Mohamed and Lamia's 13-year marriage has been blessed with four daughters, but they still feel their family isn't complete.
“We ache for a beautiful healthy baby boy,” says Mohamed. “I started hoping for a baby boy when my wife got pregnant the third time.”
The couple, whose daughters are 12, 8, 5 and 2, did not want to risk a fifth pregnancy without making sure that it will result in a boy.
That's when Mohamed's sisters told him about gender selection, where a couple can choose the sex of their babies by genetically testing the embryos.
After four months of research, the couple decided to do the procedure at the Gana Fertility Clinic.
“I co-own an export/import company with my father and I really want a boy to take over after I die,” Mohamed explained. “To be quite honest, my father is the one who really pushed me to do this. He said, you have to have a son.”
And Mohamed is not the only one. Having a boy is a dream for most Egyptians.
“I've been here for a long time and I don't know anyone who does gender selection to have a girl,” says Dr Yasmine Darwish, an embryologist at Gana Clinic “They all want a boy.”
Gender selection is usually done through in vitro fertilisation (IVF), a common fertility method to help infertile couples have a baby. During the process, women are given fertility drugs to help their ovaries produce multiple eggs. The eggs are then retrieved and fertilised with sperm in a petri dish, which then results in embryos. Three to five days later, a cell is removed from each embryo and sent to a genetics lab where they can be screened to determine the sex.
Gender selection is usually done for both medical and social reasons. Medical justifications include when a family decides to use this technology to avoid the conception of a child with sex-linked genetic diseases, such as Duchenne muscular dystrophy or hemophilia, both common among males.
“[Duchenne] affects boys and it causes paralysis and they often die by the age of 20,” explains obstetrician Gasser El-Bishry. “I have a family like that, so they do sex selection for girls.”
The main non-medical reasons couples may choose sex-selection is to achieve family balance, or to have both genders represented in a family.
This is usually common in families who have several children of the same gender and who yearn for a baby of the opposite sex.
Sex selection for non-medical reasons is banned in many countries, like the UK, Canada and Australia.
The World Health Organisation has also expressed its opposition to the practice, pointing out that it “raises serious moral, legal, and social issues,” and can result in the “the distortion of the natural sex ratio leading to a gender imbalance” and because it can “reinforce discriminatory and sexist stereotypes towards women by devaluing females”
Dr Ezzat ElSobky, director of the Generations Labs, the genetics lab that screens the embryos, says that three quarters of the cases he gets are looking to have a boy, while only one quarter of couples are doing it for medical reasons.
Dr Hossam El-Nomrosy, the medical director of Gana Clinic in Heliopolis, adds that the clinic often gets older women, usually above the age of 38, who have fertility problems and decide that since they will go through IVF anyway, they may as well choose a boy.
However, most of the couples who undergo gender selection do not suffer from any fertility problems and are undergoing the procedure only to choose the gender of their baby.
These cases can get pregnant naturally,” explains El-Nomrosy. “But they keep having girls only. [For example] they have five girls and don't want to get pregnant for the sixth time and then have a girl again.”
The couples who seek to undergo the procedure at Gana Clinic come from across Egypt, and are from different social backgrounds.
The fact that sex selection is banned in some countries has given rise to reproductive tourism, where couples fly to countries like the US to undergo sex selection or other procedures not allowed in their countries.
Egypt is also becoming a magnet for foreigners looking to undergo sex selection. According to El-Nomrosy, Arabs from across the region are also starting to come to Egypt to use IVF for sex selection, to have a boy. Couples from Kuwait, the Emirates, Yemen and recently Sudan are becoming regular IVF customers in Egypt, he says.
“Why Egypt? Because Egypt has more advanced IVF technology than them,” El-Nomrosy explains. “So it is global here. Many nationalities come here to get pregnant and then leave.”
One gender selection case that El-Nomrosy remembers resulted in multiple boys. The customer was an Arab who was married to two women. He brought his first wife to Egypt and through IVF successfully impregnated her with two boys. He went back to his native country and got his second wife and got her impregnated with another two boys.
“So now he has four children,” mused El-Nomrosy. “This is how much he wanted a boy.”
In humans, each cell contains 23 pairs of chromosomes. Twenty-two of them, called autosomes, are the same in both male and female. The 23rd pair are the sex chromosomes, and are different between men and women. Those with two copies of the X chromosome are female and those with one X and one Y are male.
According to Dr El-Sobky, until recently, gender selection was done through a technique called Preimplantation Genetic Diagnosis (PGD) using Fluorescence in situ Hybridisation (FISH), which allowed geneticists to look at 11 chromosomes.
A year ago, a new technique became available in Egypt, called Preimplantation Genetic Screening (PGS), which allows all chromosomes to be analysed. PGD is used to look at specific genetic conditions like cystic fibrosis, while PGS is used to determine if the embryo has the right number of chromosomes. Both techniques can be used to look at the sex chromosomes as well as genetic abnormalities in the other chromosomes, to ensure that the baby is healthy and normal.
These techniques, says El-Sobky, are a product of years of research. Gender is determined genetically, he says. While most people have a normal genetic makeup, sometimes with Disorders of Sex Development (DSD), the reproductive organs and genitals fail to develop normally and may result in an individual having a mix of male and female characteristics.
“So, we would take a blood sample and check their chromosomes to understand what is going on and not depend only on physical appearance,” says El-Sobky.
But advances in medicine made gender identification possible pre-birth through fetal ultrasounds and prenatal testing techniques like Chronic Villus Sampling (CVS), or amniocentesis, where a baby can be checked for chromosomal abnormalities and gender while still in the uterus during a stable pregnancy.
“Some people used to do this because they wanted to know early on if the baby is a boy or a girl,” explained Dr ElSobky. “And if they knew and wanted a boy and the chromosomes showed an xx, they would then abort the fetus, a normal healthy female, just because they don't want a girl.”
Sex selective abortions are common in countries like China and India, but not so much in Egypt.
Then in the mid-90s, geneticists were able to analyse the embryo before pregnancy took place at all.
“They thought that since we have genetic diseases, instead of letting the woman get pregnant and then take a sample, why not take a sample from the fetus through IVF before we transfer the embryos, and then we can know if it is healthy,” said El-Sobky.
For couples like Mohamed and Lamia, these technologies are heaven sent. The couple come from the conservative city of El-Hawamdeya in Giza, where patriarchal culture still rules.
“In our cultures, a girl goes to her husband, so I can't expect any of my daughters to help me with my business in the future,” Mohamed said. “But a boy is the backbone of the family. He will not only help me, but he will protect his sisters in the future.”
Mohamed says that he was mainly worried about whether the procedure will affect his wife's health and as a Muslim man, if it is against his faith. However, he was assured by his doctor that the procedure is safe for his wife.
“Then I went online and found several fatwas on Muslim sites that claim that the procedure was allowed, as long as you have several children of the same gender already,” Mohamed explained. “So I felt that I was doing the right thing.”
Mohamed's attitude is not unique. Having a baby boy is a dream that many Egyptians strive to fulfill. It is not uncommon in Egypt for couples to keep on having children until they have a boy, which results in very large families across Egypt. It is also not uncommon either for women to be divorced or for a husband to seek a second wife if they fail to conceive a male child with their first.
“Historically, this is the area where female infanticide was common before the advent of Islam,” explains sociologist Said Sadek. “This female infanticide culture continued in new forms, such as the happiness of parents when they have boys.”
Women in Egypt, he added, are seen as a source of potential dishonour, which results in the practice of female circumcision being widely used and also many girls married off early.
In Islamic culture, women also inherit half the share of a man, leading many prospective parents to prefer boys. In more conservative areas, like the south of Egypt, it can even be more complicated.
“In Upper Egypt, they consider that if you haven't had a boy, then you don't have children at all,” explains, Sayed Ali, a sociologist based in the Upper Egyptian city of Qena.
In the south, he added, often inheritance comes in the form of land, and if a family has a female child it means that the land will go to her husband's family, which is seen as a problem. Additionally, Upper Egypt is also very tribal, and the prestige of the family often depends on how big it is and how many boys they have.
“So, it is very common here for people to try to use magic, or go to certain sheikhs and religious leaders who promise to help them have a boy,” he said.
Lamia Lotfy, researcher at the New Woman Foundation, adds that Egyptians also want a boy so he can carry on the name of the family.
“Sometimes a man will marry a second woman to get the boy, or have a huge number of children that would financially stress the family and exhaust the woman health wise and psychologically in order to get a boy,” says Lotfy. “So, if a woman has a choice to get one child through IVF she will get a boy, to relieve herself from the pressure of society.”
However, according to Egyptologist Salima Ikram, it hasn't always been like that. For example, during the Graeco-Roman period, the Greeks would often throw their female newborns in garbage heaps, but then the Egyptians would rescue them, adopt them and raise them as their own.
“They obviously wanted to have sons as well as daughters, but there are many instances were daughters became complete heirs and basically did whatever a male child would have done to make sure that the parents were well looked after, that their tombs were looked after and that they achieved a happy and long prosperous life,” explains Ikram.
In modern Egypt, most doctors are aware of the social preference for boys, but some do not feel that the medical world should be involved at all.
Dr Mohamed Abu El-Ghar, the clinical director of the Egyptian IVF-ET Centre, refuses to offer sex selection to his patients.
“It is ethically not acceptable, because this procedure is only done to get a boy,” says Dr Abu El-Ghar, whose centre produced Egypt's first IVF baby in 1987. “If a man has three boys, it is finished, they would never do this procedure to get a girl. This is discrimination against women, and we totally disagree with this procedure.”
Dr Hossam Zaki's Ganin Fertility Centre (GFC) also turns away patients seeking sex selection at his clinic.
“I have a hard time, saying that this fetus is a boy, so I will leave him because I want him to continue, and this fetus is a girl, so I will get rid of it,” says Dr Zaki. “I see that this is a form of gender discrimination. I see that religion is against this.”
Dr Zaki adds that fertility is declining worldwide, and in some countries a large number of babies are born to IVF or other forms of assisted reproduction.
“In 2035, it is projected that 18 percent of the population will need IVF,” says Dr Zaki.
Although, it is believed that boys are only preferred in patriarchal societies like Egypt, China and India, Zaki says that even in Western societies like the US, couples prefer boys to girls.
“So, if you have 18 percent of these people choosing gender, then you will have a serious imbalance,” he explains.
The desire to have a boy is overwhelming though and doctors are often offered lucrative sums to make that dream come true.
“I get people daily offering thousands [to have the procedure done],” says Dr Zaki. “I once got a man who said, look I don't have anyone to leave my inheritance to, I will give you a million pounds and give me a boy.”
Gynecologist Hussein Gohar also refuses to dabble in gender selection.
“If there is a couple who are medically indicated for IVF, then in this case, I will say okay, gender selection might be acceptable,” says Gohar. “But to have a couple who have no fertility issues, go and have an IVF cycle that will cost them a lot and has risks; I believe this should be refused by the centrds themselves. But this doesn't happen.”
Many centres, adds Gohar refuse to divulge the risks of IVF to patients, such as Ovarian Hyper-Stimulation Syndrome (OHSS), when ovaries become swollen and painful due to the fertility drugs administered during IVF. In severe cases, the condition can lead to death. Additionally, there is a lot of research still being conducted on the health effects of IVF on babies.
“Every time there is a report that says IVF babies have a a higher incidence of abnormalities, immediately another report saying no is released ... It's a war,” says Gohar. “Unfortunately, many centres in Egypt don't tell people the risks.”
Also, with IVF there is no guarantee that a pregnancy will take place at all.
According to Dr Abu El-Ghar, in good IVF centres, the pregnancy rate with IVF is 40-45 percent and about 30-32 percent that the pregnancy will continue and a healthy baby will be delivered.
Prospective parents looking to do gender selection also have to find funds for what can be a very expensive procedure. IVF costs anything from EGP7,000 to EGP16,000 depending on the centre. In addition to this, couples are prescribed fertility drugs which can add a few more thousand pounds to the bill. For a couple to do gender selection, they need to pay approximately EGP2,000 for each embryo to be tested. If a couple is seeking a boy, and the first few embryo is a boy, then they pay only EGP2,000. But if the first few embryos are girls, then the testing has to continue until a boy is found, further adding to the bill.
But neither technology nor money can rule out bad luck. After going through an entire IVF cycle and paying thousands of pounds, some women may end up producing only female embryos.
“We had a case where the woman ended up with five embryos and they were all girls so the transfer was canceled,” says Dr Darwish.
The lack of regulation is also another problem with gender selection, says Dr Gohar. Although many centres prefer to offer sex selection only to couples who have several children of the same gender, this doesn't always happen.
'The medical syndicate needs to be involved,” says Gohar. “Laws have to be put in place, and those who don't apply them should be accountable.”
But despite everything, Mohamed and Lamia are excited to find out if they have indeed conceived a boy. In 15 days, they will undergo a pregnancy test to see if Lamia has fallen pregnant or not.
“If we have a boy, I will be ecstatic,” Mohamed says. “But I have prayed to God to guide me and if we fail to conceive, then I will not try gender selection again. I will feel that God doesn't want me to have a boy.”
Mohamed admits that his decision to try to get a boy to satisfy his family and culture has taken its toll on him.
“Listen, I love my girls. I never got upset when I found out that I was having another daughter,” he insists. “But there is so much pressure in our culture to have a boy. Who knows, maybe if I wasn't pressured so much, then perhaps ... perhaps ... I would have been satisfied with my girls.”