Some of the people I interviewed chose to be quoted pseudonymously. I have indicated the use of pseudonyms in the notes.
My name is called, and a doctor I’ve never met: Fifteen to eighteen percent is the chance per cycle my doctor estimated for me early in my IUI treatment, but it’s unlikely—or at least unclear—that my chances were ever this high, given the combination of factors that contributed to our infertility.
Over the course of my infertility treatment, I tried three different protocols: letrozole (brand name Femara), an aromatase inhibitor that’s prescribed off label to stimulate ovarian response; letrozole plus intrauterine insemination; and finally IVF. Though each treatment had the same goal, it was interesting to me how much more attentive my care was as the cost increased. For example, I took letrozole for eight months (it was prescribed by my gynecologist) and never had an ultrasound to monitor its effectiveness (even after my dosage was increased when I did not become pregnant). When I began IUI treatment in a reproductive endocrinology clinic, we discovered via ultrasound that the prescribed dosage was producing four to five mature follicles per cycle, which is potentially dangerous (my IUI cycle was canceled to prevent the risk of multiples). During my IUI cycles, ovulation was predicted by an over-the-counter ovulation predictor kit, but IVF involved a team of clinicians and a schedule of blood draws, phone calls, and ultrasounds.
Humans have a long history of imposing various forms of birth control and reproductive technologies on animals: More recently, when the northern white rhinoceros population dwindled to five because of poaching and habitat loss, scientists considered IVF a possible means of staving off the species’ extinction. Only one female rhino, a thirty-one-year-old resident of a Czech zoo plagued with uterine cysts, was of reproductive age. She died of a ruptured cyst in July 2015; scientists collected her healthy ovary in the hopes of eventually maturing the eggs and making use of her genetic material. If they are able to use IVF successfully, the resulting embryo will likely be gestated in a closely related subspecies.
The first evolutionary psychologist: I was introduced to the long-standing debate over the so-called child bearing instinct (versus the sex drive) through the fascinating work of Anna Rotkirch, a family sociologist whose study “All That She Wants Is A(nother) Baby?,” was the first description I found of the biological sources of child-longing. Rotkirch’s “What Is ‘Baby Fever’?,” published in The New Evolutionary Social Science: Human Nature, Social Behavior, and Social Change (edited by Heinz-Jürgen Niedenzu, Tamás Meleghy, and Peter Meyer), informs this chapter as well, especially the discussion of the function of baby fever for those facing barriers such as infertility or the absence of a relationship. Rotkirch also generously emailed with me about her work.
In America, 62 percent of reproductive-age women use some form of birth control; at current rates, 30 percent of American women will have had abortions by their forty-fifth birthdays: These statistics come from studies completed in the past ten years. I found the birth control statistic in “Current Contraceptive Use in the United States, 2006–2010, and Changes in Patterns of Use Since 1995,” by J. Jones, W. D. Mosher, and K. Daniels, published in National Health Statistics Reports, no. 60 (2012). The abortion statistic comes from “Changes in Abortion Rates between 2000 and 2008 and Lifetime Incidence of Abortion,” a paper by R. K. Jones and M. L. Kavanaugh, published in Obstetrics and Gynecology 117, no. 6 (2011).
“an emotion which may be typical for societies where women have many choices”: This quote comes from Rotkirch’s “What Is ‘Baby Fever’?,” which provides an overview of her baby-fever research.
Aside from possibly imparting a genetic proceptive tendency: I’m using proceptive as Rotkirch defines it: “behavior that favors childbearing and is the opposite of contraception.” She cites a 1999 study published in Population and Development Review by Hans-Peter Kohler, Joseph L. Rodgers, and Kaare Christensen (“Is Fertility Behavior in Our Genes? Findings from a Danish Twin Study”), which examined the first attempted pregnancy among Danish twins born from 1870 to 1910 (a high-fertility period) and from 1953 to 1964 (a time of lower fertility). The female twins in the first group showed little genetic influence in their proceptive behavior, but among the latter group, this influence increased. So baby fever may be something we inherit from our mothers and grandmothers, more argument that the desire for children is inborn. This term has also been used by Warren B. Miller, a U.S. demographer.
Pronatalism is the idea that parenting is a normalizing rite of passage: My understanding of the impact of pronatalism on infertile women is influenced by reading Marni Rosner’s dissertation, “Recovery from Traumatic Loss: A Study of Women Living without Children after Infertility” (2012). The details about the history of pronatalism in America come from Elaine Tyler May’s Barren in the Promised Land: Childless Americans and the Pursuit of Happiness (Harvard University Press, 1995).
I am not Catholic, or even religious, but I notice that my state-provided health insurance coverage for infertility matches the recommendations in the Donum Vitae: The health insurance plan I had at the time of my IUI and IVF treatment was BlueCross BlueShield of North Carolina’s health plan for teachers and state employees. Though my plan covered diagnostic tests and even expensive (and sometimes less effective) procedures to treat structural causes of infertility, such as a blocked fallopian tube, it specifically excluded “artificial means of conception.” This reminded me of the Catholic teaching I’d read regarding IVF, which puzzled me—my insurance was not provided by a religious organization (cross aside). If IVF was less expensive and more effective at overcoming infertility than certain surgeries (for both men and women), why wasn’t it covered? Additionally, I wondered why IVF, which can treat both male and female infertility factors, was generally billed to the woman’s insurance. If the woman is seen as the patient (because it is her body that receives the treatment of IVF or IUI), does that make exclusion of coverage discriminatory? In 2012, I spoke by phone about these questions with Barbara Collura, president and CEO of RESOLVE, who has worked for more than a decade on expanding state mandates for infertility coverage. Collura suggested that proponents of more inclusive insurance coverage for infertility face two primary obstacles: lack of medical understanding by some insurance companies, and fund-raising deficits among infertility organizations such as RESOLVE. At the time of our interview, Collura lamented that RESOLVE had a budget of $1.2 million a year, or about twenty cents to spend on each of the 7.3 million Americans who struggle with the disease.
Initially, some playgoers and critics struggled: My descriptions of critical reactions to Albee’s play, his correspondence with Leonard Woolf, and his unhappy childhood mostly come from Mel Gussow’s excellent Edward Albee: A Singular Journey.
Miss Anne and Miss Dierdre, the two neighbors from “In the Peanut Hospital,” are described pseudonymously.
Until about a hundred years ago, when doctors and scientists began collecting and displaying fetal specimens: I learned about early concepts of embryos and fetuses from Lynn M. Morgan’s Icons of Life: A Cultural History of Human Embryos. Morgan’s book also guided some of my thinking about the political, social, and emotional challenges of conceptualizing embryonic life.
In “Just Adopt,” Kate, the name of the birth mother, is a pseudonym. The Alexander family is quoted and described pseudonymously.
Primate mothers have even been documented as oblivious or insensitive to an accidental switch: Descriptions of primate babies’ dependency and the occasional accidental trading of babies (such as an observed example in Brazil, when two experienced muriqui monkeys traded babies by accident, then raised them successfully to adulthood) came from Sarah Hrdy’s Mothers and Others: The Evolutionary Origins of Mutual Understanding.
But more positively, perhaps the extra embryos created in a cycle can be adopted: Though the American Society for Reproductive Medicine prefers the term donation and an anonymous, nondiscriminatory process, some genetic and intended parents prefer the screening process and implications of adoption, which can include everything from a home study to the requirement that the intended parents be married heterosexual couples. Nightlight Christian Adoptions (nightlight.org), which began offering cryopreserved embryos to infertile couples in 1997, describes on its website a mission that suggests embryonic personhood: “Just as each snowflake is frozen, unique and a gift from heaven, so are each of our Snowflake Babies. We hope to help each donated embryo grow, develop and live a full life.” Nightlight even offers “waiting embryos” with identified risk factors, including health issues discovered in the genetic family or an assigned lower grade from an embryologist.
North Carolina was one of thirty-three states to pass eugenics legislation: The Winston-Salem Journal’s five-part series “Against Their Will” provides an excellent background on North Carolina’s eugenics-based sterilization program, and the paper has had on-going coverage of issues around compensation. John Railey, who wrote many of the pieces in “Against Their Will” and is an editor at the Winston-Salem Journal, published Rage to Redemption in the Sterilization Age in 2014. His book looks particularly at the state’s coercive actions in sterilizing Nial Cox Ramirez, who was one of the first victims to bring a civil case against the state.
It was a long time ago, some legislators claimed: “You just can’t rewrite history. It was a sorry time in this country,” then–state senator Don East told the Associated Press in a 2012 interview. “I’m so sorry it happened, but throwing money don’t change it, don’t make it go away. It still happened.”
there is evidence that infertility, as a stressor, is equivalent to the experience of living with cancer, HIV, or other chronic illnesses: The information about infertility as traumatic loss comes both from Rosner’s study and from phone and email interviews with Rosner.
The specialty mail-order pharmacy that miraculously accepted my insurance: Medication for IVF treatment was not covered under my insurance plan, but somehow the medications prescribed by my doctor were partially paid by insurance, and I paid significantly less than I had been told by the online pharmacy to expect. Another friend, going through IVF at the same time, under the same insurance plan, was not so lucky. I assumed the unexpected coverage was a clerical error that would be discovered at any time and was so afraid of the error’s discovery that I didn’t press the issue of another medication, Crinone, which should have been covered after my confirmed pregnancy.
The cost of medication is an unpredictable factor in IVF treatment—you don’t know, until your cycle is under way, how much injectable gonadotropin you’ll need to stimulate ovarian response. Medication is generally not covered by “cost-share” plans such as the one we purchased and can be approved or denied for coverage by insurance companies based on the treatment protocol (for example, the same injectable drugs might be covered for timed intercourse but not for IVF).
It’s also common to have drugs left over, and patients frequently give away or sell this medication at a reduced cost. In my cycle, I received Follistim left over from a friend’s completed cycle, just in case I needed it, and when my cycle was done, I passed along my leftover Follistim (and my friend’s) to another friend. Doctors and medical organizations warn patients not to accept leftover medication—you don’t know if it has been stored properly, for example, especially if you’re purchasing it from a stranger. But, with medication sharing one of the only ways patients have to reduce the cost of their cycles, it seems unlikely that the practice will end.
I found reports online: The information I found regarding Lupron’s self-reported adverse events was collected on lupronvictimshub.com, which reported numbers collected from a Freedom of Information Act request to the FDA, and from an article titled “Lupron: Do the Risks Outweigh the Benefits?” on lawyersandsettlements.com. Anyone can make a report of an adverse event or reaction to a prescription or over-the-counter drug using MedWatch, the FDA’s online voluntary reporting system. More alarming than any of these reports I found online was a line from Andrew Solomon’s Far from the Tree, which described Lupron (which is also used as an experimental treatment of severe autism) as “a castration drug that changes the body as profoundly as any medication can.”
It would have been possible to limit my exposure: We talked over a number of treatment protocols with our doctor, who was always patient with our need to compare. Although some studies (“Efficacy and Safety of Ganirelix Acetate versus Leuprolide Acetate in Women undergoing Controlled Ovarian Hyperstimulation,” Fertility and Sterility 75, no. 1 [2001]) suggest that the antagonist protocol has outcomes almost equal to Lupron down-regulation, the latter has been used for longer.
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: Steven Young later told me, “Interestingly, our new lab is so much better at making blastocysts that we only need two times the number on day three. We are doing a lot more single embryo transfers because of this—about three-fourths of women under thirty-five and probably half of women thirty-five to thirty-seven.” Though this data had not been made public yet by SART, he reported that the 2013–2014 pregnancy rate for patients under thirty-five using single embryo transfer was 79 percent.
In “Birth Stories,” Todd Jensen and Gabe Faibish are pseudonyms.
His organization funded and published a study: I first learned about this study through NeJaime’s article in the Yale Law Journal. “My Daddy’s Name Is Donor” is a study of 485 adults conceived through sperm donation, and reports fifteen findings, including a sense of confusion and loss among donor-conceived children, higher rates of delinquency and substance abuse among the donor-conceived, and higher rates of divorce in their families.
Before reading this study, I was familiar with some of the arguments about the rights of donor-conceived people through Alana Newman’s Anonymous Us project, an online collection of personal stories from people conceived through third-party reproduction. Many of the anonymous narratives on this site express anger at their genetic parents (particularly the donors) and discomfort with the idea that money was exchanged as part of their conception. The searchable database of stories (anonymousus.org) also includes posts from parents who have used or considered third-party reproduction.
The Institute for American Values, which published “My Daddy’s Name Is Donor,” and many of the participants in Anonymous Us argue against anonymity in gamete donation, which is legal in the United States but prohibited in Britain, Sweden, Norway, the Netherlands, and Switzerland. The New York Times published a discussion of donor anonymity and the question of regulation in their Room for Debate series on September 13, 2011. I was most compelled by two of the editorials. Robert G. Brzyski, chairman of the American Society for Reproductive Medicine’s ethics committee, argued that donor gametes and embryos are already subject to genetic and medical screening and that additional requirements could make the donation process even more expensive, and limit access. Sujatha Jesudason, the executive director of Generations Ahead, an advocacy group that focuses on the social justice implications of genetic technologies, expressed concern that additional regulation of ART could set a precedent for additional abortion restrictions, as well as a fear that regulation would disenfranchise more vulnerable populations. “Regulating assisted reproduction could mean higher prices and less economic access for some or could be a political opportunity to legislate morality and deny access to gays and lesbians,” she wrote. “This doesn’t mean that we don’t regulate, but we should be very careful in assessing the costs and benefits of who would be the most affected by restrictions on the fertility industry, and by extension in abortion services.”
Couples strained by years of infertility can choose new treatment options: The first report of preimplantation genetic screening that resulted in a healthy pregnancy was published in 1990. The screening, which is most often undertaken by patients with a poor prognosis or a history of miscarriages or failed IVF treatment, remains controversial and is often what people refer to when they discuss “designer babies,” in part because the process can also be used to select for sex. Likewise, many responded in alarm to the news, in 2015, that the UK would become the first country to allow IVF that replaces disease-carrying maternal mitochondria with mitochondria from a donor egg.
But even the definition of biological has changed: “It is clear that genes are not puppeteers directing behavior,” writes the anthropologist Sarah Hrdy in Mother Nature, her book on biology and the maternal instinct. “A range of non-genetic factors, such as mother’s physical condition or social status, the season when she conceived, her own diet or the one she provided her baby, the presence or absence of father—all contribute to individualization.” For this reason Hrdy takes issue with the common misuse of the phrase “biological mother” to refer to the genetic or gestational mother, and the binary thinking behind “nature versus nurture.” Further, the evolving field of epigenetics has demonstrated a multitude of ways in which environmental changes (to diet or temperature, for example), can affect the expression of genes, turning them on or off.
These treatments are so much less effective than IVF that most clinics don’t even keep careful track of them: The Fertility Clinic Success Rate and Certification Act of 1992 requires all clinics to report IVF statistics and success rates to the Centers for Disease Control and Prevention. This mandated reporting influences record keeping, Steven Young suggested.
Reading about the mandatory coverage requirements of the fourteen other states: RESOLVE publishes a useful guide to the insurance coverage mandated in fifteen states (resolve.org/family-building-options/insurance_coverage/state-coverage.html).
But it is also true that infertility is an emotionally punishing experience: In 1998, the Supreme Court found in Bragdon v. Abbott that reproduction is “a major life activity,” qualifying infertile people for some protection. Under the Americans with Disabilities Act, forbidding an infertile person from taking time off to pursue fertility treatment may constitute disability discrimination. The exclusion of fertility treatments such as IVF from employer-provided health care is not considered discriminatory under the ADA, because the exclusion applies to everyone, not just the infertile patients. Advocates for the infertile counter that by choosing to exclude from coverage a particular kind of health care, which would be used only by workers experiencing a particular health condition, employers discriminate.
Both companies announced that they would cover the cost of egg freezing and storage: This coverage was not extended to contract workers, such as receptionists and security, food-service, and maintenance workers.
While it’s easy to see how corporations might benefit if some of their best workers delay childbearing, and while work-life balance is a crucial goal, it feels presumptuous to worry about these women: Apple, Facebook, and many other tech companies are rightly criticized for vast gender and diversity gaps. In 2015, 69 percent of Apple’s workers were male, and, according to an Equal Opportunity Employment report filed in 2014, sixty of eighty-three leadership positions at Apple were held by white men. At Facebook, 32 percent of workers are women, and women hold only 16 percent of their tech jobs and 23 percent of their leadership roles. Many have suggested that the gender disparity is caused in part by expectations that employees work long hours and weekends and that egg freezing both highlights and delays a larger problem: a workplace that does not make room for having and raising children. I see the value in these arguments, yet it’s hard for me, as someone who had very limited insurance coverage while undergoing IVF, to look askance at any expansion of reproduction options.
If I had a younger sister who wondered if she should freeze her eggs while she waited for the right partner or the right moment in her life and career, I’d suggest she first see her gynecologist or a reproductive endocrinologist for a fertility workup. A simple blood test can give women and their doctors valuable information about ovarian reserve.
It took five days of watching and waiting for the gorilla keepers to decide that enough was enough; they finally sedated Olympia and gave Bomassa back to Jamani: Aaron Jesue emphasizes that it takes extensive training to build the gorillas’ trust during medical and emergency procedures. He reports that Olympia actively participated in a hand injection during the sedation process.