I dart into the elevator just as the doors shut. It’s crowded, so I carefully wedge myself between a nurse holding a lunch tray and an elderly couple who are clutching each other’s hands and a large, manila X-ray envelope. I push my arms poker-straight down in front of me to make room for others and to better secure the vial of my husband’s sperm, which is stowed snug and warm in the center of my bra.
It sounds like the setup for a punch line. A woman walks into an elevator with sperm in her bra and … But though it’s funny, it’s not a joke. It’s the prelude to my first intrauterine insemination (IUI).
In early 2002, my husband and I began trying to conceive a child. After a year or so of trying to pinpoint ovulation by daily temperature taking and peeing on over-the-counter ovulation predictor sticks, we finally accepted that the old-fashioned way was getting us nowhere. According to medical advice, because I was 35 when we started trying, we should have waited only six months before going to a reproductive endocrinologist. I say a better-late-than-never prayer and find a fertility specialist. My husband has his sperm tested and we learn that he is not the problem— or as they say in the fertility world, there is no male factor” preventing conception. I undergo blood work and a hysterosalpingogram to check for blockage in my fallopian tubes— and when everything checks out with me, too, I’m given the diagnosis of unexplained infertility. I comfort myself knowing that roughly 15 percent of all infertile couples have this label— and that with the right treatment, I can join the millions of women who give birth each year.
We begin artificial reproductive technology (ART), hoping Clomid, a synthetic hormone pill, will trick my system into ovulating. After six months with no pregnancy we’re told the next step is the IUI, which is why, a few minutes after leaving the elevator with the vial of sperm in my bra, I’m lying on an operating table with my feet in stirrups. By now, it’s a familiar position to me.
While the doctor inserts a catheter the width of spaghetti into my cervix and injects the sperm, which had been produced” by my husband in a lab two hours earlier, I gaze at the grainy, sepia-toned ultrasound photo of the two large eggs generated by taking 100 milligrams of Clomid. The doctor had printed the picture just before the procedure. I touch it and wonder which one will be my baby. Maybe both. Driving back from the hospital, I calculate my due date and toy with baby names. At home, I put the ultrasound photo in my wallet. In the checkout aisle of the grocery store that evening, I allow myself to flip through pregnancy magazines.
Two weeks later, I have a pregnancy test at the hospital and when the doctor calls to kindly explain that the result is negative, I am stunned. Crushed. I was certain that getting the right doctor, the right drugs and getting the sperm straight to the waiting eggs would do the trick.
But I shake myself out of a daze, put myself back together, with the promise of another IUI, one that will use injectable hormones instead of pills. This, after all, is the seduction of fertility treatments: there is almost always something else you might try, something more to pin your hopes on.
I tuck the grainy photo in a drawer and say my better-lucknext- time prayer. After an awkward, nervous evening of fumbling fumbling over the injectable pen, with its vial of the hormone Follistom— the DVD made it look so easy— I become a pro at sterilizing, tapping for air bubbles and administering a subcutaneous shot in the fleshy part of my stomach. I chalk up my yellow and purple bruises as badges of courage.
About a week later, I’m back in the doctor’s office, pulling a vial of sperm from my bra and waiting for another photo of the eggs I (and Follistom) produced.
Forget the birds and the bees. Fertility is a numbers game-and it starts early. Really early. Scientists estimate that that initial pool of primordial follicles in a 16- to 20-week female fetus is 6 to 7 million. By birth, a female’s ovaries contain only 2 million. By the time menstruation hits, only 300,000 or so follicles remain. Another ovarian milestone hits around 37.5 years of age, when a woman’s follicle count falls to about 25,000, the point at which researchers say the decline accelerates. Even the most fertile of young couples only has a 20 to 30 percent chance of getting pregnant any given month, but for most of history, this hasn’t been a problem. In 2003, there were 4,091,063 births in the United States and ART accounted for only about 1 percent of them. Obviously, plenty of women are conceiving on their own.
But modern life has presented a few hurdles, fertility-wise. In 1970, the average age of a woman giving birth for the first time was 21.4 years. In 2000, the average age to give birth for the first time was 24.9 years. By now, it’s not news that women are waiting longer to marry and have children. Whether it’s career, early divorce or just not being ready,” lots of us are postponing motherhood.
The downside is that it’s simply harder to get pregnant as you get older. Not impossible, but harder— sometimes much harder. An estimated one in six couples struggles to conceive and 15 percent of women of childbearing age in the United States have received an infertility service, from hormone therapy to IUIs and in vitro fertilization (IVF).
Then there’s the other part of the fertility numbers game: the cost. No question that the end result is priceless, but the hefty costs of ART are daunting for many couples. The average cost of one IVF cycle in the United States is $12,400. Some insurance companies won’t cover it, while others do, but limit the number of procedures. Then there are the options that are usually all outof- pocket, such as using a younger egg donor, which typically starts in the $20,000 range for medical, legal and donor fees. Adoption can be equally as expensive, with non-foster-care adoption generally starting at around $5,000 and topping out at more than $40,000. Infertility tests the body, heart and so many times, the wallet. My husband and I made the decision when we first saw a specialist that we would go only as far as our insurance would take us. We can’t afford any more.
On a Monday evening in September 2004, I stand in the bowels of a hospital, waiting outside the locked door of its medical library where the hospital-sponsored infertility support group will meet— just as soon as the facilitator arrives with the key. A trim woman standing next to me explains that the group leader has a new baby— her second through ART, both conceived in her 40s— so she’s running a little late. We make small talk until the leader arrives, cheerful and breathless. She opens the door for the four women (and one husband and 6-month-old twins) who have come to talk about their infertility.
I take a seat and glance at the shelves surrounding the 1960s-era conference table and chairs. To my left is a row of volumes on gastro-intestinal and liver disease, which turns out to be the perfect backdrop for a conversation heavily peppered with drug names, test analyses and questions like “fresh or frozen?” Still new to the terminology, I soon learn that “fresh” refers to embryos grown in the lab and implanted in the uterus a few days after egg retrieval. Any extra embryos not implanted are frozen for future use.
The support group is an odd, comforting mix of medical conference, cheerleading session and group therapy. The women are kind, open, upbeat— and they’re medically savvy and familiar with nearly every specialist and clinic in the area. The woman with the husband and twins (and several frozen embryos, I learn) has come to say goodbye until she and her husband are ready to unfreeze their waiting embryos and start the process again. It’s also the farewell session for the woman I chatted with earlier. After producing dozens of eggs on her first course of drugs, she and her husband went through three failed IVFs, all out of pocket. They’ve decided to use the considerable money they would have spent on more procedures to adopt instead.
After I describe the procedures and out- comes my husband and I have experienced— by then we’ve been through a second failed IUI— I feel comfortable enough to share my secret, something I rarely do when talking about my inability to conceive a child, especially when talking to a group of women who are struggling, as well. The secret is that my husband and I already have a child.
Because I have conceived and delivered successfully once before, my condition is referred to as secondary infertility. I find it an odd choice of wording, because my desire to have another child is anything but secondary. I’ve spent almost every day of the past three years either doing something to get pregnant, praying I was pregnant or thinking about why I wasn’t pregnant. Nearly a quarter of all couples going through infertility treatments have a child already, yet beyond the kind faces in this book-lined room, I feel like a second-class citizen in the world of would-be-mothers. Some doctors and friends have told me I shouldn’t be so desperate because “after all, I already have one.” I want to tell them that though my body may be trying to tell me it’s done having children, my heart is not. I want to say that I miss having a tired toddler’s head resting heavy on my shoulder, that I’m not ready for all the “firsts” of my first child to be my last. But mostly, I want to tell them that my husband and I want the child we have already to have a brother or sister, someone beyond us.
I have another, more shameful, secret, one I don’t share with the support group: infertility has made me mean. When I see a pregnant stranger, I often think “Bitch.” Or if I see a woman with two or more kids, I wonder why she gets more than one. Why her? Why not me?>
By October, with the two failed IUIS behind me, I have begun to refer to all my appointments and procedures as “futility” treatments, a joke that brings a strained chuckle from my doctor. But it describes perfectly how I am beginning to feel about my chances of getting pregnant. My hope in each new fertility treatment is now quieted by the reality of the procedures that have already failed.
Then, the day after Thanksgiving— two weeks after our third IUI— my cell phone rings. Earlier that morning, I had been to the hospital for a pregnancy test. With my husband listening in, the doctor tells me what we have been waiting two years to hear: we are pregnant. After sonograms in the doctor’s office at five and six weeks— too early to hear a heartbeat, but early enough for the tiny white dot of a heart to show up on another grainy black-andwhite photo— I return to my regular OB/GYN for pre-natal care and proudly show her my ultrasound photo.
Though we’re keeping it a secret from family and most friends, we are over-themoon happy. I doodle baby names, mostly girls’, on scratch paper while I chat on the phone. My husband and I talk about shifting the kids’ bedrooms— the plural of the word “kid” sounds wonderful— and I order maternity clothes online. I go to the attic and open the plastic storage tote that holds my child’s infant clothes, happily sorting through the cotton sleepers and soft blankets I’d put away back when I had no doubt I would have another child. After all, I’d done it once.
In early January, during my first visit to my OB/GYN, she instructs me to get a routine ultrasound. A week later, an ultrasonographer squirts jelly on my stomach while I fix my gaze on the monitors. In the darkened room, she explains that she’s going to take a few measurements. And a few more. Then a few more. After what seems like hours of listening to fluorescent lights buzz but no sound from the machines, she turns and gently says, “I’m sorry.” Though I should be around nine weeks pregnant, she explains that based on her measurements, my baby only lived to about seven weeks.
She hugs me, hands me some tissues and gives me some time alone. Again, I’m stunned. Crushed. I didn’t see this coming When you undergo fertility treatments, the brass ring is the pregnancy. I really hadn’t thought beyond that. I call my husband, who leaves work to meet me— neither of us envisioned any kind of problem, so why would he have come to such a routine appointment?— and the ultrasonographer calls my OB/GYN. I go back out to the waiting room filled with very pregnant women, trying not to make eye contact as I search for a magazine without a smiling woman with a bulging stomach on the cover. A week later I undergo my first dilation and curettage (D&C) to remove my pregnancy, or what is now referred to on my chart as “the products of my conception.”
Over the next few days, I try to tell myself that miscarriages happen all the time to all kinds of women— about 15 to 20 percent of all pregnancies end this way. At our request, my OB/GYN has the tissue analyzed for chromosomal issues. We learn that a common chromosomal abnormality caused the miscarriage, nothing that should stop us from moving forward in our fertility plans. After breaking down at The Gap while returning my maternity clothes, I try to move forward, too. There’s still IVF to try. In my head, I count all my friends who’ve had success with it— many on the first try— and I hope I can join the club.
Bssed on my age-now a onth shy of 39-and my history of infertility, I am placed on an advanced protocol for IVF. We sign a series of forms agreeing to implant up to four embryos and consenting to freeze any extra. I give myself a series of shots at my kitchen counter in the morning and just before dinner, and as a result, I produce six eggs that are placed into a petri dish with my husband’s sperm. Not all of them fertilize and thrive, and by implant day we have only two embryos to work with: one of average quality and one of “below average” quality, according to the lab. My husband and I joke that if we get twins, how will we know which one is which? I go home to a day of bed rest, magazines and takeout from my favorite restaurant.
Like the first IUI a year earlier, I am convinced I will get pregnant with my first IVF. And I do. The blood test is positive, though my pregnancy hormone numbers, the nurse tells me, are in the low range. I don’t hear that. All I hear is that I am pregnant. Two days later, I return for another routine blood test and instead of the numbers doubling, which should happen, they have sunk to the non-viable range. I was effectively pregnant for 48 hours. Though my second IVF two months later uses the most advanced protocol possible, I produce only four eggs and one resulting embryo. The nurses and my husband keep telling me that “all it takes is one,” but this time I cry as the doctor inserts the catheter to place the embryo in my uterus— not from physical pain, but from emotional exhaustion. As a nurse prepares to wheel me back to recovery, the doctor clasps my hands and wishes me luck.
Two weeks later, the result of the pregnancy test is as I expected: negative. What is unexpected is the news that my ovarian reserves are in rapid decline. According to the doctor, I should be producing much larger quantities of eggs than I am, given the level of drugs I am taking. With a delivery both honest and kind, the doctor tells me that my best chance of conceiving is with a much younger donor egg. This news is still sinking in as I write this.
I wish that I could finish the joke with a happy ending. “A woman walks into an elevator with a vial of sperm in her bra … and walks out with a baby in her arms.” But next month, I’ll undergo the last IVF that my insurance will pay for. So I don’t know the ending yet.
What I do know is that this is not the kind of experience that lends itself well to metaphor. It’s not a “journey” or an “odyssey” or a “quest.” When undergoing fertility treatments, the journey is as far from the point as you can get; it’s all about the destination. And to call it an odyssey or a quest implies that some great truth is revealed along the way, that some all-important lesson is learned. All I’ve learned is how to administer a shot, and that I waited too long to try to have another child.
No, for me, this has been more like a really crappy road trip with an older model car that needs serious body work and maps that may or may not get me there. But the destination is worth it— more than worth it— so I lurch ungracefully down high-tech highways and bumpy side streets. And, as I grapple with the real possibility that my final destination will be a place in which I never expected to find myself, I press on the gas, still hopeful that this road will be the one that leads home.