procréation
• technologies de procréation médicalement assistée (PMA)
• embryons
• bioinformations, imagerie biomédicale

Introduction

In the UK it is estimated that about one in seven couples will experience difficulty conceiving (National Health Service, 2020) and the prevalence of in vitro fertilisation (IVF) as a response to infertility has risen steadily over the past decades to almost 70,000 cycles across 54,000 patients in 2018 (Human Fertilisation and Embryology Authority, 2020). Yet the process and technique of IVF has undergone significant change since its first human application in the 1970s, in large part due to the rapid development of new treatments and technologies. This article is specific in its focus on the emergence of a novel form of biomedical imagery and the implications of this for patients’ experiences of assisted reproduction. In particular, we examine the spatial relationships between the fertility clinic and the home as these sites come into being through the movement of biomedical imagery from the embryology lab and into domestic space, which we explore through fertility patients’ deeply spatialised accounts of their encounters with such imagery. This article thus extends a diverse scholarship on the lived geographies of assisted reproduction (England et al., 2019) by examining the continuously evolving social and spatial dimensions of fertility treatment and bringing this into conversation with conceptualisations of bioinformation (Parry & Greenhough, 2018) and the places of biotechnological ‘products’ – such as embryo imagery – in the spaces of everyday life (Greenhough & Roe, 2006).

A relatively recent innovation in IVF has been the widespread introduction of time-lapse imaging technologies (TLIT) in embryology labs across the UK. Whereas previously embryologists observed the in vitro development of embryos at certain intervals by manually placing the Petri dish under a microscope, time-lapse incubators have integrated cameras that take frequent photos of the embryo without needing to remove the dish from the incubator. These photos are stitched together to produce a video that shows the embryo developing, or ceasing to develop, over its first days. This more continuous visual record offers a rich source of visual and temporal data from which embryologists are able to evaluate the appearance and development patterns of embryos (for an analysis of how TLIT is used by professionals, see, Perrotta & Geampana, 2020). TLIT therefore offers information about embryo development that has not been available previously. The introduction of TLIT in IVF is also indicative of a broader process of datafication in the field of assisted reproduction. Through data, new in silico ways of seeing and evaluating embryos are produced (Van de Wiel, 2019, p. 196) with the aim to improve the grading and selection of ‘the best’ embryos that are most likely to lead to pregnancy (Perrotta & Geampana, 2021). Extending beyond the use of TLIT in the lab, many clinics also share time-lapse embryo videos with patients as a way to involve them in their treatment.

To explore patients’ encounters with embryo imagery, we build on established literature that explores how foetal visualising techniques enable new conceptualisations of embryos and foetuses that are situated and multiple (Morgan, 2009; Petchesky, 1987; Roberts, 2012a; Taylor, 2008). Although the public narrative around foetal imaging suggests that the content of the foetal image is self-explanatory (Petchesky, 1987), a growing body of research examining routine ultrasound has found that these images are not universally meaningful (Mitchell, 2001). In particular, the scan room is one site of meaning production where interpretations of imagery emerge from the social interactions between ultrasound workers and patients, in which the former ‘show the baby’ while the latter ‘see the baby’. Encountering 3D or 4D imagery during ‘bonding scans’ in the more advanced stages of pregnancy also relies heavily on a process of ‘collaborative coding’ in which sonographers and expectant parents create meaning together (Roberts, 2012b, p. 299). Sonographers are central to both clinical and social interpretations of ultrasound images by producing clinically-necessary assessments (such as measurements of foetal anatomy) as well as take-home pictures for the intended parents, which are often referred to as the ‘baby’s first picture’ (Mitchell, 2001). As Taylor (2008, p. 67) has suggested, foetal ultrasound scanning needs to be understood as a ‘hybrid practice’ that involves navigating the blurred boundaries between medical practice and consumer culture.

Here we investigate how TLIT produces new ways for patients to visualise and know about embryos, including their own embryos, in the context of their IVF treatment. In the following sections, we provide a brief description of the IVF procedure and locate our focus on embryo imagery within broader scholarship on the spaces of reproduction, reproductive technologies and bioinformation. Then we describe the research methodology before turning to the empirical material.

The IVF procedure

In the UK, IVF is provided both via the National Health Service (NHS) and private fertility clinics. The availability of funded fertility treatment, and the eligibility criteria for this funding, is determined by the patient’s local Clinical Commissioning Group (CCG). If a patient uses up their funded treatment, which is usually between one and three cycles, they have the option to continue on a self-funded basis at either a blended NHS/private or fully private clinic. This study included patients from across NHS and private fertility clinic settings.

It is important to note that IVF patients have often been trying to conceive for many years prior to starting IVF. Becoming an IVF patient is therefore one part in a longer pursuit of conception and the birth of a child. In practice, IVF involves collecting ova through a surgical procedure and mixing these with sperm in a petri dish. Any fertilised ova, or embryos, are placed in an incubator to develop for up to six days. Embryologists observe how the embryos develop over these days, either under a microscope or via an integrated camera. The patient is called back to the clinic when the embryologist deems it appropriate to attempt an embryo transfer, usually after three to five days. During the embryo transfer procedure, the ‘best’ embryo, or occasionally two embryos, are selected and placed in the patient’s uterus. Any remaining embryos can be frozen and stored for future use. It is often at the embryo transfer stage that the clinic staff will offer patients imagery of the transferred embryo, usually in the form of a printed picture or a USB containing the time-lapse footage. From the perspective of the clinic, the transfer appointment is potentially the last time that staff will see the patient in person and it offers a convenient opportunity to provide the patient with these visual materials.

After the embryo transfer, patients will wait for approximately two weeks until they can take a pregnancy test. Failed implantation or early pregnancy loss is usually determined by the patient themselves through a negative pregnancy test and the onset of menstrual or uterine bleeding. If the transferred embryo(s) implant in the uterine lining then a pregnancy has started and, if the pregnancy progresses, there is usually no reason for the patient to return to the fertility clinic. However, about three out of four embryos transferred do not result in a live birth (Human Fertilisation and Embryology Authority, 2020), which means that most patients will undertake multiple ‘rounds’ of IVF.

Spaces of assisted reproduction

Geographical studies have offered critical attention to a diverse range of embodied encounters with reproductive biomedicine as these shape experiences of health and illness and unfold in specific places, such as ultrasonography clinics (McNiven, 2016). Places of medicine are never static but fluctuate in response to a whole range of socioeconomic, cultural and historical circumstances, such as the incursion of neoliberal and consumerist ideologies into medical sites. The growth of a private sector where medical expertise is considered a service that can be purchased and ‘consumed’ has transformed patients into customers (Kearns & Barnett, 1997). Fertility clinics in the UK frequently combine treatments provided on the NHS and treatments offered at additional cost to the patient, which has prompted public debates about the business of the fertility industry and the moralities of ‘selling hope’ to patients (Perrotta & Hamper, 2021).

Fertility treatment primarily takes place at a fertility clinic due to the frequency of surgical or other specialist procedures, such as ultrasound scanning, egg retrieval and embryo transfer, combined with the need for these procedures to take place in close proximity to the embryology lab. Yet the highly regimented and medicalised treatment protocols of the clinic seep into the spaces and organisation of domestic life for patients (Sheller, 2020), who are required to participate in their treatment through, for instance, self-administering medication and hormone injections. The everyday management of treatment regimens constitutes a significant part of patients’ experience, yet this ‘private’ work is largely invisible from dominant representations of IVF, which tend to favour the ‘supremely technological moments of the process’ such as fertilisation or the embryo transfer (Throsby, 2002, p. 75). Geographers of health and medicine have long been critical of the notion that the home provides privacy or a safe space of health care. The incursion of medical devices, technologies or logics of care into the home can constitute a loss of autonomy and reveal the co-vulnerability of both the home and the body (Dyck, Kontos, Angus & McKeever, 2005). There is no universal experience of the home that guarantees more private encounters in this location and the preservation of private spheres has been deeply problematic for how it legitimises the confinement of ‘inappropriate’ bodies or acts of reproduction to a feminised home space (Longhurst, 2008).

In the broader field of social studies of reproduction, intimate spatialities and places of assisted conception outside of the clinic have been examined most closely in relation to LGBT conception, especially home insemination. For instance, in Mamo’s (2007) study of lesbian conception she states that the home is often perceived as the ideal place for performing insemination with a sperm donor. She notes how the women she interviewed described home insemination by drawing on tropes of romance, sexual intimacy and comfort attached to the home, but that these descriptions did not exclude medicalised and ‘high-tech’ procedures of insemination. Home insemination constitutes what Mamo calls a hybrid-technological practice that brings together multiple meanings, technologies and settings in a complex negotiation of medical and non-medical as well as high- and low-tech forms of conception.

Also considering lesbian conception, Nordqvist (2011) discusses how couples managed closeness and distance in their relationships with sperm donors through strictly managing their access to and use of domestic space. For couples undergoing donor insemination at a reproductive health clinic however, procedures for enabling donor anonymity and the managing of donor samples through screening and sanitising provided integrated means for patients to distance themselves from the donor. Nordqvist’s research shows how the social, spatial and symbolic organisation of the clinic and the home significantly shape practices and experiences of conception. In this way, personal and familial boundaries and intimacy are curtailed and enabled through spatial strategies. Yet it is also worth emphasising that the home is certainly not the only location in which practices of assisted reproduction take place. Sometimes, hormonal drug regimens require women to self-inject while at work (Throsby, 2002), and some donor conception arrangements are designed to avoid the home and clinic altogether in favour of meeting in more transient locations (Morton & Bell, 2016).

Experiences of fertility treatment are therefore shaped by the choreographed (Thompson, 2005) but also differentiated movement of people and things between places, including labs, clinics, hospitals and the home or other places of living. Sheller (2020) has conceptualised the physical, virtual and imaginative mobilities of reproduction – or reproductive (im)mobilities – to explore how processes at the microscopic and bodily scale have been ‘disembedded, dispersed, and put into motion’ (Sheller, 2020, p. 189) across a whole range of extended geographies. This is demonstrated through the movement of gametes, stem cells and female reproductive tissue that become imbricated in the global networks of value and meaning (Fannin, 2011; Parry et al., 2015) as well as geographical imaginations of biological origins and relatedness as these traverse the scales of family, nation and global humanity (Nash, 2005).

Following England et al. (2019), attending to the spatialities of reproduction is central to understanding changing reproductive lives. It is widely acknowledged that the rise of a global fertility market has intensified the commodification of reproductive labour, bodies, bodily resources and technologies (Schurr, 2017). This fertility market is deepening the uneven distribution of agency and power that privileges certain kinds of reproduction – and certain kinds of ‘legitimate families’ – over others (Lewis, 2019, p. 22). Reproductive politics materialise for individuals through their experiences of and access to reproductive technologies. Foetal imaging, for example, offers individuals some control and choice over reproductive outcomes but it also creates new and potentially difficult knowledge, decisions and dilemmas (Petchesky, 1987; Roberts, 2012a; Taylor, 2008). We explore the consequences of innovation in embryo imaging technologies for the complex enactment of patient agency at the scale of the individual.

Conceptualising embryos

While our focus in this article is on patient encounters with particular visual representations of embryos, our analysis of these encounters draws on broader conceptualisations of IVF embryos in social and cultural analyses of reproductive technologies. Franklin (2013a) has demonstrated how the embryo has become a visually iconic image of IVF and central to the public imagination of assisted reproduction. More fundamentally, she shows how the visual culture of embryos has shaped understandings of the ‘natural facts’ of life and become ‘a highly public spectacle that refigures sex as something that is made’ (Franklin, 2013a, p. 25). Franklin (2013b) uses IVF as a lens through which she explores the dissolving boundaries between the biological and technological – or what she terms ‘biological relativity’ – where biology is increasingly understood as technological and vice versa. In IVF, biology becomes de-naturalised, in part through its detachment from the body and relocation to the lab, but also re-naturalised through a normalised logic of intended parents wanting a biologically related child. While the actual making of embryos through IVF is confined to the embryology lab, embryos have a social – and spatial – life that enables them to become imbued with familial, emotional, legal and commercial value.

Geographers have started to engage with the extracorporeal, mobile embryo and the ways in which it opens ‘up the biology of fertility to flexible spatial possibilities’ (Collard, 2020, p. 108). While physically detached from the body and displaced from the uterus, embryos come from somewhere and are attached to biographical histories (Mansfield & Guthman, 2015; Schurr, 2017). Collard (2020) has explored how embryos move through and between networks of biovalue, including the fertility clinic and the tissue economy, and how definitions of embryo normality, abnormality, health and illness emerge in and from particular times and places. Historically, embryo collection has been shaped by social and political contexts that enable the surveillance of pregnancy and collection of embryos through, for instance, early abortion (Fannin, 2019). Attending to representations of embryos in medical descriptions of pregnancy, Stratford (2015) shows how the procedure of IVF enables the body interior and spaces of the clinic to be mapped out through the movements, rhythms, scales and spatial relations that come together through the moving embryo. Beyond the medical domain, prolific artistic representations of embryos in pregnancy smartphone apps have become central to contemporary visual cultures of pregnancy, and these digital representations can produce new spatial and temporal opportunities for making relations to an embryo as a future child (Hamper & Nash, 2021). Our focus on time-lapse embryo videos is similarly attentive to how embryo imagery materialises in different ways in different places, and how this shapes people’s understandings of and relationships to biological material through visual information.

This brings us to geographical approaches to biotechnologies and bioinformation, which examine how an ‘embodied biotechnological analysis’ can renegotiate expert knowledges in ways that make sense within people’s social worlds (Greenhough & Roe, 2006). Greenhough (2006) considers how bodies and bioinformation become a resource and commodity, and importantly, how the ‘distinctive qualities of bioinformation are, in part at least, to do with its ability to be detached from its original (human) biological context’ (Greenhough & Roe, 2006, p. 447). For instance, the movement of medical records from the clinic into other domains and associations prompts the renegotiation of the value and capacity of these documents. Following the definition provided by Parry and Greenhough (2018), time-lapse videos of embryos can be conceptualised as a form of bioinformation in that they emerge from a living entity and provide data that are used to describe, stratify and differentiate.

Parry and Greenhough (2018) emphasise how bioinformation is central, especially in the medical sciences, to processes that remake biology into a form that can be read and analysed. Yet the interpretation and consumption of bioinformation are situated practices shaped by the qualities and significance assigned to bioinformational entities. As shown by Morgan (2009, p. 4), embryos are a relatively recent ‘invention’ of modern science but they have since taken on meaning through their centrality to stories of human origin and future. In this article, we explore IVF patients’ perspectives on and encounters with embryo imagery as a particular kind of reproductive bioinformation. Through this focus, we show how reproductive bioinformation constitutes and facilitates relationships to embryos, which has important implications for the redistribution and expansion of reproductive knowledge and experience.

The study

This article emerges from a broader research project that considered the perspectives of both fertility professionals (including clinic staff, consultants and embryologists) and patients on technological innovations in IVF (Perrotta & Geampana, 2020; Perrotta & Hamper, 2021). Here, we draw on interviews with 42 participants, including 34 women who were going or had been through IVF, seven male partners and one female partner. At the time of the interview, 16 participants were undergoing or about to start IVF treatment, 16 were pregnant or had pregnant partners, and 10 had one or more children from IVF. While we recognise that partners may be patients at certain points in the treatment process (through their role in diagnostic tests or gamete donation), for simplicity we use the term patient to define the individual who intended to receive the embryo. Participants were aged between 29 and 47, with a mean age of 36, and they were recruited from across England.

Participants had diverse trajectories through fertility treatment. Most had tried to conceive for one to three years before attending their General Practitioner as a first point of contact. This would often be followed by months or years of diagnostic tests and other less invasive treatments such as intrauterine insemination. At the time of the interview, 17 participants had been trying to conceive for over five years. In terms of their IVF experiences, just over half of the patient participants had completed one or two embryo transfers in total. At most, two patients had completed six and seven transfers respectively. For many participants, their fertility treatment involved experiences of loss. Over a third reported pregnancy loss(es) either shortly following implantation or later in the pregnancy. Many also talked about the loss of embryos following unsuccessful embryo transfers or the perishing of frozen embryos through thawing. Reflecting McNiven’s (2016) emphasis on the diversity of loss experiences, our participants’ descriptions of loss were not always associated with pregnancy, nor did they necessarily indicate the loss of a living entity. Whereas some described embryo losses as the loss of potential babies, others talked about them as the loss of valuable biological material. Patients’ experiences of fertility, pregnancy and loss undoubtedly shaped the meanings that they attached to embryo imagery.

The recruitment of patients and partners took place through two routes. 22 participants were identified and recruited by research nurses at participating NHS fertility clinics. Research access was granted at these clinics, giving the research team permission to interview patients on-site. Interviews were pre-arranged by research nurses and took place in vacant consultation rooms, usually during weekends or evenings. Participants attended the clinic especially for the interview, which was arranged separately from any other clinical appointment. A further 20 participants were recruited via an online survey (n = 314) that was distributed in relevant social media groups. On average, interviews undertaken at the clinics lasted 40 minutes, whereas interviews over the phone or at the participant’s home were often longer at around an hour. All interviews were conducted by author Josie Hamper. In combination, these recruitment methods enabled us to reach patients who were undergoing NHS-funded treatment, privately funded treatment, or a combination of both. The study was approved by the university’s research ethics committee, the Health Research Authority¹ and locally at the participating fertility clinics, and all participants provided written consent.

Interviews were semi-structured, including a broad introductory question that invited the participant to narrate a timeline of events relating to their IVF treatment, followed by questions organised broadly around treatment choices and options, and patients’ encounters with visual imagery of embryos. During or after the interview, several patients offered to show the interviewer videos or photos of their embryos or themselves at various moments in their treatment, usually via their personal phones. While these images were not documented as research data, this sharing offered rich insights into the materialities of digital and printed images and their circulation.

Interviews were recorded and professionally transcribed, then analysed following the basic tenets of a grounded theory approach (Charmaz & Belgrave, 2012). Our analysis is organised into four sections. Firstly, we explore how participants conceptualised the value of TLIT in relation to the clinical procedure and science of IVF. Secondly, we attend to patients’ encounters with a diverse range of still, moving and live embryo imagery in the fertility clinic and explore how seeing visual representations of embryos in this setting made sense as part of the clinical encounter. This discussion enables us to examine how time-lapse videos of embryo development differ in important ways from the other kinds of imagery that patients routinely encounter during IVF. Thirdly, we refocus specifically on the times and places in which patients received and viewed time-lapse videos of their embryos, and fourthly, we explore how participants managed personal attachments to these videos. Finally, we develop our analysis of embryo videos as bioinformation in the discussion section.

Patient perspectives on time-lapse embryo imaging

Viewing embryos is, first and foremost, essential to the laboratory procedure of IVF, where embryologists rely on being able to see the gametes that they manipulate. IVF professionals emphasise various advantages that TLIT tools offer, including their ability to support embryo selection, their potential for knowledge production in embryology, and the role they play in the management of patient expectations and treatment (Perrotta & Geampana, 2020). Patients and partners would often describe TLIT as a lab tool that was beyond their realm of knowledge or experience, yet they also articulated what they thought its value to be. Mirroring professional narratives, this value referred both to improving the knowledge base of embryology as a science and, at the scale of the individual patient, improving the embryologist’s ability to select the most viable embryo to transfer first. The following participant explained how a more continuous view of development enables events to be observed that may otherwise go unnoticed:

Time-lapse photography looked to me, I could be wrong, it’s simply instead of taking a set photograph at a certain point of time you take a video of something developing over time to try and pick the best one. […] It’s not simply which [embryo] is healthiest at this point in time, if it’s something that is healthy looking but hasn’t done anything in six hours, something that is slightly less healthy looking but on video shows it’s growing at a steady rate, possibly you’d pick a slightly different one based on the video rather than a still image. (Partner, aged 47, preparing for fourth embryo transfer)

For participants who were familiar with TLIT, their evaluations of the benefits of this technology were closely tied to an acceptance that more information about embryo development enables better decision-making for embryologists. The following patient described how time-lapse imaging and associated large-scale, quantitative analysis would aid the embryologists’ evaluation of the embryos:

I think with [the analysis software] they said that they then kind of compare what they’re seeing to a big collection of data that they’ve gathered and put it into whatever statistical analysis tool they use, which helps them to identify which are the best embryos, basically. (Patient, aged 38, four embryo transfers, one child from IVF and starting further treatment)

Participants frequently cited algorithms and electronically aided decision-making as central to the value of TLIT. They connected this to the evaluation and grading of embryos, which the previous quotes refer to in terms of selecting the ‘best’ and most ‘healthy looking’ embryos. Patients’ conceptualisations of this technology thus become sites where discourses of poor and good quality, normality and abnormality, and health and illness regarding embryos and reproduction materialise (Collard, 2020; Fannin, 2019). Similarly to how testing and measurement play a role in establishing the ideals of ‘normality’ (Nelkin & Tancredi, 1989), TLIT enables the observation of even more minute or subtle deviations from what is considered normal embryo development. In this way, aggregate data plays a role in categorising individual embryos.

Participants’ descriptions of TLIT demonstrate a key characteristic of bioinformation as highlighted by Parry and Greenhough (2018, p. 25), which is that the value of bioinformatic data is both big and small in scale. This means that the value of improved embryo selection for the individual patient going through IVF is, at least in part, reliant on insights gained from generalised population-scale patterns of embryo development. Many participants were able to explain why the embryos had been graded in a certain way and what this meant for their chances of pregnancy. However, they were also highly attentive to the limitations of these evaluations, and would provide anecdotal evidence from other IVF patients who had become pregnant from low-grade embryos, or conversely, examples of highly graded embryos that did not lead to pregnancy.

From the patients’ perspective, the evaluation and grading of embryos does not necessarily determine individual chances of success. One participant, who was pregnant from her first embryo transfer, noted how informational material from the fertility clinic ‘said something about algorithms and it looks for what’s, you know, for a normal, they can see how a normal embryo should develop’. She then went on to challenge the interpretive power of algorithms when scaled down to the individual ‘because it’s the body, it’s not, it’s not as predictable as something, you know, as information, as set information’. This participant highlighted how particular forms of bioinformation are constituted differently at different scales, where ‘normal’ embryo development constituted at the scale of a database does not necessarily provide insights into what would happen to the embryo when transferred into her body. In the following section, we focus on participants’ experiences of seeing visual representations of their embryos, and explore how this made sense to them in the context of appointments and procedures that took place at the clinic.

Introducing embryos on screen

The embryo transfer is a significant milestone in patients’ treatment trajectories. It is a medical procedure that usually only lasts a couple of minutes and takes place without general anaesthetic, yet it is a complex procedure that relies on the coordination of specialist tools, the skill of embryologists, fertility doctors and nurses, a patient and a living embryo. It is during the transfer that patients (and partners, if present) are often shown images of their embryos, either via printouts or on screen in the transfer room. There is no universal way to encounter images of embryos during the fertility treatment process and while the majority of participants in our research had seen some kind of visual representation of their embryos in the clinic, some had not seen, or could not recall seeing, any such imagery.

Participants often described the embryo transfer in terms of visually tracing the embryo from the lab, through the transfer room and into the patient’s body, where the embryo is made to appear through a range of screen interfaces. The following participant narrated the visual and physical movement of the embryo prior to the transfer. Firstly, the embryo appears on the screen while it is being prepared in the lab, which is immediately adjacent to the transfer room:

In front of the hospital bed on the wall there’s, it was a relatively small TV, about 28-30-inch TV. And the room joins onto the lab where the embryos are all prepared and everything. So the embryologist basically places the petri dish or the sachet, whatever it’s in under the camera, the image comes onto the screen, it’s like, it’s quite like a nice pale blue image and then in flows your embryo and it’s like ‘wow, there it is.’ (Patient, aged 34, two embryo transfers, one child from IVF and is an egg donor)

In this quote the embryo visually appears in the room via the screen (‘there it is’). The next step of the process is to physically pass the embryo to the medical staff, at which point the embryo disappears from the screen: ‘The embryo comes off the screen, it comes into the room. It comes into the room in like a really long, it’s almost like a catheter type tube with a syringe on the end of it.’ What we want to highlight here, is how seeing the embryo made sense as part of the material setup of the transfer room and the transfer procedure.

Crucially, the imagery seen at the clinic is usually not time-lapse videos (we will come back to the significance of this later). Within the participant group, only one patient had been shown the time-lapse videos in a consultation with her fertility specialist at the clinic. She had been through three embryo transfers, which had resulted in one chemical pregnancy (when a pregnancy is detected via a home pregnancy test or blood test but lost shortly after implantation) and two miscarriages, and she was waiting to start a new IVF cycle at the time of the interview. In the following excerpt, she describes the setting where she watched the embryo videos:

You’re prepped for theatre and get ready to do what you need to do. And then the embryologist comes down and says ‘this is how the embryos are doing, here are the images.’ She’s got like an iPad and she’ll show you the pictures of the embryos literally taken just before she’s come down to see you. So me and [my husband] are sitting there with the embryologist and then she’ll also show us the videos of the embryos developing. So any embryos that didn’t make it you don’t get to see. (Patient, aged 33, preparing for fourth embryo transfer)

This participant described an invitation to view ‘how the embryos are doing’ as part of preparing for the transfer and being involved in what was about to happen. The focus on the embryos that had developed as expected over those that did not survive emphasises the successes of IVF and thus instils a sense of confidence in the upcoming procedure. The clinic enrols visual representations of embryos as a central and expected part of the IVF procedure, and participants generally enjoyed and actively participated in viewing their embryos in these situations.

Watching embryos at home: problems of interpretation

Unlike other embryo imagery that was shown during appointments, the time-lapse videos of embryos were often received by patients once they had left the clinic. Participants reported receiving the video via their online patient portal or an email link, purchasing or being given the video on a USB at the clinic, or having the USB posted to them at home. These methods of receiving the video mean that it was unseen by patients until the video file was opened, which happened after the transfer and in places outside of the clinic. The videos are therefore temporally and spatially removed from the clinic.

While some participants were not interested in accessing the videos outside of the clinic, many identified the home as the primary site for encountering videos of their embryos for the first time. A participant who had been through several transfer procedures described how she and her partner were given the embryo videos on a USB and could ‘go home and have a watch of those’ on their laptop. She remembered this as an exciting and positive experience that instilled a sense of amazement in the technology of IVF: ‘We just said “oh wow” you know, they look really good. Did a little dance. Yeah, it’s just amazing’. However, on further reflection this participant described difficulty interpreting the videos outside of the clinic setting:

I suppose in our case we didn’t, it probably would have been nice for the clinic to have shown us the development perhaps and talked through it because that’s what we didn’t have. They just sort of gave it to us.[…] So perhaps the clinic could talk through and say ‘okay, this is how we’ve graded it and this is why’. (Patient, aged 37, four embryo transfers, one baby from IVF and starting further treatment)

Many participants described shifting emotions and thoughts about the embryo videos, which reflects the difficulty they experienced in interpreting or contextualising this imagery. Being in the clinic enables patients and partners to ask questions. Seeing videos at home, however, does not allow such conversations to take place.

The imperative to interpret embryo development is tied to participants’ conceptualisations of the videos as containing key information about embryo quality and their personal likelihood of treatment success. In the absence of expert guidance on how to interpret embryo imagery, some participants turned to the internet to compare the videos of their embryos to others that they found online:

In the beginning stage, I think it [having the time-lapse video] was almost a curse because I was looking at other videos online and seeing what the outcomes were and comparing them to our video like with the fragmentation and everything like that and how fast it developed and all the different things. And obviously I don’t know anything about it whatsoever but just looking with the naked eye I was finding myself comparing to other people who’d had successful or unsuccessful transfers. (Patient, aged 31, pregnant from first embryo transfer)

The internet offers relatively immediate access to a wealth of information about embryo development. The ‘local’ circulation of embryo videos between the clinic and the patient thus come to overlap and intersect with a global circulation of online biomedical imagery (Parry et al., 2015) in ways that position distinct biomedical images in direct comparison to a plethora of representations from people and clinics in other locations.

The unknown quality of embryo videos was also present in how many participants described an element of surprise in receiving the video: ‘As soon as I saw it [in my online portal] I just opened it. And then, yeah, I was, I didn’t, really didn’t know what to expect’. Similarly, a partner described how he was given a USB stick that contained the videos at the clinic, which he paid £10 for and then watched for the first time at his mother-in-law’s home: ‘It wasn’t till we got home and I kind of looked and said “what is this?” And [my wife] was like “oh, it’s that, it’s that!” And she knew what … Because she had done far more online research than I’d done’. Being a relatively new technology, embryo videos are not culturally familiar in the same way that images from foetal ultrasound scans are (Taylor, 2008). For IVF patients and partners, videos of embryos are doubly decontextualized; firstly, the videos are evidence of embryos in vitro – existing externally to the body – which is essential to the procedure of IVF as a whole; and secondly, the encounter with videos at home detaches this biomedical imagery from the clinic or lab where it ‘belongs’. These videos are therefore detached from their place of origin, both in terms of representing embryos that are detached from the body and the video itself having a mobility beyond the clinic and lab.

Managing connections

Participants sometimes described deeply personal connections to the embryo videos, which signifies how the value of this material extends into times and places beyond its potential to support embryo selection. One participant described the treatment and personal value of videos as these changed over time: ‘[The video] is one of the most important things I have, even though it doesn’t now serve a purpose I don’t think. You know, it has done its job in terms of the IVF, it serves a personal purpose’. The following participant, who was pregnant at the time of the interview, reflected on what the video meant to her at the time of undergoing IVF:

I felt like it was, it was a baby. It sounds really weird but it felt like I was looking at a potential baby there and watching it move and do all the stuff and I just looked, it looked … And I know it wasn’t just cells for me. I know it was just cells at that point, it was but for me it was eight years of all the stuff that I’d been through, eight years where it’s not actually worked. (Patient, aged 29, pregnant from second embryo transfer)

The connections that this participant made through the video were diverse. She constituted the embryo as both cells and a potential baby, thus acknowledging the complex status of embryos in the context of fertility treatment as well as cultural sensitivities around how to define prenatal life (McNiven, 2016). For her, the video also represents eight years of trying to conceive.

Sometimes, watching embryo videos at home required certain forms of emotional management, which involved managing the location of the videos, especially in cases where participants had experienced a miscarriage, as well as managing other people’s encounters with the videos and pre-empting their reactions. Many participants who had not become pregnant from IVF described how the visual evidence of their embryos could have a ‘haunting’ presence in the home (McNiven, 2016). While they did not want to dispose of the imagery, they detailed how they carefully managed the risk of encountering printouts or USB sticks at a future date through, for instance, placing these objects in drawers, boxes or in deep computer storage:

We’ve still got it [the USB stick] upstairs but it’s not, we’ve never … I think because we’ve miscarried those it’s not, we’re not interested in seeing that now. It’s too much really. We don’t know what are we going to do with it. We’ve obviously when … we were really excited, the embryo had been transferred, we was looking back at it thinking ‘wow, like this could be the start of our family’ and it’s really exciting but then when it goes wrong you don’t really want to have a look at it. (Patient, aged 33, preparing for fourth embryo transfer)

Many participants were clear about the potential for the videos to prompt emotional connections or feelings of bonding with the embryo as a future baby. One participant, who had recently given birth to her baby following IVF, had decided not to engage with the video in her online patient portal:

I just didn’t want to look at [the video] at all because I just […] I just didn’t want to build up any sort of emotional connection with this embryo at all. And to me like, logging on and looking at it developing, I just thought, no, I just want to pretend it’s not even there. So that part of it didn’t appeal to me really. I think some people really like that but for me, it wasn’t for me. I have got it somewhere, but yeah. (Patient, aged 38, four embryo transfers, one child from IVF and preparing for further treatment)

Avoiding visual representations of embryos could offer a strategy for curtailing emotional attachments. Women undergoing prenatal testing during pregnancy may suppress feelings of attachment or describe their pregnancies as ‘tentative’ until deemed viable (Rothman, 1993), and experiences of foetal imaging technologies reveal the tensions between reassurance and heightened perceptions of risk during pregnancy (Taylor, 2008). TLIT visualises another stage (the development of the embryo) in an increasingly complex process of conceiving through IVF and thus adds new information for patients to reconcile. In a similar way to the tentative experiences of pregnancy described by Rothman, women undergoing IVF experience a tentativeness around how to define when a conception and pregnancy has potentially occurred (Sandelowski, 1993).

Discussion: watching one’s own embryo

Time-lapse embryo videos are unique in relation to other IVF imagery in that they are usually not encountered in the clinical setting where the patients’ gaze is guided, but rather their spatial and temporal detachment facilitates their entering into a whole range of other practices and associations, including familial, biographical and emotional domains. The videos can be representative of a personal IVF ‘journey’, offer visual evidence of a treatment milestone or signify hoped-for future familial relations. Diverse associations are therefore facilitated through the extraction of embryo videos from the embryology lab and the clinic, combined with the persistent affective and relational connection between the portrayed embryo and the patient or couple, which enables the experience of watching one’s own embryo. Tracing the spatial and conceptual processes through which the videos become meaningful provides insights into the diverse detachments and attachments that are created with and through this material across multiple sites and scales.

While other visual representations of embryos are an expected part of the treatment process, participants’ experiences of watching videos are more challenging, unknown and unpredictable. As we have discussed, this is due not only to the novelty of these videos, but also the fact that watching them outside of clinical encounters removes the visual and interpretive mediation of fertility professionals or clinic staff. Similarly to the case of foetal imaging, embryo imagery requires not just specialised equipment but also particular kinds of interpretation. Watching embryos on screen during the transfer procedure demonstrates what Roberts (2012b, p. 299) describes as a process of ‘collaborative coding’ in which professionals and patients create a meaningful discourse on the embryo together. However, watching embryo videos at home without professional mediation, introduces problems of both clinical and social interpretation.

This article has also attended to how new forms of bioinformation and biomedical knowledge are translated and dispersed unevenly across different actors, sites and scales (Hall, 2005). For patients, TLIT make possible new ways of seeing and knowing embryos that take on multiple meanings. Yet this multiplicity of interpretation is not exclusive to patients and is also present in the work practices of IVF professionals, and embryologists in particular. As we have outlined elsewhere (Perrotta & Geampana, 2021), knowledge about the embryo is contentious. IVF professionals question the role of algorithms as an authoritative knowledge source and view embryo ‘scores’ generated by algorithms with a degree of scepticism. Patients recognised that the clinic’s evaluations of embryo quality were partial and that applying information from TLIT to their own treatment cases was not straightforward. Information about embryo quality is negotiated alongside the many other strands of bioinformation that patients encounter (Hall, 2005). Many emphasised the multitude of factors (beyond the embryo) that would determine whether they would achieve and sustain a pregnancy, including the role of genetics, the immune system, hormone levels and uterine receptivity. Patients whose embryos were consistently described as poor quality described how they had investigated lifestyle changes or additional treatments that might compensate for poor quality embryos or assist embryo implantation. Biomedical evaluations of embryos can therefore directly impact on a patient’s treatment decisions (Perrotta & Hamper, 2021) as well as their sense of individual agency and responsibility for treatment success (Nelkin & Tancredi, 1989).

The temporal detachment of patients’ encounters with embryo videos from the transfer procedure added a further layer of complexity to their felt attachments to this imagery. Many of the participants in this study were given the video shortly after the embryo transfer and before they were able to take a pregnancy test, which means that examining where the videos are encountered necessarily involves the question of when they are encountered during treatment. The videos portray a snapshot in time (the embryo’s first days) and place (the petri dish and time-lapse incubator), where the development of the embryo signifies its status as ‘living’ and through this imbues it with the promise or potential of becoming a baby (Thompson, 2005). However, patients who receive the video prior to being able to test for pregnancy do not know whether the in utero embryo will lead to a pregnancy or baby, or even if it is still alive. Making the decision to avoid embryo imagery can therefore be a form of self-protection from building expectations (Petchesky, 1987). The suspended feelings of hope and attachment that some participants described in watching the videos outside of the clinic were closely informed by their awareness of the likelihood that an embryo transfer would not result in pregnancy or a baby. In this way, interpretations of reproductive bioinformation are deeply entangled with the uncertain temporalities of reproductive potentiality.

Conclusion

This article contributes to literature on the lived geographies of assisted reproduction (England et al., 2019) by examining the spatially and temporally extended circulation of time-lapse embryo videos and exploring their potential for contending with the social, cultural, embodied and emotional responses to the possibilities of bioinformation. While we have structured our analysis by attending to the clinic and home separately, we draw out connections between these locations through the movement of embryo videos between these sites. We argue that a discussion of places beyond the clinic is central to understanding patients’ lived experiences of fertility treatment and medicine more broadly (Nordqvist, 2011; Throsby, 2002), including the times and places of embryological science and biomedical imaging technologies in people’s lives and relationships.

Building on Parry and Greenhough’s (2018) conceptualisation of bioinformation, the example of embryo videos demonstrates how detaching information from its source enables it to ‘operate across many different “registers” simultaneously’ (Parry & Greenhough, 2018, p. 6). We have traced some of the registers pertaining to IVF patients and partners’ understanding of the value of time-lapse imaging as a bioinformational resource for embryology and embryological science, as well as their ‘actual’ encounters with these videos as they are incorporated into clinical consultations or watched at home. Parallels can be drawn here to the global circulation of genetic knowledge and testing, and the strategies that people employ to incorporate information about genetic relatedness into their own sense of personal identity and belonging (Nash, 2008). Whereas in vitro embryos have been situated in commodity networks of biovalue at the national and transnational scale (Collard, 2020; Fannin, 2019; Schurr, 2017), we have shown how processes of categorising and evaluating embryos are implicated in a more intimate circulation and valuation of bioinformation in the spaces of everyday life.

Exploring the travel of embryo videos also offers a unique insight into how different kinds of knowledge about embryos, and reproduction more broadly, circulate and are co-produced through particular places, technologies and collaborative practices of interpretation (Hall, 2005). For patients, embryo videos are made meaningful through their embeddedness in scientific evaluations of embryo quality, clinical incentives towards data-driven treatment optimisation, and their association with culturally powerful ideas of the embryo as a potential baby. Investigating the complex and personal negotiations of meaning, value and knowledge reveals how translations of reproductive bioinformation are always embedded in social and material contexts. Our analysis of the intimate circulation of embryo videos highlights their contested nature for IVF patients and their partners. Extending beyond the individual, we have shown how the tensions and opportunities that arise from encountering novel biomedical imagery are central to the contemporary visual culture and experience of assisted reproduction.

Acknowledgments

We would like to thank the anonymous referees for their constructive comments and the editorial team at Social & Cultural Geography for their support during the review process. We are also very grateful to all the research participants and the clinic staff who facilitated the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was funded in whole by the Wellcome Trust [Grant number 108577/Z/15/Z].

Notes

1. Health Research Authority IRAS project ID: 225739.