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.”‎