In February our tap water still smelled of chlorine tablets disinfecting the well we drilled the month before, giving our tiny house the damp, close feel of an indoor public pool. I was running load after load of white laundry, trying to flush out the chemicals, when the UPS driver arrived with my first shipment of IVF medication. I signed for the three large cardboard boxes, marked PERISHABLE OPEN UPON RECEIPT. They were surprisingly light, like props, and I waved off the driver’s offer of help and carried them inside.
After the truck was gone, I sliced open each box to find rounded Styrofoam coolers and frozen gel packs protecting my cartons of Lupron, Follistim, and Menopur. I set the medicine, the syringes, the sharps container, and the alcohol swabs on my kitchen table: more shots than my body had ever received, more medicine than I had ever taken. I photographed the eleven cartons of drugs, the three sizes of needles, the pages-long lists of instructions and precautions; then I put them all away where I wouldn’t have to see them.
The phrase my doctor uses to describe the way IVF works is take over—We’ll take over your whole cycle, he told me enthusiastically. As in, Don’t worry about your short luteal phase, your thin uterine lining, or predicting when you might ovulate. Your body will not be trusted to perform any of its biological tasks. We will do it all for you. To you.
The first means of this takeover is often Lupron, a drug prescribed to treat early-onset puberty, prostate cancer, and endometriosis and to delay puberty in children who might be transgender. In IVF, Lupron has a primarily suppressive effect; those new to IVF protocols are often surprised to see that they will first take birth control pills, then Lupron and birth control simultaneously. They’ll wait to get their periods, continue taking Lupron, then add a gonadotropin, or follicle-stimulating hormone, while easing off the dosage of Lupron. Lupron shuts off portions of the pituitary gland, tricking the body into thinking it is menopausal; fertility doctors use it to prevent ovarian cysts from forming, to time the onset of menstruation, and to suppress the body’s natural tendency to promote the development of a single follicle. IVF’s goal is many follicles, many eggs, and Lupron makes that possible. Like a lot of medications used in reproductive endocrinology, it’s prescribed off label.
I googled “dangers of Lupron” and found personal stories posted to message boards, court cases and testimonials on lupronvictimshub.com, advertisements from attorneys, and a detailed (and convincing) overview of the risks from National Women’s Health Network, a feminist health-care lobbying group. According to an article by Susan K. Flinn, editor of the Women’s Health Activist newsletter, “there have been no prospective or clinical studies on Lupron’s safety for ART patients.” Flinn notes that it causes birth defects and is categorized by OSHA as a hazardous drug; OSHA advises health-care workers to don protective gloves while handling Lupron, and those intending to get pregnant or father a child to avoid it entirely. Flinn sprinkles her article with posts from distraught patients, including this one, collected from lupronvictimshub.com:
I have been to a total of 17 doctors since taking Lupron with many different diagnoses and there doesn’t seem to be an end in sight. I don’t know why we can’t seem to get someone in the medical field to look into the on-going side effects of this drug. There is something definitely wrong with a drug when you go from being perfectly healthy to having all kinds of medical problems and you know that in your heart it started while on Lupron. I do know that I am not alone. I used to think I was but I have personally spoken to people that have [taken] Lupron and they are experiencing the same problems.
It’s hard to know, in an ART cycle, exactly which drug is causing which side effects, but I’d heard plenty of complaints about Lupron—hot flashes, tearfulness, anxiety. Possible long-term side effects of prolonged Lupron therapy—the kind prescribed for severe endometriosis and uterine fibroids—include bone-density loss, debilitating headaches, chronic generalized pain, depression, immune system disorders, and paralysis. Takeda Abbott Pharmaceuticals, the drug company that manufactures Lupron, paid $875 million in 2001 to settle a claim that it promoted Lupron to doctors through illegal kickbacks and Medicare fraud. I found reports online that the FDA has received between twelve thousand and twenty-two thousand reports of adverse events linked to Lupron, including hundreds of deaths.
In the conventional IVF cycle our doctor recommended, I’d inject this drug for two weeks. It would have been possible to limit my exposure either with a natural-cycle IVF, which would harvest the single egg my body might naturally produce, or with something called an antagonist protocol, which supplants Lupron with an antagonist such as Ganirelix. Our doctor told me that Lupron down-regulation, in which Lupron is prescribed to control the onset of menstruation and suppress initial follicle development, had the best success rates for someone in my circumstances. All of our choices so far (except waiting) had been carefully made to maximize our chances—at Dr. Young’s suggestion, we even skipped the first cohort of IVF patients to be treated in our clinic’s new laboratory, just in case there were kinks to be worked out.
By the time I received my six-week calendar of medication from the clinic, my fear had already shifted, a common experience among those moving up the fertility-treatment ladder. A friend who became pregnant after years of treatment by three different reproductive endocrinologists put it this way: “In the beginning I definitely worried about the long term effects of the hormonal drugs on my health, yet as I got further along, I cared less about the consequences on myself. I remember thinking that I would never do IVF or take the heavy duty drugs.”
I thought the same thing. But the IVF cycle, so complicated and demanding, replaces fear for your own body with anxiety over its production, and you suddenly wonder, Will it be enough? My friend, a scientist and former Peace Corps volunteer, got accepted into a study at one of the premier “natural cycle” IVF clinics in the country—the same clinic that gave Martha Stewart her first grandchild—and traveled to New York to participate. The study was evaluating the difference between “mini” IVF, which calls for minimal injectable medication, and conventional IVF, which requires between thirty and fifty injections. Doctors using mini IVF collect one or two eggs per cycle, while conventional methods could produce twenty or more. The protocols were randomly assigned, and my friend drew the conventional one: lots of those expensive shots she once dreaded. But she was relieved, even after months of research about the benefits of mini IVF: less stress on her ovaries, no risk of ovarian hyper-stimulation, potentially healthier eggs. When it came time to begin the cycle, she wanted the greatest number of eggs, the best chance of success.
For most of human history, doctors knew less about human reproduction than what today’s average middle-schooler learns in health class. The presence of eggs, or ova, was not confirmed until 1827; it took another sixteen years for scientists to discover that sperm must fertilize an egg for conception to take place. Though folk remedies for infertility had been practiced for thousands of years, the Western medical establishment would bumble along for decades before finding promising treatments. Marion Sims, a surgeon-gynecologist working in the mid-nineteenth century, assumed the problem was one of access: to help the sperm better find their target, he widened his patients’ cervixes with a terrifying-looking speculum and completed an early study of artificial insemination, which he called “ethereal copulation.” Out of fifty-five attempts with six couples, he reported only one success, possibly because he believed that ovulation occurred during menstruation. Others looked for infertility’s causes—Harvard professor of medicine Edward Clarke suggested in 1873 that too much education gave women “monstrous brains and puny bodies,” injuring their reproductive organs. Men, it was commonly believed, became infertile through sex with prostitutes (this was likely true for some).
Though the early twentieth century brought discoveries of important sex hormones and fertility tests, patients had to wait until the late 1950s for promising but risky hormonal treatments, using medication sourced from the pituitary glands of cadavers and the urine of post-menopausal women. Carl Gemzell, the Swedish doctor who pioneered the use of gonadotropin to stimulate egg production in acyclic women, nearly ended his research after one of his patients gave birth prematurely to six babies, who all died. “I felt I hadn’t the right to let even one more patient run the terrible risk of having so many babies,” Gemzell told the Australian Women’s Weekly in 1966. By then Gemzell’s protocol had spread to clinics in seven different countries. “To do what I had done—to be the instrument of making a woman bear the agony of giving birth to six children at once was a frightful thing to do,” he said. Gemzell changed his mind soon after, when four of his patients each gave birth to a single, healthy child. Those babies, he said, renewed his hope and confidence: “The joy on the faces of their mothers, the happiness of the fathers—oh, it was wonderful to see.” Gemzell and the other doctors using his protocol of injectable gonadotropin attempted to use the lowest effective dose, but it was impossible to predict the outcome of each cycle. Some patients bore healthy singletons, while others faced traumatic births of up to seven babies. Infertile couples were willing to risk treatment, perhaps imagining a crowded nursery rather than the reality of long hospital stays and painful deaths. “Four, five, even six babies—it was a gamble we decided to take,” a Swedish housewife told the same magazine. “We wanted a child so very much.” Years later, some of Gemzell’s patients died from Creutzfeldt-Jacob disease, apparently transmitted by the cadavers he used to source gonadotropin.
Though their treatment was risky and clumsy by today’s standards, Gemzell’s patients were among the first to experience the takeover of their reproductive systems, and the therapy he developed—injectable gonadotropin—is still used worldwide by reproductive endocrinologists. It’s difficult to imagine what women considering or experiencing treatment might have thought—in the pre-Internet era, there were no message boards on which to share fears or hard-won research, and stories in the press, though they reported the deaths of sextuplets and septuplets, often gave voice only to happy mothers. Five babies. How lucky! an infertile woman may have thought, gazing at a photograph of a beaming, attractive mother of adorable quints.
Reproductive medicine has a long history of absent or incomplete patient understanding. The first recorded artificial insemination by a donor was performed in 1884 on a wealthy Philadelphia woman who happened to be anesthetized—and who would never know that her son’s biological father was a handsome young medical student and not her own (gonorrheal) husband. Lesley Brown, a British factory worker and the first IVF patient to give birth, had no idea she was a pioneer. “I don’t remember Mr. Steptoe saying his method of producing babies had ever worked, and I certainly didn’t ask. I just imagined that hundreds of children had already been born through being conceived outside their mothers’ wombs,” she wrote in a 1979 memoir coauthored with her husband.
Unlike Gemzell’s patients, and unlike most IVF recipients today, Brown’s treatment was accomplished surgically, without medication to stimulate ovarian production. Her doctor, Patrick Steptoe, referred to it as an “implant,” and the process sounded so simple to Brown that she “wouldn’t have believed it if Mr. Steptoe had told me straight out that, after years of trying, no one had ever had a baby from an implant.” But it had been years—more than twenty since scientist Robert Edwards began studying and conducting experiments on mouse, rat, hamster, sheep, cow, rhesus monkey, and human oocytes, and almost ten since he began working with Steptoe on the oocytes of volunteer patients. In 1977, the year she unwittingly made history, Brown was twenty-nine years old; blocked fallopian tubes had left her barren and depressed over her inability to conceive, but also the perfect candidate for Steptoe and Edwards’s trial.
The two doctors had for a time administered gonadotropin to their infertile patients, producing mild ovarian stimulation and multiple egg-bearing follicles. Steptoe collected the oocytes through the delicate laparoscopic technique he developed in his gynecological practice. Edwards fertilized the mature eggs and grew them in various media; his descriptions of the resulting embryos, in an essay for Nature Medicine written decades later, still sound breathlessly pleased. “Most had normal nuclei, even-sized blastomeres and approximately diploid chromosomes, developed to a strict timetable, compacted excellently, secreted blastocoelic fluid, and were obviously vibrant as blastocysts with 100 or more nuclei and many mitoses on day 5. Some blastocysts grew to 9 days, their expanding embryonic discs stuffed full of embryonic stem cells!” But once they began transferring the embryos back to their mothers, in 1972, Steptoe and Edwards began to see problems related to their patients’ hormonal treatment. They could fertilize mature eggs, watch as they developed into beautiful embryos, and transfer them back at just the right moment, but they could not control what happened next, within the woman’s uterus.
“Something must be fundamentally flawed with a reproductive system that allows only 20% of embryos to implant, even in younger couples,” Edwards complained near the end of his life. Back in the 1970s, the naturally low human implantation rate was compounded in clinical trials by the ovarian-stimulating medicine given to Steptoe’s patients. This medication thinned the uterine lining or otherwise created short luteal phases, and some patients menstruated five to six days after ovulation. Not one was pregnant. Steptoe and Edwards experimented with different medications and techniques, including oocyte recovery with tubal insemination, but finally settled on natural cycle as the best way to establish IVF as a legitimate treatment of infertility.
Brown did not require hormonal treatment; she produced healthy eggs just fine. The problem was mechanical—because of blocked tubes, her husband’s sperm never encountered her eggs. So in the fall of 1977, Steptoe checked her in to a hospital in Oldham and laparoscopically removed a naturally produced egg from her ovary, which he passed along to Edwards. Edwards fertilized Brown’s egg in the laboratory using her husband’s sperm, then returned it to her uterus two days later as a perfect, eight-celled embryo.
Nine months later, she gave birth to a healthy baby girl, giving hope to infertile couples around the world. Still, the unusual nature of her daughter’s birth also left a legacy of suspicion and fear for her health and the health of her child.
Lesley Brown was not administered any pituitary-suppressive drugs or gonadotropin tainted with disease, and she had a healthy pregnancy and a routine cesarean birth. But even after her death, in 2012 (of complications after a gallbladder infection), she remains the object of curiosity and speculation. Google her, and one of the first suggestions is “Lesley Brown IVF cause of death.”
On YouTube, if you search for “Follistim injection” or “Lupron injection,” you’ll get hundreds of results, most of them recorded by women in treatment for infertility. This is useful for new patients, like me, who have never self-administered shots, and some of the videos have thousands of views. The injections are given in kitchens and living rooms and dining rooms, in front of bathroom mirrors, sometimes by the women themselves and sometimes by their partners. Before starting IVF I watched dozens of these videos, not to learn to do my own injections but to feel a kind of kinship with these women as they tap their syringes free of air bubbles, swab their bellies, and hold the needle at just the right angle. In the backgrounds of the videos I watched were the messy signs of daily life you might find anywhere—piles of mail on the table, a television left on, houseplants growing toward a window—but there was a formality to their voices as they slowly narrated each step. I have all of the stuff I need right here … See how I swab the top of the medicine bottle … Next I’ll clean my skin … Ready, one, two, three. Sometimes I could hear the commentary of an unseen partner, holding the camera: Look at how brave, look at how tough. I sensed that they were documenting something important—not the expense, not the pain, but the chance they were taking, the desire, the all-in commitment.
Richard injected me between six and seven every evening. Preparing the injections—measuring and mixing the medication, drawing the solutions into the needle, tapping out the air bubbles—took about twenty minutes, and during that time our kitchen table was cluttered with papers, boxes, vials, and syringes. He spread out the instructions from our clinic each time, watched the online tutorial, checked and double-checked the amounts before saying, “Okay, ready?” As with the well drilling, there was an element of excess and surrender to this experience that felt unfamiliar and frightening, but it was too late to turn back.
I’d turn my head as soon as he swabbed my stomach with alcohol, biting into a piece of dark chocolate—a trick I learned from a friend, another woman who never imagined conception this way. The shots didn’t take long; I’d feel the needle pierce my skin, then a stinging, and then it was over. Each one left a pink mark that quickly faded, and sometimes a small, faint bruise. Afterward I’d look for the injection sites under a strong light, even though it was too early to know what was happening beneath the skin.
It is not just the takeover of your body that makes IVF so challenging, but the takeover of your schedule, your life. Every-other-morning appointments, waiting by the phone for news about the results of blood draws, timing injections precisely, ordering more medication or procuring discounted or free leftovers from women finished with their cycles: it all takes time. While Richard came to every appointment and performed every injection, I knew that if he had a sudden work emergency, he would be able to step away. Infertility was our problem together, but it was my body being treated, my body that had to attend every appointment and accept the shots. I handed over my insurance card. I ordered the medicine and dealt with the pharmacy and changed my workout routine. I was dimly aware that if I became pregnant, this imbalance would still exist, and would become even more pronounced with a breast-fed newborn.
More than my body and my schedule, it took over my mind. I was always thinking of my possible pregnancy or looking out for superstitious tricks to bring it about. I watched the clock for 11:11, walked until I found good-luck clovers, prayed though I don’t believe in God. I was always desirous and worried, never at peace. If it didn’t work, we’d have more tries: six at most, three using fresh embryos and three with frozen embryos, if there were any left over from our other cycles. And if those didn’t work—what then?
I tried not to think of what then.
Few studies have examined the effects of involuntary childlessness after medical treatment, but some psychologists have suggested that the myriad treatment options make it difficult for women to know when to stop. If Clomid doesn’t work, maybe your ovaries will be more receptive to Femara. Or maybe you need an injectable gonadotropin and estrogen patches? If one IVF protocol fails, there are others, and if those fail too, you can try donor egg or surrogacy, provided you can pay the increasingly hefty bills. There is also the choice of clinics—a woman in Raleigh might interview doctors at four different practices; a New Yorker could see more than a dozen.
The availability of choices is known to decrease our happiness: gathering the information necessary to select among a range of options creates a sometimes paralyzing anxiety, and once we’ve chosen, we are prone to second-guessing and remorse. Reproductive medicine presents a twist to the choice paradox: while in treatment, patients report feeling hopeful, even excited, but each treatment cycle is just a few weeks long. Even the most advanced and expensive treatments offer a poor success rate: a thirty-five-year-old woman, on average, has a 31 percent chance of having a baby through a single IVF cycle. If unsuccessful, she must decide: try again? Try something new? The abundance of options also makes it more likely that she will blame herself, fearing that she has made the wrong choice or has taken too long to settle on the right one. Though I heard women in my support group state firmly that after the next cycle, they’d be done, studies of women who have completed unsuccessful courses of treatment suggest otherwise. The desire for a biological child does not fade into ambivalence or deepen into wise acceptance, post-treatment: it only grows stronger.
Despite worldwide attention and acclaim, it took Steptoe and Edwards two and a half years after Louise Brown’s birth to open Bourn Hall, the world’s second IVF clinic, in a renovated Jacobean mansion in Cambridge. Unlike Lesley Brown, Steptoe and Edwards knew all along that they were doing something remarkable, and they wanted an impressive home for the groundbreaking work they expected to continue.
Edwards, in particular, had great plans for his clinic: “IVF had to become large-scale, in a center providing the necessary clinical, scientific, consultative, nursing and counseling backup services, and even providing ward and dining facilities for the immense patient numbers on Steptoe’s waiting list.” He boasted that, though the clinic was not the first, it was the most beautiful. With its stately brick face, crenellated turrets, and engraved motto—jour de ma vie—Bourn Hall, still in operation today, looks more like an exclusive boarding school or university than it does a medical facility. John and Lesley Brown, who paid for their first appointment with Steptoe using winnings from a soccer pool, had been intimidated by the posh, fur-coat-wearing patients in the waiting room of his nondescript Oldham clinic. What would they have thought of Bourn Hall?
Our clinic, newly settled in to the third floor of a bland brick office building, looked more like a hotel for business travel, with furniture that appeared (but was not, in fact) comfortable, textured wallpaper patterned with ginkgo leaves and bamboo, soft recessed lighting. There was a Keurig coffeemaker stationed below a television tuned to CNN, and free tiny hand sanitizers in a basket. Plaques on the wall described the eco-friendly building practices—sustainable flooring, low-VOC paint. The receptionist’s voice as she called each of us to the desk to sign paperwork and offer insurance cards (just in case) was low, discreet.
At the old clinic, we waited in chairs with mysterious stains, barely shielded from the rest of the hospital by leaf-dropping ficus trees. It was depressing and public but not unbearable. It felt as though we were there for a medical problem, which we were. The moneyed, leisurely atmosphere at the new place hardly reflected my own state of mind and didn’t change it; I have never felt more vulnerable or hurried than I did in that waiting room. Though we were in a high-income suburb of Raleigh—increased proximity to a larger number of patients was another motivation behind the clinic’s move—the other patients I saw looked like they might just as easily have been in the waiting room of a Patient First or in the terminal of an airport. No one was dressed to go back to a corporate job; everyone looked tired. I remember a man in a hockey jersey, a woman wearing an Aéropostale sweatshirt. We sat on the edges of our comfortable-looking chairs and listened for our names.
When I was a child, I had fantasies of sickness and treatment. Though I was rarely sick, my younger brother had severe asthma, and for a few years we were in and out of doctors’ offices and hospitals. His resigned endurance of medication, shots, and breathing treatments looked valorous to me—he never cried and rarely complained, while I once required a sling after a vaccination. I can remember when they allergy-tested him, his skinny, pale back pricked and marked dozens of times, and how I coveted the marks (if not the pricks).
The nurses at my fertility clinic were gentle, but my veins were small, or they rolled to the side, or my blood pressure was too low. Kim, my favorite, humored me as I swung my arms to increase my heart rate, and still it took several tries to get a good stick. Kim was monitoring my estradiol, a measure of the estrogen secreted by my ovarian follicles. In an unmedicated cycle a woman might produce 200–300 pg/mL of estradiol from a single mature follicle. Thanks to my daily injections, I was super ovulating, and we were waiting for my estradiol to rise above 2,000 before triggering ovulation. In the afternoons I waited for her phone call, when she’d tell me the result and whether I should adjust the dosage of my medication. Everything about my cycle was artificial and controlled, from the follicle-stimulating hormones that swelled my ovaries to the shot of human chorionic gonadotropin that would complete the maturation and time the release of my eggs so that the doctor could aspirate them into a hollow needle. Even the meeting of egg and sperm would be assisted by a doctor’s steady hands—our embryologist would select “the fastest, strongest, best swimmers” and inject one into each mature oocyte.
In the exam room, I opened to a fresh page in my notebook and lay back on the table as the doctor stretched a condom over the transvaginal ultrasound transducer. A woman in my support group said she named this wand Simon, because you have to do what Simon says—but all I could think of was the recent fight in Virginia, my home state, over abortion. The pro-lifers wanted to require all women seeking abortions to have at least one transvaginal ultrasound before termination. Certainly this ultrasound was unnecessary, prohibitively expensive for many, and horribly invasive. Opponents also said it was painful, akin to state-sponsored rape. I lay on my back with my feet in stirrups; it was more uncomfortable to me to consider the distance between my circumstances and the circumstances of someone seeking an abortion than it was to receive this ultrasound. It barely hurt—I feel traitorous admitting that—but by then I must have had a dozen. I couldn’t make myself picture what it would feel like to be internally prodded before terminating a pregnancy. I didn’t try.
“You’ll feel my touch,” all of the nurses and some of the doctors would say before touching me. “Some pressure,” they’d say, before turning the transducer’s wand to the left or the right. Everything that touched me, as gentle and respectful as the nurses and doctors were, was nevertheless heavy with symbolic, perhaps inaccurate, meaning. The wand was a symbol of control and power; lying prone, feet in stirrups, I was the picture of submission. Watching the black-and-white images of an ultrasound machine, Richard and I were hopeful future parents. I wrote down the thickness of my endometrial lining (6 mm) and the approximate sizes of the six follicles on my right ovary (ranging from 11 to 12.5 mm), the four on my left (10 to 12.7 mm). The numbers meant little to me in real terms, but I knew from scanning message boards until my eyes burned that they were reassuring.
By the time Kim took my blood for a final estradiol level, a few days later, there was scar tissue on my veins. Even this was a metaphor, for the addiction I feared would take hold once we started down the path of assisted reproduction. One more cycle, one more treatment, until all our money and emotional resources were spent. Already I was addicted to Internet message boards, reading one on Momtastic.com’s assisted-conception page each morning about the current IVF cycles of women from all over the world, Linesmanswife and Worriedone and Everhopeful and Mamali. “Praying we are going to be 3rd time lucky,” wrote africaqueen, the thirty-one-year-old woman from Liverpool who started the conversation. She and her Nigerian-born husband had already exhausted England’s public funding for IVF with two failed cycles and were counting on a loan from family—her father’s life savings, she said—to pay for their final round. She had more than six thousand posts to Momtastic forums and was tirelessly upbeat and encouraging, despite her past disappointments. “Who else is gearing up for the patter of tiny feet? This thread is gonna be full of PMAs and also BFPs!” I had to look up PMA; it stands for “positive mental attitude,” a difficult state of mind to maintain, given the ups and downs of the average ART cycle, when almost every day brings news about estradiol levels (too high? too low?), the numbers and sizes of follicles, the thickness of the uterine lining. This news, bad or good, is so specialized that it takes another person who has been through IVF to understand. “Lucky threads” like the one africaqueen created allow women to feel, at their most vulnerable and isolated, a sense of community that they probably could not with their girlfriends, mothers, or sisters. On their lunch breaks or in a spare moment, they can commiserate and seek advice and cheer each other on. They send each other sticky vibes and hopes for big, healthy follies and strong, beautiful embies. Their posts are embellished with animated emoticons—smiley faces offering hugs, smiley faces dancing or crying, pregnancy tests with two flashing pink lines. I was a lurker—I never posted, had no handle or icon to identify myself with—but I sent them lucky vibes as well as I could.
On the morning of our last scheduled ultrasound, my estradiol was 2,248 pg/mL, and a doctor I’d seen only once or twice, known in our support group for her brisk bedside manner, counted ten large follicles. This would be a win for most of the women on the message board, but I worried it wouldn’t be enough. The doctor said things looked “good” but didn’t elaborate. We were given precise written instructions about how to measure out the hCG injection that will mature my eggs so they can be retrieved. “Pay attention,” she said, tapping the page as if we might be daydreaming.
Two mornings later, the day of our retrieval, it was raining and cold. We arrived at 7:45 a.m. with a plate of cookies for the staff and were led to a part of the clinic we’d never seen before, which looked reassuringly medical—more like the pre surgical area of a hospital than a hotel. They gave me a gown to change into, and a nurse named Lenora attached my I V. It took her three tries to find a vein; I turned my head while she searched, and didn’t complain.
A few minutes later I was clutching my gown closed behind me, wheeling my IV to the retrieval room. It was very much like the image I feared for years—a long hallway, all the doors closed, with IVF at the end. But I was far from alone, and it didn’t feel routine or workaday or cold. Kim helped me onto the table. Dr. Young was there, and Dr. Ramos, the effusive Brazilian embryologist I interviewed when we first seriously considered IVF, greeted me with a jaunty wave that morning. Richard waited just one room away; he’d be there to help me back into my clothes and drive me home. I lay down, counted backward, and fell asleep.
Michelle, our embryologist, called with news the next morning—of the thirteen eggs they retrieved, eleven were mature and ten fertilized. She told me they wouldn’t check the embryos again until day three, when I could choose to transfer or to wait until day five. I recorded this in my notebook, then went for a walk by the river and found four four-leaf clovers. I saw a bald eagle perched in the huge pine tree across from our neighborhood easement, near her nest. I recorded these things too, and pressed a single clover into the notebook.
On Momtastic’s lucky thread, Mells54 was PUPO (pregnant until proven otherwise), a term of optimism many women use after transfer. Ashknowsbest produced twenty-five mature eggs; indeedaseed, now pregnant, only had three. The general consensus: it only takes one. Will eating the core of a pine apple help with implantation? Will eating too much cause contractions? LPEAR, now pregnant, recommended Brazil nuts. Africaqueen, still struggling to finance her cycle, uncharacteristically reported feeling “very down” and taking a trip with her father to the zoo to see baby elephants, a baby meerkat, and a baby anteater. Sunshine24 wrote: “Work was soooo crazy and stressful today though and they are making cuts left and right and I may end up losing my job in a few months but I cant even focus or think about that right now, not the most important thing I have going on, by far!” Africaqueen had an idea from her last cycle: what if she organized a “secret sister chain,” like a secret Santa through the mail? “It is a lovely little game to cheer the spirit and you dont need to send anything expensive, it can be anything that will raise a smile,” she wrote. “We used to send a baby item, cards, sweets, keepsakes, anything at all to help cheer us up on this journey.”
Lesley Brown entered into her treatment unaware of its remarkable nature, unable to research the procedure, consult with other women in support groups, or join any secret sisterhoods. Though she envisioned hundreds of other women secretly giving birth to babies who’d been implanted by Steptoe, infertility, in her imagination, made her abnormal. How long have you been married? newcomers to the cheese factory where she worked would ask. The next question was always the same: How many children? Brown had even given up the chance for better-paying work to avoid having to explain her blocked fallopian tubes all over again.
And so it was a revelation for Brown to share a hospital room with another of Steptoe’s patients while they waited for retrieval, transfer, and a pregnancy test: “Having imagined for so long that I was the only one in existence who couldn’t have a baby, it had been amazing to meet someone in the same position as me,” she wrote. The two women talked about how childlessness isolated them and planned visits once they each got their babies. “Being the same age,” Brown said, “our children were bound to be friends.”
When her roommate got her period before she could take the pregnancy test, Brown was left alone again. Steptoe’s patients had been segregated from the rest of the hospital’s maternity ward, but she didn’t feel like talking to the other women—some of whom were busy giving birth, yelling and moaning—anyway. John brought her a portable television, which she barely watched. “I couldn’t concentrate on anything except what was happening inside me,” she said.
So she took her meals alone, visited daily with Dr. Steptoe, and prayed.
Richard and I had a phone conference with Dr. Young two days after the retrieval. The standard number of embryos transferred by someone my age was two, but I was eligible, Dr. Young mentioned, to transfer three. We told him about our desire to transfer a single embryo, a choice made then, at our clinic, by only 3 percent of patients in my age bracket. We wanted to avoid the risk of twins—not so much of twin car seats and double strollers and double college tuition bills, but the risk to my body, the risk to the fetuses carried within.
Waiting until day five would make it clearer which of the embryos was most “competent,” or likely to develop normally. Not every embryo makes it to day five—some divide perfectly, into round morulas on day four and complex blastulas on day five—but others short-circuit somehow, dividing unevenly or stopping division entirely. Waiting would allow us to choose the best one, I insisted to Dr. Young, who countered that my uterus—part of the reproductive system he spent weeks taking over—was actually the best place for the embryos, which was why most women my age chose to transfer two embryos on day three. Their natural environment, I think he said. Richard scribbled notes in red pen on plain white paper, but he didn’t write this part down.
Dr. Young had a formula: if three times as many embryos as we wished to transfer (for us, that meant three competent embryos) were developing normally on day three, we could wait.
Here is what I wrote down when Michelle called on day three:
10 embryos
7 8-cell
1 9-cell
1 11-cell
1 5-cell
4 look perfect
4 look almost perfect
1 has 1 slightly bigger cell but is appropriately celled
1 is 5-cell (may make it to blast on day 6)
I wondered which one they would transfer. I wished I could see photographs. I wished they could do all their development inside the laboratory, which I had come to trust more than my body.
“There’s something really wrong about the fact that my body doesn’t function in the way that it was born to function,” confided a woman in Marni Rosner’s study of involuntarily childless women. “There is a sense … that my body failed me and I try not to sort of allow that to take over my mindset because it’s not particularly healthy, but I do feel that … in certain circles, makes me feel like I don’t have any credibility.”
ART patients often see their bodies as suspect and view medication and surgery as the body’s replacement rather than its assistant. Doctors who glibly tell us they can get us pregnant, or that they will take over our cycles, feed this system of belief. Lesley Brown, who spurned her husband’s sexual advances for years after her diagnosis of infertility, telling him to find a “normal” woman, blamed her ovaries while she waited for Dr. Steptoe to retrieve her egg. The other two women in her ward had already had their operations, and she worried that her chance had passed. “But, as it turned out, it was just my body’s fault,” she wrote. “I was later in reaching a state of ovulation than the other girls.”
Our bodies are miracles is a message most often given to two groups of people: children entering puberty and women preparing for childbirth. It makes sense to lie to children facing years of bodily inconvenience (monthly bleeding, wet dreams, unexpected erections) or to women facing many hours of agony, but evolutionary biology suggests that our bodies are not really the miracles we proclaim them to be but jury-rigged compromises. Like the physiology of all living things, human physiology has evolved to be not perfect but only good enough to allow individuals to survive and pass along our genes. “Neither we nor any other species have ever been a seamless match with the environment,” writes evolutionary biologist Marlene Zuk in Paleofantasy, her book about the ways we romanticize nature and evolution. “Instead, our adaptation is more like a broken zipper, with some teeth that align and others that gape apart.” Our fishlike vertebrate plan makes us prone to hiccups and hernias; unassisted childbirth has a high mortality rate, thanks to the large brains of our babies. We waste all kinds of things that take energy to produce, like our monthly allotment of eggs or sperm, and live (we hope) beyond our reproductive capacity. We each carry inside of us a relatively useless organ—the appendix—which at any moment could rupture and threaten our lives.
Before the advent of reproductive medicine, an infertile woman could not expect to pass along her genes—her body was not only not perfect, but not even good enough by the metrics of evolution. Edwards and Steptoe were frequently criticized because their work did not cure infertility—their patients were just as infertile after IVF, whether or not they gave birth. Edwards, who would receive the Nobel Prize in medicine in 2010, handily brushed off the complaints: what about spectacles, false teeth, and heart transplants?
We blame our bodies because we idealize them; we apply a metaphor—miracle—that does not fit. The first IVF baby, Louise Brown, was called a miracle too—as well as a freak of nature, a test-tube baby, and the first step onto a slippery ethical slope. Well-wishers from around the world sent Louise cards and gifts, but her Bristol neighbors would often peer curiously into her pram, her mother said, as if they expected her to be made of glass.
Our Miracle Called Louise: A Parents’ Story is the full title of Lesley and John Brown’s memoir. They each have their say, alternating chapters in a candid and conversational style, and spend most of the book describing their loving but rocky relationship, which began when John noticed sixteen-year-old Lesley at a café in Bristol and said, admiringly, “What a cracker.” Reading it, I felt a little impatient to get to the IVF treatment—the miracle part—and then let down by the lack of detail there, compared with the bustling chapters about hanging out in cafés and sleeping in railcars. But for them, this was the story of how they came to be Louise’s parents—a story that begins not in a clinic’s waiting room but with the extraordinary series of random events that leads any of us to our partner.
“Louise is special because she would never have been born at all in the normal way,” Lesley writes near the end. “It was a miracle that I was chosen to have her.”
I imagine, if given the choice between the birth they had and a more conventional one, that John and Lesley Brown would have gladly repeated all the turmoil they experienced on the path to their daughter: the waiting, the financial hardship, the tabloid attention, all culminated in the one and only Louise. After the surrogate birth of his IVF-conceived son, Andrew Solomon felt an even deeper connection to the hundreds of parents he interviewed for Far from the Tree and reflected that parenting makes the subjective, which emphasizes fate over randomness, more real than objective truths. Our children, according to Solomon, “are the children we had to have; we could have had no others. They will never seem to us to be happenstance; we love them because they are our destiny.”
“All that really matters is that we’ve got her,” wrote John Brown thirty-five years earlier, with less eloquence but the same conviction. “I couldn’t be without Louise now.”
On the day of transfer, Dr. Young brought us a photograph of the blastocyst they chose, “the prettiest one,” the embryologist reported, that she had seen all year. This handing over of image (or images, for women transferring two or more embryos) is part of the ritual of ART; if you get this far, it is the proof of what the takeover accomplished, the closest thing to those fetal ultrasounds posted to fridges and Facebook pages. I wasn’t sure how I would feel looking at a mass of cells in medium—let down? ambivalent? motherly? But I clung to the embryologist’s words; I wrote them down in my notebook before I even looked at the photograph.
I’d seen enough of these images online, in medical journals, and in Dr. Ramos’s office to know that this was a good-looking embryo. The grainy black-and-white picture showed a mostly hollow sphere with many cells in the center, an already complex planet floating in space. Each cell of the inner mass, at this point, could become almost anything: heart, brain, lung. The embryo was hatching, just starting to break free of the smooth walls of the zona pellucida in preparation for implantation. At the bottom of the image, the embryologist had written my last name and the date.
Some clinics routinely offer sedation during embryo transfer, usually a Valium, and they’ll let you play soft music if you like. The theory is that it relaxes you, so your body is better prepared to receive your embryo. This sounds like a thoughtful, considerate touch, like the little coffee-and-tea station in the lobby, but in reality it’s often necessary. Some women who make it this far are on their third, fourth, or sixth IVF. Sometimes they are transferring embryos with little chance of implantation. Some of them have had miscarriages and D & Cs and traumatic ectopic pregnancies, and the padded stirrups and instruments they use in this room are full of meaning that has to be blocked out if they are to go forward.
Richard and I were lucky to have had none of those memories or bad experiences, just our years of waiting, and the takeover had gone better than we expected. Entering the transfer room, which days before had been my retrieval room, I didn’t need a pill or music. This first time, which I hoped was my only time, I didn’t want anything buffering the experience.
It was quiet enough to hear the humming of machines, and there was a strange formality as Dr. Young read my name aloud—an oddly low-tech precaution, given our circumstances. I held as still as I could while he threaded a thin catheter past my cervix. Kim, standing next to me, pressed an ultrasound wand into my stomach so he could select just the right spot. There was a spark of light on the monitor.
“There it is!” said Dr. Young. “Your embryo.”
Richard and I squeezed hands. Nothing about this experience had been what we expected when we thought of having children, or even when we first guessed that the road to parenthood might be a long one. It was more uncomfortable and expensive than we imagined, and less private—there were three other people in the room with us, plus family and friends who would want to know, in less than two weeks, if our IVF was successful.
Then the doctor, the nurse, and the embryologist all left, and it was just us: two people who might never have met, had these struggles, and made this embryo. A clock ticked on the wall, but we knew that no one would rush us. Though we were usually talkative with each other, even in examination rooms with my feet in stirrups, a shyness and reserve came over us as we considered the seriousness of what we’d done. We might have a baby in nine months, or more choices to make. For now we waited, again.