Treating Infertility :Amid a confusing array of resources, how to decide which you can trust

by Barbara Seaman

First published in Women's Review of Books: A Feminist Guide to Good Reading http://www.wellesley.edu/WomensReview/homepage.html .

IT IS COMMON ENOUGH. You may have a friend or relative or neighbor who underwent fertility treatments. You yourself may have experienced the painful and costly rounds of pills, injections, egg harvesting, and implantation. There's a lot at stake when you sit down to research the safety and efficacy of different kinds of reproductive medicine. You must be prepared to ask tough questions. You must be skeptical of the claims made in mainstream websites and books, for some are nothing more than marketing tools. What follows is an overview of the history of treating infertility in this country, some feminist ideas about it, and some recent thinking.

Although we often think of the medicalization of infertility as a 1970s phenomenon, it actually began nearly two centuries ago, according to The Empty Cradle (1996), the splendid history of infertility in America by sisters Margaret Marsh and Wanda Ronner. They reveal that Lydia Maria Child and Amelia Jenks Bloomer were among the heartbroken first-wave feminists who could not bear children. "Beginning in the 1870s," say Marsh and Ronner,

gynecologists routinely made women's roles a subject of discussion at their annual meetings... The idea that inappropriate behavior causes infertility was dominant in this era and has recurred periodically ever since... The young woman who sought a college education--or worse, a career after she earned her degree--would most likely find herself suffering from sterility brought on by "uterine inflammation." (p. 82)

Such ideas may sound quaint, but even today, drug companies such as Serono and Organon, which dominate the field of infertility treatment, encourage patients to feel guilty by promoting suspect notions, implying that infertility is on the rise because feminism tricked women into focusing on careers. (These corporations have even come to dominate resolve, the major support group for patients. Although the group began as a genuine grass roots organization, disillusioned ex-members say it has gone "Astroturf.") In a 1997 Minnesota Public Radio interview, feminist historian Sara Evans interpreted the late 20th century's message to women as: "See what you did? You should have been having babies and you went off and got a PhD instead or started a business... And now you deserve what you get." In fact, say Marsh and Roner, the infertility rate has remained constant for a century at ten to 13 percent.

Women are also told that their fertility decreases after age 30. But if we examine our family trees, most of us find female relatives who bore children after age 40. My own mother bore her third and last child at 41. My stepmother, who married late, bore her first and second children during her early 40s. In a 1993 interview, Swiss billionaire Fabio Bertarelli, president of Serono, which then manufactured 70 percent of the world's infertility treatments, admitted, "Our usual customers are women over 30 who have been taking birth-control pills since they were teenagers or in their early 20s." In the 1960s, new female methods of contraception like birth control pills and intrauterine devices grew popular. Young girls were started on high-dose pills too early and kept on them too long. Some experienced temporary infertility when they stopped taking the high-dose pills, since their normal cycling sometimes took a year or longer to return or did not return at all without medication.

At the same time, men abandoned condoms. As a result, gonorrhea and other sexually transmitted diseases (STDs) such as chlamydia, which may scar the fallopian tubes, increased, making women under the age of 24 the group with the most steeply rising infertility rate. The Centers for Disease Control (CDC) estimate that one million US women experience pelvic inflammatory disease each year: 50 percent become sterile after three episodes; 12 percent after just one. STDs are underdiagnosed and undertreated. In 1991, the CDC issued a new recommendation: "Use barrier methods. Even if contraception is not needed."

In addition, during the 1950s and 1960s, several million women were exposed to DES in their mothers' wombs, as this hormone was erroneously claimed to prevent miscarriages. Instead, it caused vaginal cancer in some daughters and T-shaped wombs that could not hold a fetus securely in many others. All in all, the flight from barrier contraceptives and the consequent blossoming of STDs plus the carelessness and naïve readiness of doctors to try out new techniques on patients who are not informed that they are experimental subjects contribute as much or more to infertility today as women's refusal to remain "barefoot and pregnant."

Fertility doctors often overstate the benefits and understate the risks of taking drugs, pushing their patients into ever more dangerous and costly treatments while averting their eyes from obvious problems and non-drug solutions--for example, the body-fat connection to fertility. Modern women were understandably skeptical of grandmothers who told their sons, "Don't marry her. She's too skinny to give you children." But in Female Fertility and the Body Fat Connection (2002), Rose E. Frisch implies that the grandmothers were on the right track. She found that athletic or exercising women, in splendid condition, sometimes cross the line of having too much muscle in proportion to their body fat (although they may not be "skinny"), causing them to fail to ovulate. Is it malpractice to start such a woman on Clomid instead of teaching her to slightly tweak her diet and exercise regimen? As one forthright insider explained, "Bear in mind that if you wish to develop a reputation as a fertility doctor, you don't want patients getting pregnant on their own."

Recent articles from medical sources such as Fertility and Sterility and The British Medical Journal , as well as lay sources such as Popular Science, The New York Times , and my own February 2004 piece in Oprah magazine warn that a backlash against some US fertility practices is underway. Wannabe parents and disinterested taxpayers alike are paying an outrageous price for our failure to regulate fertility doctors. In England , the Human Fertilization and Embryology Authority is firmly committed to reducing multiple births. Here, we have no such regulatory body, and for the first time since 1958 our infant mortality rate is rising. This is attributable to the increase in low birth-weight babies due to the multiples resulting from the use of fertility drugs and assisted reproduction techniques (ART). (If you live in a neighborhood populated with affluent young families you may have noticed an increase in extra-wide or extra-long baby strollers containing twins, triplets, and more.) In the US , 55 percent of all ART births are multiples, since we set no limits on the number of embryos that can be inserted in a patient's womb. Besides upping our infant death rates (five times higher for twins than for singletons and nine times higher for triplets), these ART babies engender huge hospital bills (one estimate disclosed that premature triplets cost $1 million each). They experience a number of long-term health problems at a higher rate than singletons, including cerebral palsy and oxygen-induced retrolental fibroplasia, a form of blindness.

What is more, among patients who become pregnant after assisted conception, about one in 25 will have ectopic pregnancies--twice the normal risk. Peter Braude and Paula Rowell wrote in the British Medical Journal ( October 18, 2003 ) that this may be due to embryos' being "inadvertently placed" in the fallopian tubes when the transfer from the laboratory takes place.

FERTILITY HAS HISTORICALLY BEEN a controversial and confusing issue, even among feminists. In 1970, Shulamith Firestone argued in her classic The Dialectic of Sex (reissued in 2003) that women cannot achieve parity with men until babies are produced by extra-uterine methods. She envisioned artificial wombs and placentas, declaring, "Childbirth is at best necessary and tolerable. It is not fun." Simone de Beauvoir and Ti-Grace Atkinson had similar ideas. In contrast, the women who founded the Feminist International Network of Resistance to Reproductive and Genetic Engineering (finrrage) vehemently opposed such concepts. Feminist critiques of reproductive technologies included The Mother Machine (1985) by Gena Corea; Infertility, Women Speak Out about Their Experiences of Reproductive Technology: It's a Con (1989) by Renata D. Klein; and Women as Wombs: Reproductive Technology and the Battle over Women's Freedom (1993) by Janice Raymond. Raymond summarized the views of the finrrage feminists: "Reproductive technologies violate the integrity of a woman's body in ways that are dangerous, destructive, debilitating, demeaning and a form of medical violence against women."

In Baby Steps: How Lesbian Alternative Insemination is Changing the World (2004), the sociologist Amy Agigian tells the story of some feminists who took reproductive technology into their own hands. These days, there are two ways to make a baby--the old-fashioned way or in a lab. But in the 1970s and '80s there was a third way, practiced by lesbians at home with turkey basters and mason jars. Lesbian alternative insemination (AI), or insemination outside the medical context, was inspired by the Los Angeles-based self-help gynecology movement that began in 1971. Agigian describes facilitating AI in the 1980s:

Women having the opportunity to parent without men seemed to me an important procreative freedom, especially for lesbians. I took a part-time job as an anonymous sperm courier for an AI program geared toward lesbians.... I worked to facilitate the pregnancy and ensure the privacy of the program's participants. I met sperm donors in parking lots, parks and their homes and relieved them of small containers that I placed immediately into the crook of my armpit. I handed cash to anonymous men, some of whose faces were still flushed, in exchange for a small warm vial.... I responded to late night phone calls from women whose ovulatory status required insemination the next morning... I tried to respect everyone's privacy and always to forget the names, faces, addresses and voice of both clients and donors. (pp. xvi-xvii)

Agigian maintains that

[L]esbian AI radically challenges the power structure, assumptions and presumed "naturalness" of major social institutions.... Lesbian AI is unique among modes of procreation because it enables women to create families with no legal or psychological father, and because it involves the commercialization of men's procreative capacities rather than women's. (p. 2)

A 1988 study found that most fertility doctors rejected lesbians, says Agigian:

Doctors were more likely to accept a woman who was "welfare dependent," had medical risks from pregnancy, was infected with syphilis, gonorrhea, genital herpes, hepatitis, cytomegalovirus (CMV) or chlamydia, had a criminal record, had "less than average intelligence" or had less than a high school diploma, than they were to inseminate a known lesbian. (p. 5)

However, Agigian reports that a decade later most lesbians have gone high tech, and many clinics now welcome their business.

ROBIN MARANTZ HENIG begins Pandora's Baby (2004), her history of mainstream in vitro fertilization (IVF), in 1944, when John Rock and his Harvard colleague Miriam Menkin achieved the first successful fertilization of a human egg in a Petri dish. Many readers of Science magazine, where they published their results, doubted this could be possible. Henig introduces Landrum Shettles, a doctor at Columbia University , who almost made a "test-tube baby" for Doris Del-Zio in 1973. But Shettles' department chair, Raymond Vande Wiele, filched and destroyed Del-Zio's harvested eggs, and Del-Zio sued him and Columbia , stating they had ruined her life. She won. Shettles' admirers still insist that he, not Patrick Steptoe in England , would have been the father of IVF if not for the violent interference.

Henig says that currently, IVF has a 24 percent success rate (I wouldn't be surprised if the lesbian AI rate were equally good or better). In contrast to the low profile of "turkey baster babies," the birth of "test-tube baby" Louise Brown in England on July 25, 1978 , was greeted as the greatest science news since the moon-walk a decade before. "IT'S A GIRL!," hailed the New York City tabloids. "HERE SHE IS!," the London papers announced. Henig adds,

[T]he acclaim was not universal; the test tube baby's very existence made lots of people uneasy…. Nothing in the process of artificial conception even vaguely resembles love-making. With IVF she counts, and waits, and prays, and gets a bill for each individual attempt...and every step carries risk. The woman is stoked with hormones to stimulate the maturation of multiple eggs, and these hormones may increase her risk of cancer or other problems later in life. (p. 235)

But Henig is by no means a foe of the new technologies. On the whole, she is an affectionate admirer of many of the stars of the field--competitive, ego-driven, and part mad-scientist though they may be. The difference between her book and others in the mainstream is that, in the end, Henig honors patients' right to know and decide for themselves whether the information they receive is threatening or empowering.

In The Empty Cradle , Marsh and Ronner quote the 1930s infertility treatment pioneer, physician Sophia Josephine Kleegman, who said, "In no field of therapy has the human body been so frequently assaulted as has that of the barren woman. No surgery on the women should be done unless the husband's sperms are within fertile limits." While the universally respected Kleegman pushed for acknowledgment of the "male factor," her colleague Frances Seymour played the "bad cop" to her "good cop." Seymour provoked "apoplectic reactions" from her colleagues for her forward thinking views--radical even for today:

She had no qualms about making the procedure [donor insemination] as available as possible and did not insist that her patients be married. She later claimed that she had inseminated many unmarried career women. Insisting that any woman who wanted children should be able to have them, Seymour viewed donor insemination for women without husbands as "a decent and moral method of acquiring the children nature intended them to bear." (p. 160)

Although many women love the idea of "test tube babies" and only wish their health insurance would pick up the cost, three distinct groups of US critics remain wary of assisted reproduction technologies: feminist scholars and health activists, cautious scientists and public health professionals, and right-wing conservatives. These same "strange bedfellows" also lined up during the 1960s to ask the tough questions about high-dose birth control pills. We now know that the early pills contained a massive estrogen overdose--eight to ten times what we use now. History may be repeating itself.

Available on this website with kind permission of Barbara Seaman.