Contrary to popular belief, there is no infertility crisis sweeping the nation. We’ve just lost all sense of what it takes to get pregnant. Reproductive technology has made us lose patience with nature. So for a growing number of couples, creating a new human being has become a strange, inhuman process.
My great-aunt Emily and great-uncle Harry never had children, and no one in our family ever talked about it. Growing up, I knew not to ask. It would have been rude, as rude as asking about their income or weight. The message was clear: If they didn’t have children, they couldn’t have them, and talking about it would be insulting.
How times have changed? Today, a couple’s fertility prospects—or lack thereof—are no longer just a topic of conversation at casual dinner parties, they’re also the subject of countless news stories detailing the infertility “crisis” across the country.
Last year, Newsweek reported on infertility, reporting that more than three million American couples sought reproductive assistance in 1995. Diagnostic tests, hormone treatments, fertility drugs, and assisted reproductive technologies—with names like in vitro fertilization, intrafallopian gamete transfer, intrauterine insemination, intrafallopian transfer, and intracytoplasmic sperm injection, to name a few—have become as much a part of the process of procreation as the more sensual aspects of starting a family. While some of these more than three million couples were legitimate candidates for the array of high-tech options now available to them, most ended up needing only low-tech assistance, like panties instead of underpants.
In early 1996, the New York Times published a four-part series on the growth of the fertility industry and the increasing competition among clinics.
This is how the infertility crisis began and continues. Contrary to popular belief, infertility rates are not rising. Infertility rates in America haven’t been rising in decades, says sociologist Shirley Scritchfield of Creighton University: In 1965, the infertility rate for the entire U.S. population was about 13.3 percent; in 1988, it was 13.7 percent. According to the U.S. Office of Technology Assessment, infertility rates among married women have fallen from 11.2 percent in 1965 to just under 8 percent in 1988. These rates even include “subfertility,” the term used to describe people who are having children but not as many or as quickly as they would like. That means more than 90 percent of couples are having as many children—or more—as they would like.
LettingNatureTakeItsCourse
Instead of an infertility crisis, we have a society that has allowed technology to supplant biology in the reproductive process, effectively dehumanizing the most human of events. At the very least, this means that stress replaces spontaneity, with women tied to thermometers—constantly checking when they’re ovulating—while men stand around waiting to perform. At the very most, it involves women and men subjecting themselves to expensive surgical procedures. What happened to love, romance, and the idea of letting nature take its course? Instead, we seem to have embraced the idea that science, not sex, offers the best chance of producing biological children. Technologists have stolen human reproduction. There are about 300 fertility clinics—with $2 billion in annual revenue—to prove it.
Infertility has become a big business, virtually exempt from government regulation. It’s not for the weak—or their pockets. But all the hype has made us lose sight of what it takes to make a baby. Getting pregnant takes time. Infertility is defined as the inability to conceive or carry a child to term after a full year of unprotected sex two to three times a week. On average, it takes less time for younger parents (in their 20s) than for older parents (in their 30s); as couples move into their 30s, experts suggest staying on track for two years. But even couples in their prime—in their mid-to late 20s—need about eight months of having sex two to three times a week to conceive a baby. (In December 1995, the New England Journal of Medicine reported that healthy women are most fertile, and therefore most likely to conceive, when they have sex during the six-day window before ovulation.)
The link between how often a couple has sex and how quickly they conceive may seem obvious. But psychologist and University of Rochester School of Medicine professor Susan McDaniel says she counseled an infertile couple for six months before discovering they were only having sex once or twice a month!
Of course, these days, many would-be parents feel like they don’t have the time. During the baby boom, couples started having children around the age of 20. But by 1
After about age 37, a woman’s eggs tend to show their age and may degrade more easily, making it harder for women to get pregnant or maintain a pregnancy. That doesn’t mean there’s anything unusual about a 40-year-old woman having a baby. Older women have been having babies for ages — but not their first. In many cultures, the average age of the last child is around 40.
Some older women may be just as fertile as their younger sisters. A 40-year-old woman who has been on the pill for much of her reproductive life — thus preventing the release of an egg each month — may benefit from preserving her eggs, says Monica Jarrett, a professor of nursing at the University of Washington. She may even have a slight advantage over a 40-year-old mother who has one or two children and is trying to conceive.
“The focus on aging as the primary source of infertility is a distraction,” says Scritchfield. “Age becomes a factor when women are unknowingly infertile. These women, even if they tried to get pregnant at 20 or 27, would have had difficulty getting pregnant despite the best technology.”
GenderPolitics and Infertility
Some feminists suggest that all this talk about infertility is part of a backlash, an attempt to push women out of the boardroom and back into the nursery. While there may be some truth to this, it is only part of the story. The fertility hype is also the result of a growing expectation that normal men and women control nature.
Ironically, the growing intolerance of the natural course of pregnancy stems from technological advances in contraception. Contraception is more reliable than ever. The confidence we have in preventing pregnancy has given us a false sense of control over our fertility. “People have this idea that if they can prevent pregnancy, they should also be able to get pregnant when they want to,” says McDaniel.
This illusory sense of control weighs particularly heavily on women, says Judith Danyluk, a psychologist at the University of British Columbia and a fertility researcher. “Women are told that if they forget to take a pill, they risk getting pregnant. That means they feel very responsible when it comes to getting pregnant, too.”
If we allow technicians to steal our fertility, it’s probably because it’s been so accessible to everyone. Until recently, infertility was considered a woman’s problem, not a couple’s. In the 1950s, doctors and psychologists believed that women whose inexplicable infertility was “suppressing” their true femininity. Of course, men were rarely evaluated in those days; the limited technology available was mostly focused on women.
When couples enter the infertility arena today, both partners receive full evaluations—in theory. But in practice, that’s not always the case, because technology has become so advanced that even a few sperm from an infertile man are enough to perform a high-tech insemination procedure. About 40 percent of infertility cases are due to “female factors”—problems with hormones, eggs, or reproductive organs. Another 40 percent are due to “male factors”—problems with low sperm counts or slow sperm motility. The remaining 20 percent are unexplained or are due to factors in both partners. There may be an immune problem, where the sperm and egg are “allergic” to each other. There have been some advances—such as ICSI, a method of injecting a single sperm into an egg during in vitro fertilization—to overcome this immune system conflict. There have also been advances in understanding male infertility, including treatments for low sperm motility that involve extracting sperm directly from the testicles. However, the bulk of fertility treatment still focuses on women. McDaniel says women also tend to “carry” the problem for their partners. “As much as men are invested in having children, they don’t have to think about it, or maybe they’re as aware of it — because women are so focused on the problem. So it makes sense that men are the ones who are putting the brakes on infertility when it comes to infertility screening. If both partners are racing to the conveyor belt, it can get messy. So what happens — and this is largely due to gender roles — is that women become champions of the process, and men, who might be more hesitant, become skeptical and wonder if it’s time to stop.”
Danyluk notes that women go to great lengths to protect their partner from diagnosis, as well as treatment. They will protect their partner from blame when he or she is the infertile one, she says.
Forced To Have Children
No matter what the cause, infertility deals a profound blow to people’s sense of self, who they are, and who they think they should be. To understand how devastating infertility can be, it helps to know why we want children in the first place.
Anthropologist Helen Fisher, author of The Anatomy of Love, insists that “the most important thing the human animal does is reproduce.” Citing species survival as a reason for our drive to reproduce, Fisher says it’s no surprise that couples go to great emotional and financial lengths to conceive. “The costs of reproduction have always been high. The time-consuming and expensive procedures that modern couples use to achieve their reproductive goals may never be as costly as they were in the grasslands of Africa, where women regularly died in childbirth.”
Men, too, feel obligated to sow their seed or die, says Fisher, so they work very hard to conceive and raise their children. And they’re not exempt from social pressures either. “Male sexuality has always been about power,” says William Doherty, a professor of family sociology at the University of Minnesota. “The colloquial term for male infertility is ‘shooting the ground.’ After all, what good is a man if he can’t have children? Maybe that’s why we’ve blamed women for infertility for thousands of years. It’s so degrading to men.” Animal instincts may provide the primary drive to have children. But notions of masculinity and femininity are another big influence. Infertility taps into our deepest fears about what it means to be a man or a woman, a core part of our identity. McDaniel says many of the infertile women she sees talk about feelings of inadequacy. They talk about a loss of self-esteem, helplessness, and isolation. Women are still being taught that much of their femininity comes from motherhood, rather than men being taught that their masculinity comes from fatherhood. The loss of motherhood can fill a woman with such grief that she will avoid places where children live. It’s a loss that can be hard to share because it’s the death of something that never existed.
Infertile men also experience loss, says McDaniel. They may isolate themselves from the world of children. They may be less likely than women, says Doherty, to talk about their grief. “Men feel that if they can’t transfer their seed, they’re not living up to what’s expected of them as men,” says Andrew McCulloch, director of the Male Sexual Health and Fertility Clinic at New York University Medical Center. Parental expectations are another powerful reason why people feel the desire to have children. “When it comes to having children, there can be a lot of family pressure,” says McDaniel. “And if you don’t have children, everyone wonders why.”
TechFertilityTakeOver
With all the pressure to have children, is it any wonder that couples are falling into the maze of technological fertility? Seduced by well-meaning doctors who trumpeted hope and all sorts of treatments, two vulnerable people were left to decide on their own how much reproductive assistance they would or would not accept. There were no guidelines.
This could only have happened after nearly seven years of fertility treatment, when their doctor told them that the chances of having a baby were slim, given their ages – 37 and 32 – and the efforts they had put into that point. Steve had developed varicocele, a twisted vein in his testicles, and Lori had undergone multiple laparoscopic ovarian explorations to look for ovarian cysts, in addition to two failed IVF attempts.
“My wife’s gynecologist turned out to be unqualified to talk to us about fertility treatments,” Steve says. “It ended up being like going to the auto parts store. First, they tell you to take care of one thing, but it turns out you need to take care of another. Then they tell you to go do a third thing. You end up going from place to place without a plan. It’s rare to find a doctor who will explain in plain English what’s going on and help you weigh your options. Instead of talking to Lori and me and asking us what was in our hearts, they would say, ‘Well, you want a baby, how can we make one for you?’” Even as they went through test after test, procedure after procedure, it all seemed a little funny to them at least: the sunrise drive to a remote clinic, the painful injections Steve had to give Lori, even the “hamster penetration” test, which involved Steve producing a sperm sample to see if his sperm would penetrate a hamster egg. It was hard to resist. “I think it was partly the adventure that kept us going,” Steve says. “Once you commit and say you’re going to try it, you don’t want to stop halfway through. There’s always a chance it’s going to work. I mean, medicine is great; you take some pills, you put some stuff in your body, and you might have a baby.”
“Fertility treatments are so focused on technology that people’s emotions get left behind,” McDaniel says. She advocates a more humane, “biosocial” approach. “The emotional needs of the couple should dictate the pace of decision-making as they move up the technological ladder of possibilities. But in some clinics, maybe even most, there’s very little attention paid to the process, only to the potential product. And as a result, patients suffer.”
Even under normal circumstances, pregnancy is a no-brainer—it tends to clear the mind of everything else. As people begin to plan for a family, McDaniel says, their worldview narrows. But with technological fertility, a couple’s worldview can narrow to the point of excluding everything else. Because the outcome is the focus, fertility treatments intensify our instincts to have and raise a child. And so the same technology that ignores a couple’s emotions also intensifies their desire to parent. For women in particular, maternal instincts are heightened by comprehensive fertility treatments that leave little time for anything else and push women to define themselves solely as mothers.
Indeed, as soon as prospective parents seek help, statistics and biology become the focus. Before long, they are reading the latest research and talking in terms of “control groups,” “statistical significance,” and “replication.” The walls of fertility clinics are lined with photos of newborns, and staff and clients alike talk endlessly about “home birth rates,” the bare minimum when it comes to success. But home birth rates are more than just numbers. They represent people’s hopes for a family.
As a result, couples undergoing intensive fertility treatments lose their broader perspective on life. They may fall behind in their careers and be cut off from friends and family, all in the narcissistic pursuit of replicating their genes. Technology may give us the illusion that it helps us control our reproductive destiny, but in reality, it increases narcissism. “As technology becomes more and more hi-tech in treatment, couples become more and more self-centered,” says Doherty.
“Biological connections are so emphasized in our culture that it’s hard not to get caught up in ourselves,” Steve explains. “You even see that in adoption. Couples often worry that the children they’re adopting will have similar characteristics to them. But the truth is, children are children.” (Steve and Lori have since adopted a child.)
The fertility industry’s over-hyped success rates appeal to couples and feed narcissism. Fertility clinics typically have a 25% success rate. But that’s usually calculated after the clinics have screened out the most desperate cases. The true rate—which counts all those who sought assisted reproduction, and counts live births rather than pregnancies as successes—is closer to half, says Scritchfield. “Unfortunately, that’s not what people hear,” he says. “If we were concerned about infertility, we would be working on preventative measures. But biomedical entrepreneurs don’t address this because they’re not dealing with people, they’re dealing with body parts.”
But fertility technology can create such stress in a couple that it can destroy their relationship—the very reason they want to have children. McDaniel recalls a couple who were at odds with each other when they came to see her a year after five years of unsuccessful fertility treatments. The wife still hoped the technology would help them, but the man felt his wife had gone too far; the procedures were too invasive, and the lack of results too painful. In an attempt to protect them both from further disappointment, he insisted they stop.
The husband questioned why they had gotten involved in the first place, and the wife felt unsupported by his reaction. No one at the fertility clinic helped them work through any of their reactions. In therapy with McDaniel, they finally admitted to themselves—and each other—their expectations and the anxiety and grief they felt over the easy loss of a pregnancy. They decided to adopt.
Given the single-minded drive to have children, adding infertility and technology to the mix creates the perfect recipe for obsession. But it’s a wealthy-only obsession. That means having a baby becomes a luxury that many truly infertile couples, who would otherwise be great parents, can’t afford.
Who’s Infertile?
Although infertility rates aren’t rising overall, Creighton University sociologist Shirley Scritchfield, Ph.D., suggests they are rising among certain subsets of the population: all young women ages 20 to 24 and women of color. She says this is due to an increase in sexually transmitted diseases among young people. Sexually transmitted diseases, including chlamydia, gonorrhea, and genital warts, can permanently damage reproductive organs. Pelvic inflammatory disease, which women can contract as a result of other sexually transmitted diseases, is probably the biggest culprit in infertility among young women, in part because it—and other sexually transmitted diseases—often goes undetected.
Given the paucity of records, it’s hard to say whether male infertility is on the rise. A 1992 study by Norwegian scientists looked at semen quality over the past 50 years by pooling available evidence from previous research. They concluded that sperm counts have declined overall.
While the Norwegian study suggests a significant decline in sperm counts over half a century, the decline is not “clinically significant,” says Rebecca Sokol, MD, professor of medicine, obstetrics, and gynecology at the University of Southern California. That is, if sperm counts have declined over time—and many scientists disagree—they have simply gone from very high to moderate levels.
“We are exposed to higher levels of estrogen than ever before; we inject cows and other animals with estrogen and estrogen-like hormones to keep them healthy. There is no data to directly prove that this affects sperm counts, but we do know that high levels of estrogen in men are toxic to sperm. The theory is that this constant exposure to estrogen eventually changes the sperm.”
DollarsForBabies
The fertility industry may boast about its dedication to healthy babies, but in reality, it seems to be interested only in producing rich babies.
A comprehensive fertility workup to diagnose the source of a couple’s problem can take up to two months and cost anywhere from $3,000 to $8,000. That’s just the beginning. A simple procedure, such as hormone injections to stimulate egg production, costs $2,300 per cycle. Expect to pay $10,000 for a single round of in vitro fertilization (IVF). About 30,000 women a year try to get pregnant through IVF. Intracytoplasmic sperm injection, where doctors inject a single sperm into an egg, adds $1,000 to the price of IVF. A procedure that requires an egg donor (a popular choice among older mothers) costs $8,500 to $16,000 — per cycle. A varicocelectomy, to correct varicose veins around the testicles, costs $3,500. Few health care plans cover fertility treatment. And even when insurance does, it doesn’t cover all the direct costs, let alone many of the indirect costs, including lost income from missed work and childcare expenses.
How Couples Cope With Infertility
In general, couples who don’t have children are more likely to break up than couples who do, according to demographer Diane Lee, Ph.D., a professor of sociology at the University of Washington. What about couples who can’t have children, or who want to but are struggling? Researchers don’t know about those who don’t seek fertility treatment — who tend to be poor. But Laurie Pasch, Ph.D., a psychologist and fertility researcher at the University of California, San Francisco, studied 50 couples who had been trying to conceive for an average of two years. She says that infertile couples who seek fertility treatment tend to have higher rates of marital satisfaction than the rest of the population.
“Most couples who seek infertility treatment are committed enough to their relationship that they will endure the pain and suffering to have a child together,” says Basch. “And if they have the skills to work through their problem, their relationships tend to be stronger—even if they never have a child.”
So what kind of skills do couples dealing with infertility need? Basch says couples with similar coping styles are best, noting that infertility, like other major stressors, tends to bring out people’s natural ways of coping. “Couples who have similar ways of coping and easing their distress do better than those who have different styles,” says Basch. “They may both be support seekers, or they may both be isolators and keep it to themselves. As long as they’re coping the same way.”
Basch finds that couples who rely on emotional expression can be damaging to their relationship. That’s because they tend to express their feelings to their partner rather than share them with him or her. (That’s the adage that talking things out always makes things better.) “In this destructive communication pattern, one partner ultimately demands and the other withdraws,” says Bach. “One partner pushes for change, while the other withdraws, refusing to discuss the problem.”
Although both the demanding and withdrawing partners can change, women are usually the ones who demand more, and men are the ones who withdraw. In the case of an infertile couple, the woman may be more horrified than her husband about her inability to have children. But they may switch roles, and she may become more resigned while he becomes more anxious and wants to start treatment. Either way, the couple is at odds.
Tammy and Dan, parents of two — the product of five IVF and eight ART “The years of fertility treatment were like this. I was the boss, I took over,” Tammy says. Her daily routine involved being at the fertility clinic at 6:30 a.m. every day for blood tests and returning every afternoon for more tests. Once she became pregnant, she had to stay in bed practically from the day she conceived until the day her children were born. “When you’re trying to get pregnant, it becomes your entire focus. Everything you do is planned around it. You’re told what to do every day, and you can’t do much. Then, all of a sudden, you realize that you’ve focused your whole life on getting pregnant and not on your relationship. After our second child was born, and we didn’t have a crisis to deal with every day, it was hard to be normal.”
The emotional climate becomes even more difficult when one partner opts out of the fertility process altogether. Psychologist Susan McDaniel, Ph.D., of the University of Rochester School of Medicine, saw a couple in which the wife underwent extensive testing to see if she was infertile. Meanwhile, her husband could never get to the urologist for a test. He couldn’t stand the idea that his sperm count might be low. Naturally, his wife was furious. She went through painful, stressful tests—not to mention the high cost—and when her husband finally went to the urologist, he couldn’t bring himself to bring a sperm sample. When he finally did, it turned out that he was the infertile one. Each partner had difficulty understanding the other’s infertility prospects. Eventually, they decided to divorce.
