Motherhood at 40 and the Bioethical Quagmires of Reproductive Technology
The following are excerpts from Cracked Open: Liberty, Fertility and the Pursuit of High Tech Babies by Miriam Zoll, including chapter titles. (Interlink, May 2013)
One Egg, Please, and Make It Easy
I am an official member of the Late Boomer Generation. We grew up after the Pill and the Baby Boomers, in the socially transformative 1970s and ‘80s, watching with wide eyes while millions of American women—some with children and some not—infiltrated formerly closed-to-females professions like medicine, law, and politics. This exodus from the kitchen into the boardroom created a thrilling, radical shift in home and office politics, in the economy, and in relations between the sexes.
“Shoot for the stars,” some of the more thoughtful women advised us, “but don’t forget about the kids.”
We are the generation that also came of age at a time of burgeoning reproductive technologies. We grew up with dazzling front-page stories heralding the marvels of test-tube babies, frozen sperm, surrogates and egg donors; stories that helped paint the illusion that we could forget about our biological clocks and have a happy family life after—not necessarily before or during—the workplace promotions.
Each week newsstands brimmed with stories about older celebrities becoming mothers with the help of miraculous fertility treatments. A few years ago, photographer Annie Leibovitz birthed her first child at the age of fifty-two, while actress Geena Davis delivered at forty-eight and supermodel Christy Brinkley at forty-four. More recently we read about singers Mariah Carey and Celine Dion delivering twins at forty-one and forty-two, and actresses Courtney Cox and Marcia Cross became mothers at forty-three and forty-five, respectively. From where we stood, science and technology was the New God, giving women once considered over the hill a chance to start a family in middle age. Whether we knew it or not, we comforted ourselves in a security blanket of medical and media reassurances that age and motherhood no longer mattered.
On the morning of our first appointment at the fertility clinic, Michael and I were nervous and excited. The clinic literature cited studies claiming, “Well over two-thirds of all couples seeking treatment for fertility- related problems become parents.” It didn’t occur to us then to ask if this statistic meant that two-thirds of parents birthed their own babies or a donor egg or embryo baby, or if they became parents through adoption or surrogacy. We were as green as could be about what to expect and what to ask, and we were eager to hear how the doctors thought they might help us.
The world’s first test-tube baby had been born in Britain in 1978. Data from the European Society for Human Reproduction and Embryology indicates that globally in 2012, approximately 1.5 million assisted reproductive technology (ART) cycles were performed and roughly 1.1 million failed (77 percent). In the United States, the Fertility Clinic Success Rate and Certification Act of 1992 requires the Centers for Disease Control (CDC) to publish self-reported ART pregnancy “success rates” from almost 500 fertility clinics scattered throughout the country. In 2010, the most recent data available, there was an overall failure rate of 68 percent. With no standardized reporting mechanism, the rates are based on cycles that require manipulation of egg and sperm outside of a woman’s body. They do not take into account success or failure rates of intrauterine insemination (IUI), hormone treatments alone, or donor egg cycles that are c cancelled.
That first day, my husband and I met with two health care professionals, one who examined my female interior and another who walked us through the ins and outs of the medical aspects of fertility treatments. A marble egg sat on a little pedestal on both staff members’ desks, and at one point during our meetings they each held it between their thumb and index fingers. In the spirit of Vanna White, the former Wheel of Fortune hostess, they smiled and said, verbatim: “Like we say here at the clinic, it only takes one good egg to make a baby.” It was obviously the clinic’s mission statement. I immediately thought that, if all we had to do was find one good egg, we were certainly the right candidates for the job. How hard could that be, really? We had the best of modern science and medicine at our fingertips. I was in great mental and physical health. I exercised and practiced yoga regularly. I ate well. What more could a doctor ask from a patient? Little did I know that the process of finding one good egg would be a bit like panning for gold in a mine that had already been stripped of much of its bullion.
A few weeks later, we met with a veteran physician I like to refer to as the Silver Fox. He greeted us with a warm handshake and a smile, and gave us time to look at his marble egg and photos of ferocious sperm fertilizing healthy eggs. Once he read through our medical records, he sighed very dramatically, clasped his hands together on top of his desk and looked me straight in the eye.
“The first thing I want to say is that you’re old.”
I winced as his words cut through me like a razor-sharp sword, and then within a split second I found myself in a serious state of denial, fighting back the urge to tell him that he was the one with the white hair, not me. He was the old geezer in the room, not me. No sir, not me. All my life I had to convince people that I wasn’t as young as I appeared. I knew I was teetering on the brink of officially entering middle age, but I didn’t think I was there—yet.
“Women your age have a harder time conceiving, especially if they have endometriosis, like you,” he continued. “You should have come to see me when you were thirty.”
Why thirty? My friend Sarah became pregnant the first time she tried at the age of forty, and Tracy got pregnant the first time she tried at forty, and then again at forty-three. Susan and Stephanie, my colleagues at the United Nations where I was working, both delivered without IVF at forty-two and forty-three. I was a little shocked by the doctor’s recommendation, but I quickly learned that, after witnessing the failure of the technology time and time again, a growing number of fertility specialists around the world were now advising women to have their children in their twenties.
Welcome to Casino Fertile
…I was confident that, since my mother had birthed me later in life, I would have no trouble doing the same thing. During that first meeting with the Silver Fox, I proudly told him that my mother had been thirty-nine years old when I was born.
“Just because your mother did it doesn’t mean you will too,” he replied. “Do you think there’s a gene for birthing in middle age that your mother passed onto you?”
In response to that question, I distinctly remember that I blinked three times. Um, yes, think me an idiot, but actually I did believe that since mom had done it I could do it. Why would I think otherwise? For decades, the Sunday New York Times and PEOPLE magazine had reported that it was possible to birth a baby later in life, and American pop culture is loaded with messages telling women that they can become pregnant when they are older. In the movie Parenthood, Mary Steenburgen and Dianne Wiest both play the role of older women who have no trouble birthing babies, and in Father of the Bride, a middle-aged Diane Keaton delivers a baby on the same day her 21-year-old daughter does. And Barbara Kingsolver's novel Prodigal Summer introduced us to Deanna Wolfe, a wildlife biologist who mates with a younger man and miraculously births a baby with no problems at the age of 46. Year after year, the headlines and cultural messages screamed out: "Relax and sit back. You’ve got science on your side."
But now this doctor was telling me that I might not have science on my side, after all. He was telling me that I had deluded myself with misinformation and false hopes about my own biology—and, according to global research, I am not alone. Studies conducted among college students in Sweden (2005), Canada (2010), and Israel and the United States (2012) all point to a pervasive lack of knowledge about women’s fertility and overestimations of the success rates of reproductive technologies.
Of the 400 women and men surveyed in Sweden, only a small minority knew that women's fertility declined after the age of thirty, or that it rapidly declined in their late thirties. A full one-third of the Swedish men thought a woman's fertility did not sharply decline until after the age of forty-five. The Canadian study of undergraduate women found that "they significantly overestimated the chance of pregnancy at all ages and were not conscious of the steep rate of decline for women in their thirties." In Israel, where 4 percent of all children are born as a result of ART compared to 1 percent in the United States, college-age participants were "overly optimistic about women's capacity to conceive, not only naturally, but also with the aid of IVF."
In the survey of undergraduates in the United States conducted in 2012, two-thirds of women and 81 percent of men believed that female fertility did not markedly decline until after the age of 40. One-third of women and nearly half of men believed this marked decline occurred after the age of 44—an age at which an IVF cycle is least effective. A full 64 percent of men and 53 percent of women surveyed overestimated the chances of couples conceiving a child following only one IVF treatment. The study concluded that "the discrepancy between participant's perceived knowledge and what is known regarding the science of reproduction is alarming and could lead to involuntary childlessness."
In 2001, years before these studies were conducted, the American Society for Reproductive Medicine (ASRM) launched an infertility prevention campaign that met with fierce criticism on a number of fronts. The advertisements featured an image of a baby bottle in the shape of an hourglass with text explaining how factors such as age, smoking, weight, and sexually transmitted infection can hamper future fertility.
The International Council on Infertility Information Dissemination said the ASRM’s effort focused too much on preventable infertility rather than on more serious conditions like endometriosis, polycystic ovarian syndrome, poor egg quality, inherited disease, and bad sperm motility. The campaign, they said, blamed the victim rather than the disease. Kim Gandy, then president of the National Organization for Women (NOW), was quoted as saying: “Certainly women are well aware of the so-called biological clock. And I don't think that we need any more pressure to have kids.” In an op-ed piece, NOW commended the ASRM for attempting to educate women about their health, but said their approach blamed individual women and their behavior for a more complex medical condition. “The ASRM gets free publicity,” NOW said, “and women are, once again, made to feel anxious about their bodies and guilty about their choices.”
Still, I berated myself for being one of the those women who believed that technology had finally eclipsed Mother Nature and that my biological clock, in fact, didn’t matter as much as it used to. A steady column of fear and sadness rose inside of me like a tidal wave about to hit.
“In a situation like yours,” our doctor said, “where your hormones are not stimulating the kind of egg production needed for pregnancy, we like to recommend that couples think about egg donation or adoption.”
Entering into the world of assisted reproductive technologies is a bit like traveling to another planet. The process challenges you to reassess everything you thought you knew about yourself and the world. All the loose ends that took you decades to tie into a nice, neat package called your life are suddenly untied again. Long-held beliefs about right and wrong begin to flake off your psyche like old paint on a windblown house. Moral dilemmas about eugenics and cloning become common themes in your midnight dreams. You find yourself actually considering what it might be like to create new life, not just in a Petri dish but also in a Petri dish with someone else’s eggs.
… I first entertained the possibility of working with a donor egg agency after the second IVF cycle failed. The very idea of Michael’s sperm fertilizing a stranger’s eggs and then having those embryos inserted into my uterus made me wince. But, given what the doctors had told us about the quality of my eggs early on, I wanted to be open to the idea of a donor—just in case. While some of the literature said there was great success with older women using younger women’s eggs, other data suggested just the opposite. Once again, it was a crapshoot: you either win or you lose, but the big question was, do you want to play the game?
The first donor egg website I happened to stumble upon was a California agency where the majority of potential donors looked like contestants for the Miss California pageant. They were all slender, blonde, and buxom and their price tags were high, ranging from $8,000 to $10,000. Why did they call them donors, I wondered? I spent only five minutes on the site before I hastily clicked off.
I felt like an eggless sociopath for even considering asking one of these young women to risk her health so that I might purchase her eggs. The vast majority of donors on this site and elsewhere in the United States were in their twenties. How and why do they decide to sell their eggs to someone like me? How do the donor agencies and these young women determine that their eggs are worth $8,000 while someone else’s eggs are worth only $5,000? Were blonde, blue-eyed donors always more expensive than brown-eyed, overweight donors? Were Caucasian eggs worth more than Asian, Asian worth more than African-American? We were told on more than one occasion that it is not unheard of for infertile Ivy League alums to post a classified ad in campus publications offering up to $100,000 for an egg donor with high SAT scores, 36-24- 36 body measurements, and a penchant for Mozart.
One thing this boom in fertility medicine has done is to help us apply an economic value to women’s reproductive labor. This may or may not be a good thing, depending on how you look at it. In today’s U.S. marketplace, a woman’s egg is valued at anywhere between $5,000 to $100,000 or more, depending on her bloodline. On average, though, let’s say an egg is worth between $5,000 and $10,000. Some people think it is immoral to put a price tag on genetic material and women’s reproductive hardware and capabilities. But, considering that the global fertility industry generates billions of dollars a year, why not calculate women’s economic contributions, too? Surrogates in the United States, at least, are usually paid anywhere between $75,000 and $200,000 to carry another couple’s embryo to term. Why not apply the marketplace values generated by surrogates and egg donors to healthy women who have conceived on their own? A typical mother of four, for example, would be compensated $20,000 immediately—$5,000 per egg—simply for the use of her eggs. Then, since she is carrying the embryo to term, she would be paid an average of $100,000 per pregnancy on top of the initial egg fee. That would roughly translate into a total of $420,000 just for those four reproductive cycles alone.
That same value is calculated at a lot less in Eastern Europe and in India and other South Asian countries, the fastest growing region of the “reproductive tourism” industry, a new niche of the global medical tourism phenomenon. More and more poor women are crossing borders to sell their eggs and rent their wombs to childless couples from wealthier nations, primarily the United States and Europe. In India, for example, where the Indian Council of Medical Research regulates fees, women earn a fraction of the U.S. rates—anywhere between $2,000 and $10,000 for surrogacy and between $250 and $400 (all USD) for eggs. Some consider this exploitation; others say it gives women a chance to earn unprecedented wages that can drastically improve their family’s wellbeing. Is the West colonizing poor women’s bodies, expanding their employment opportunities, or both? Having spent much of my time at the United Nations researching new global initiatives to combat female poverty, this sure feels like a strange remedy to me.
The Waiting Game
Based on what I had read, medical technology could on occasion breathe life into an embryo that had been frozen for some time. I knew of a woman whose healthy five-year-old son had been timelessly suspended in frozen space for four years prior to his being implanted in his mother’s womb. In cases such as these, I often wondered if the child was really five or was he nine? I supposed it depended on whether you believed life began at conception—whether in a Petri dish or not— or if it began when a child was actually born. These were the kinds of tough philosophical and ethical questions assisted reproductive technology consumers were forced to contend with everyday but that most Americans did not necessarily even think about unless they were prompted by the media.
There was a disturbing article in the Los Angeles Times right before Christmas 2012 that described an anonymous donor embryo program at a clinic in Davis, California. For the last couple of years, California Conceptions had been uniting anonymous donor sperm and eggs in a Petri dish and selling the resulting embryos in the marketplace—three tries for $12,500—a “bargain” said Ernest Zeringue, the clinic doctor who initiated the program. Those that aren’t sold to patients are considered clinic property and stored in an embryo bank.
This was not the first time a clinic in the United States had offered such a service to its clientele. In 1997 the New York Times reported that Columbia-Presbyterian and Reproductive Biology Associates were offering “ready-made embryos.” A New York State court later ruled that embryos were to be created only at the behest of patients, not for the purpose of storage in an embryo bank. In a similar case in 2007, the Texas-based Abraham Center of Life’s embryo program was initially investigated by the FDA for operating out of the founders’ house, and purchasing eggs and sperm from “attractive” donors at wholesale prices in order to make “designer babies.” The FDA later ruled that the case fell out of their jurisdiction, but the center did eventually close down.
Like these other clinics, California Conceptions believed that their program reduced a couple’s costs and the length of time they might have to wait to receive a donated embryo. The clinic claimed that success rates were high, with some pregnancies resulting in twins. There were happy families out there, to be sure, but a much bigger question needed to be asked: Did we really want to be selling potential human life in the marketplace? It’s one thing when a couple donates their frozen embryos to another family, but to actively engineer an embryo with the specific intention of selling it?
That is another question all together, and one that the American Society for Reproductive Medicine’s (ASRM) ethics committee was scheduled to debate in January 2013. In truth, it really doesn’t matter what the ethics committee decides. They don’t have the power to enforce standards and protocols, only to suggest them. California Conceptions’ donor embryo program made me think of the assembly line at the Ford Motor Company factory in Detroit. Do we really want to go there?
We began our fourth IVF cycle with the new super drugs in April. This time, Michael and I took turns with the injections. Just as it had one cycle earlier, injecting myself gave me that comforting illusion of power and control over my own destiny at a time when I desperately needed to feel that I was in the driver’s seat. After ten days of shots, suppositories, and vitamins, I went for my first ultrasound appointment. As usual, the room was dark when I hopped up on the table and put my feet in the stirrups. I had never worked with this particular technician before. She was a bit more talkative than the others had been. I told her that this was my first cycle since the miscarriage.
“Well, let’s see what’s happening in there,” she said with a smile, as she greased the probe and slid it into my vagina. She pushed first on the right side and then the left, measuring here and there, making tap- ping noises with her fingers on the keyboard.
“Okay. That’s it.”â€¨
“That was fast,” I said, as I stood up.â€¨
“There’s nothing there,” she said. “The doctor will call you.”â€¨
Did the technician really say there was nothing there? I was still bleeding every month, on time, regularly, like I’ve done since I was 11 years old. My blood was still a rich red, not some sickly brownish color. I was healthy. I was strong. But it simply didn’t matter. No matter how clever I thought my arguments were, the doctors’ tests and Mother Nature kept proving me wrong. Even with this hyper-egg-producing hormone, my ovaries were too tired to run the race. It seemed as though I was now more infertile and pre-menopausal than ever before.
Michael was deeply perplexed by the news.
“How can you have eggs and become pregnant one month and then only two months later have none at all?”
With great humility, we both recognized that human innovation could push the biological envelope only so far, and that ultimately it is still Mother Nature who decides. We found ourselves at a new impasse. If these new drugs had been our only hope to spawn a biological child, we now had only three options left to consider: a donor egg, adoption, or life with no kids.
Our doctor gently reminded us again and again that, despite my shortage of fresh, healthy eggs, I was in fine physical condition to carry a child to term.
“Women four or five years older than you are giving birth to healthy children with donor eggs,” he said. “I’m fairly confident that you could too. You’re still young.”
I was thrilled to learn that as a possible donor egg recipient the clinic would reclassify me as “young” instead of “old.” It was too bad that I now considered myself to be almost too over the hill to even keep trying. Maybe it was okay for some women to give birth when they were forty-eight or fifty, but it wasn’t okay with me; something about it didn’t feel right. I had read the news article about a New Jersey woman who birthed twins at the age of sixty, and about Rajo Devi, an Indian woman who supposedly birthed a baby girl at the age of seventy! Were these medical victories over nature really something to celebrate? As Ann Patchett captures so vividly in State of Wonder, her novel about the desire for eternal fertility, aging, and the onset of menopause and conditions like osteoporosis significantly alter women’s strength and endurance over time. Pregnancy at those ages poses serious health risks to women, not to mention the fetus they are carrying. Just because men who are in their sixties and seventies might continue to procreate (despite potential fetal health risks), it doesn’t mean that women in the same age group can, or should. As for me, I could end up with 22-year-old eggs, but I would still be a middle-aged woman wondering how on earth I was going to muster the energy to be a first-time mother in my forties—the same age my friend Leigh was when she became a granny.
Published with permission from Interlink Books.