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Who Stole Fertility?

With a growing business in the medical field of fertility products, are Americans as infertile as they'd like to believe? Or is the industry a response to the new impatient nature of the nation?

Contrary to popular belief, there is no infertility crisis sweeping the nation. We've just lost all conception of what it takes to conceive. Reproductive technology has made us impatient with nature. So for increasing numbers of couples the creation of a new human being has become a strangely dehumanizing process.

My great-aunt Emily and great-uncle Harry never had kids, and nobody in our family talked about it. Growing up, I knew not to ask. It would have been impolite, as crass as asking about their income or their weight. The message was clear: If they didn't have kids, they couldn't have them, and talking about it would only be humiliating.

How times have changed. Today, a couple's reproductive prospects—or lack of them—are not only apt to be a conversation topic at your average dinner party, they're the subject of countless news stories illustrating our nationwide infertility "crisis."

In an infertility cover story last year, Newsweek reported that more than 3 million American couples would seek procreative help in 1995. Diagnostic tests, hormone treatments, fertility drugs, and assisted-reproduction techniques with names like in vitro fertilization (IVF), gamete intrafallopian transfers (GIFT), intrauterine insemination (IUI), zygote intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI)—to name the top five procedures—have become as much a part of the reproductive process as the more poetic aspects of family making. While some of those 3 million-plus couples were legitimate candidates for the host of high-tech options now available to them, most wound up needing only low-tech assistance, such as boxer shorts instead of briefs.

In early 1996, in a four-part series, the New York Times reported on the fertility industry's growth and the increased competition among clinics.

And that's how an infertility crisis is created and perpetuated. For contrary to popular belief, infertility rates are not on the rise. Creighton University sociologist Shirley Scritchfield, Ph.D., says that American infertility rates have not increased during the past decades: In 1965, the infertility rate for the entire U.S. population was around 13.3 percent; in 1988, it was 13.7 percent. According to the U.S. Office of Technology Assessment, infertility rates for married women have actually decreased from 11.2 percent in 1965 to a little less than eight percent in 1988. These rates even include the "subfecund," the term used to describe people who have babies, just not as many as they want as quickly as they want. This means that more than 90 percent of couples have as many babies—or more than as many babies—as they want.

Letting Nature Take Its Course

Rather than an infertility crisis, what we have is a society that's allowed technology to displace biology in the reproductive process, in effect dehumanizing the most human of events. At the very least, this means stress replaces spontaneity as women become tied to thermometers—constantly checking to see when they're ovulating—while men stand by waiting to give command performances. At the most, it involves women and men subjecting themselves to invasive procedures with high price tags. Whatever happened to love and romance and the idea of letting nature take its course? Instead, we seem to have embraced the idea that science, not sex, provides the best chance for producing biological children. Technicians have stolen human reproduction. And there are some 300 fertility clinics—with annual revenues of $2 billion—to prove it.

Infertility has become big business, one that's virtually exempt from government regulation. And it's not for the faint of heart—or pocketbook. But all the hype has made us lose sight of what it really takes to make a baby. Conception takes time. Infertility is classically defined as the inability to conceive or carry a baby to term after one year of unprotected sex two to three times a week. On average, it takes less time for younger (in their 20s) would-be parents than older (in their 30s) ones; as couples move through their 30s, experts suggest staying on the course for two years. But even couples in their reproductive prime—mid- to late 20s—need around eight months of sex two to three times a week to make a baby (In December of 1995, the New England Journal of Medicine reported that healthy women are most fertile, and therefore most likely to conceive, when they have intercourse during the six-day period leading up to ovulation.)

The correlation between how often a couple has sex and the speed with which they succeed in conceiving may seem obvious. But psychologist and University of Rochester Medical School professor Susan McDaniel, Ph.D., says she counseled one infertile couple for six months before discovering they had only been having sex once or twice a month!

Of course, these days the one thing many prospective parents feel they don't have is time. During the baby boom, couples began having children at about age 20. But by 1980—when women were in the workforce in record numbers and putting off motherhood—10.5 percent of first births were to women age 30 and older. By 1990, 18 percent of first births were to women age 30 and up. Because more would-be parents are older and hear their biological clocks ticking, they're more likely to become impatient when they don't conceive instantly But how much of a factor is age in the conception game? Men have fewer age-related fertility problems than women do. The quality of their sperm may diminish with age; when they reach their 50s, men may experience low sperm motility (slow-moving sperm are less likely to inseminate).

After about age 37, women's eggs tend to show their age and may disintegrate more easily This makes it increasingly difficult for women to conceive or maintain a pregnancy That's not to say there's anything unusual about a 40-year-old woman having a baby, however. Older women have been having children for eons—just not their first ones. In many cultures, the average age of a last child is around age 40.

Some older women may even be as fertile as their younger sisters. A 40-year-old woman who has been taking birth control pills for a good part of her reproductive life thus inhibiting the release of an egg each month—may actually benefit from having conserved her eggs, says Monica Jarrett, Ph.D., a professor of nursing at the University of Washington. She may even have a slight edge over a 40-year-old mother with one or two children trying to conceive.

"Focusing on aging as the primary source of infertility is a distractions" says Scritchfield. "Age becomes a factor when women have unknowingly always been infertile. These are women who, even if they'd tried to get pregnant at age 20 or 27, would have had difficulty despite the best technology."

Gender Politics and Infertility

Some feminists suggest all this talk of infertility is part of a backlash, an effort to drive women out of the boardroom and back into the nursery. While there may be some truth to this, it's only part of the story. The fertility furor is also a result of increasing expectations of control over nature by ordinary men and women.

Ironically, the growing intolerance for the natural course of conception stems from technological advances in contraception. Birth control is more reliable than ever. The confidence we have in preventing pregnancies has given us a false sense of control over our fertility "People have the idea that if they can prevent conception, then they should also be able to conceive when they want to," says McDaniel.

This illusory sense of control, says Judith Daniluk, Ph.D., a University of British Columbia psychologist and fertility researcher, weighs most heavily on women. "Women are told that if they miss taking even one birth control pill, they risk becoming pregnant. This translates into feeling extremely responsible when it comes to getting pregnant, too."

If we've let technicians steal fertility from us, perhaps it's because it was up for grabs. Until recently, infertility was considered a woman's problem rather than a couple's problem. In the 1950s, physicians and psychologists believed that women whose infertility couldn't be explained were "suppressing" their true femininity. Of course, in those days men were rarely evaluated; the limited technology available focused mostly on women.

When a couple steps into the infertility arena today, both partners receive full evaluations—in theory. In practice, however, this doesn't always happen because technology is such that even a few sperm from an infertile man are enough for high-tech fertilization. About 40 percent of infertility is the result of "female factors"—problems with hormones, eggs, or reproductive organs. Another 40 percent is explained by "male factors"—problems with low sperm count or slow-moving sperm. The remaining 20 percent is unexplained or due to factors in both partners. There may be an immune problem, where the sperm and egg are "allergic" to each other. Advances—such as ICSI, a way of injecting a single sperm into an egg during IVF—have been made to get around this immune system clash. Advances have also been made in understanding male infertility, including treatments for low sperm motility that involve extracting sperm directly from the testes. But the bulk of fertility treatments still focus on women.

Women also tend to "carry" the issue for a couple, says McDaniel. "As much as men are invested in having children, they don't have to think about it, or perhaps be as conscious of it—because women are so focused on the problem. It makes sense, then, that when it comes to an infertility workup, men will often be the ones to put on the brakes. If both partners were running headlong onto the conveyor belt of technology, there'd be a mess. So what happens—largely because of sex roles—is women become advocates of the process, and men, who may be more ambivalent, question it and wonder whether it's time to stop."

Women will go so far as to protect their partner from the diagnostic process, as well as treatment, observes Daniluk. She says they'll even shield their partner from blame when he's the infertile one.

Compelled To Produce

Regardless of its cause, infertility is a profound blow to people's sense of self, who they are, and who they think they should be. To understand just how devastating infertility is, it helps to know why we want babies in the first place.

"The most essential thing the human animal does is reproduce," insists anthropologist Helen Fisher, Ph.D., author of Anatomy of Love. Citing survival of the species as the reason why our drive to reproduce is so strong, Fisher says it's not surprising that couples will go to great emotional and financial lengths to conceive. "The costs of reproducing have always been great. The time-consuming and costly procedures a modern couple uses to pursue their reproductive ends may never be as costly as it was on the grasslands of Africa, when women regularly died in childbirth."

Fisher says men, too, feel obliged to plant their seed or die out, so they'll work very hard to sire and raise their own kids. They aren't exempt from social pressures either. "Male sexuality has always been tied to potency," says William Doherty, Ph.D., a professor of family social science at the University of Minnesota. "The slang term for male infertility is 'shooting blanks.' After all, what good is a man if he can't reproduce? That's probably why we've blamed women for infertility for millennia. It's too humiliating for men."

Animal instincts may provide the primal motivation for having kids. But notions of masculinity and feminity are another big influence. Infertility taps into our deepest anxieties about what it is to be a man or a woman, a core part of our identity McDaniel says many of the infertile women she sees speak of feeling incomplete. They also talk about a loss of self-confidence and a sense of helplessness and isolation. Women still get the message that much of their femaleness is derived from motherhood more so than men are taught their maleness is tied to fatherhood. Losing the dream of motherhood may fill a woman with such grief that she'll consciously avoid the places kids populate. It's a loss that can be difficult to share because it's the death of something that never was.

Infertile men also experience a loss, says McDaniel. They, too, may insulate themselves from the world of kids. They may be even less likely than women, says Doherty, to talk about their sad feelings. "Men feel if they're not able to pass on their seed, they're not living up to what's expected of them as men," says Andrew McCullough, M.D., director of the Male Sexual Health and Fertility Clinic at New York University Medical Center. Parental expectations are yet another powerful reason people feel the pro-creational pull. "When it comes to having kids," says McDaniel, "there can be a lot of familial pressure. If you don't have them, everybody wonders why."

Technofertility Takes Over

With all of these pressures to produce, is it any wonder couples get caught up in the technofertility maze? Seduced by well-meaning doctors who hold out hope and the availability of all kinds of treatments, two vulnerable people—alone are left to decide how much reproductive assistance they will or won't accept. There are no guidelines.

It wasn't until about their seventh year of fertility treatments that a physician finally sat Steve and Lori down and told them that their chances of having a baby were slim, given their ages—37 and 32—and their efforts until that point. Steve had had a varicocele, a twisting of veins in the testicles, and Lori had had various explorations of her ovaries by endoscopy in search of ovarian cysts, plus two failed IVFs.

"It turned out that my wife's gynecologist wasn't really competent to tell us about fertility treatments," Steve says. "It ended up being like going to the Motor Vehicle Bureau. First, they tell you to take care of one thing, but it turns out you need to take care of something else. Then they tell you to go do a third thing. You wind up moving from place to place with no particular plan. It's rare that you get a doctor who explains in plain English what's going on and helps you evaluate your choices. Instead of talking with Lori and me and asking us what was in our hearts, they were saying, 'Okay, you want a baby, how can we make one for you?'"

Even as they went through test after test, procedure after procedure, it seemed at least semicomical to them: drives at the crack of dawn to a distant clinic, painful shots Steve was obliged to administer to Lori, even a "hamster penetration" test that involved Steve producing a sperm sample to see whether his sperm could penetrate a hamster's egg. All of it was very difficult to resist. "I think it was partly the adventure that kept us going," Steve says. "Once you commit and say you're going to give it a go, you don't want to stop midstream. There's always the chance that it might work. I mean, medicine is fantastic; you take some pills, stick some stuff in you, and maybe you get a baby."

"Fertility treatments are so technically focused," says McDaniel, "that people's feelings get left behind." She advocates a more human "biopsychosocial" approach. "Couples' emotional needs should dictate the pacing and decision making as they move up the pyramid of technological possibilities. But in some, maybe even most clinics, little or no attention is paid to the process, only the possible product. As a result, the patients suffer."

Even under normal circumstances, conception is immaculate—it tends to clean all else out of the mind. Whenever people begin to plan a family, says McDaniel, their worldview narrows. But with technofertility, a couple's worldview can narrow to the exclusion of all else. Because the outcome is the entire focus, fertility treatments intensify our instincts to give birth and nurture a baby. So the very technology that disregards couples' emotions also heightens their desire to nurture. For women, especially, maternal instincts are intensified by all-consuming fertility treatments that leave little time for anything else and cause women to define themselves solely as mothers.

Indeed, as soon as prospective parents seek help, statistics and biology become the focus. Before long, they're up on the latest research and talking in terms of "control groups," "statistical significance," and "replication." The walls of fertility clinics are plastered with pictures of newborns, and staffers and customers alike speak endlessly about "take-home baby rates," the bottom line when it comes to success. But take-home baby rates are more than numbers. They represent people's hopes for a family.

As a result, couples undergoing intensive fertility treatments lose their wide-angle perspective on life. They may fall behind in their careers and cut themselves off from friends and family, all in the narcissistic pursuit of cloning their genes. Technology may provide us with the illusion that it's helping us control our reproductive fate, but in reality, it just adds to the narcissism. "The higher tech the treatment, the more inwardly focused couples become," says Doherty.

"Biological connections are so strongly emphasized in our culture that it's hard not to become self-absorbed," Steve explains. "You even see it in the adoption process. Couples are often concerned that the kids they adopt have similar characteristics to their own. But the truth is, kids are kids." (Steve and Lori have since adopted a baby,)

An overestimation of success rates by the technofertility industry hooks couples in and fuels the narcissism. Fertility clinics typically report about a 25 percent success rate. But this rate is usually calculated after clinics have screened out the most hopeless cases. The true rate—which counts everyone who has sought reproductive help and which considers live births rather than pregnancies as success—is closer to half, Scritchfield says. "Unfortunately, this isn't what the public hears. If we were really concerned about infertility, we would be working on preventive measures. That's not addressed by biomedical entrepreneurs because they don't deal with people, just body parts."

Yet technofertility can create such stress in a couple that it can come dose to undoing their relationship—the raison d'etre for baby making. McDaniel remembers one couple who were at complete odds, having come to see her a year after having undergone five years of unsuccessful fertility treatments. The won-tan still hoped technology could help them, but the man felt his wife had gone too far; the procedures were invasive and the lack of results too painful. Attempting to protect both of them from any more disappointment, he insisted they stop.

The husband questioned why they'd ever gotten involved in the first place, and the wife felt unsupported by his reaction. No one at the fertility clinic had helped them work through any of their reactions. In therapy with McDaniel, they ultimately admitted to themselves—and to each other—what their expectations had been and the anxiety and grief they felt over the loss of an easy pregnancy. Then they decided to adopt.

Given the single-mindedness of baby making, adding infertility and technology to the mix creates the perfect recipe for obsession. But it's an obsession only for the rich. Which means having a baby becomes a luxury that many truly infertile couples, who might otherwise make wonderful parents, will never be able to afford.

Who Is Infertile?

Although infertility rates are not on the rise overall, Creighton University sociologist Shirley Scritchfield, Ph.D., points out that they are rising among some subgroups of the population: all young women between the ages of 20 and 24 and women of color. She says this is due to an increase in sexually transmitted diseases (STDs) among the young. STDs, including chlamydia, gonorrhea, and genital warts, can permanently harm reproductive organs. Pelvic inflammatory disease, which women can develop as a consequence of other STDs, is perhaps most responsible for infertility in young women, in part because it—as well as other STDs—often goes undetected.

With few records having been kept, it's difficult to determine whether male infertility is on the rise. A 1992 study by Norwegian scientists looked at semen quality over the past 50 years by pooling the evidence available from earlier research. They concluded that, in general, sperm counts had decreased.

Rebecca Sokol, M.D., professor of medicine and obstetrics/gynecology at the University of Southern California, says that while the Norwegian study reports a significant reduction in sperm counts over half a century, the reductions are not "clinically significant." That is, if sperm counts have decreased over time—and many scientists do not agree that they have—they've simply gone from a very high count to moderate levels.

"We're exposed to higher levels of estrogens than ever before; we inject cows and other animals with estrogens and estrogen-like hormones to keep them healthy. There isn't any data that directly proves this alters sperm counts, but we know an increase in estrogens in men is toxic to sperm. The theory is that in some way, this low-grade constant exposure to estrogen is ultimately altering sperm."

Bucks For Babies

The fertility industry may boast of its dedication to bringing healthy babies into the world, but in reality, it appears to be interested in producing only wealthy ones.

A thorough fertility workup to diagnose the source of a couple's problem can take up to two months and cost from $3,000 to $8,000. That's just for starters. For a simple procedure, like hormone shots to stimulate egg production, it's $2,300 per cycle. Expect to pay $10,000 for one round of in vitro fertilization (IVF). About 30,000 women a year attempt pregnancy via IVF. Intracytoplasmic sperm injection, where doctors inject a single sperm into an egg, adds $1,000 to the price of IVF. A procedure requiring an egg donor (in demand among elder mothers) runs from $8,500 to $16,000—per cycle. A varicocelectomy, to correct varicose veins around the testicles, costs $3,500. Few health plans include coverage for fertility treatment. Even when insurance does kick in, it doesn't cover all of the direct costs, to say nothing of the many indirect costs, including lost income from missed work and childcare expenses.

How Couples Cope with Infertility

In general, couples without children are more likely to split up than partners with children, reports demographer Diane Lye, Ph.D., and professor of sociology at the University of Washington. What about mates who can't have kids, or who want them but encounter difficulties? Researchers don't know about the ones who don't seek fertility treatment—and who tend to be poor. But Lauri Pasch, Ph.D., a psychologist and fertility researcher at the University of California at San Francisco, did study 50 couples who, on average, had been trying to get pregnant for two years. She says infertile couples going for fertility treatment tend to have higher rates of marital satisfaction than the rest of the population.

"Most couples who seek fertility treatment are committed enough to their relationship that they will go through pain and suffering to have a child together," says Pasch. And if they have the skills to address their problem, their relationships tend to become stronger—even if they never have a baby."

So what kind of skills does a couple confronting infertility need? Mates with matching coping styles do best, says Pasch, who points out that infertility, like other major stressors, tends to bring out people's natural ways of coping. "Couples who have similar ways of living with problems and relieving their distress are better off than those with different styles," says Pasch. "Both might be support seekers, or both might be private and keep to themselves. So long as they both go about things in the same way."

Pasch finds that spouses who rely on emotional expression can do harm to their relationship. That's because they tend to let their feelings out at their partner rather than sharing them with him or her. (So much for the old saw that talking things out always makes them better.) "In this destructive communication pattern, one person eventually demands and one withdraws," says Pasch. "One member of the couple pressures for change, while the other one withdraws, refusing to discuss the problem."

Though which partner demands and which one withdraws can shift, typically women are the ones who demand more, and men are the ones who withdraw. In the case of an infertile couple, the woman may get alarmed sooner than her husband about not being able to have children. But they may switch roles, and she may become more resigned to it while he becomes more concerned and wants to start treatment. Either way, the couple is at odds.

Tammy and Dan, the parents of two children—the products of five IVFs and eight years of fertility treatments—were just such a couple. "I was the leader, taking care of everything," says Tammy. Her daily routine included being at the fertility clinic at 6:30 every morning for blood tests, and returning every afternoon for more exams. 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 whole focus. Everything you do is planned around it. You are told what to do every day, and you can't do very much. Then, all of a sudden, you realize you have 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 difficult being normal."

The emotional climate becomes even more difficult when one partner chooses to withdraw from the entire fertility process. Psychologist Susan McDaniel, Ph.D., of the University of Rochester School of Medicine, saw one couple where the wife underwent extensive tests to see whether she was infertile. Her husband, meanwhile, could never seem to make it to the urologist to be tested. He couldn't tolerate the idea that his sperm count might be low. Of course, his wife was furious. She had gone through painful and stressful—not to mention expensive—workups. When her husband finally went to the urologist, he couldn't produce a sperm sample. When he finally did, it turned out he was the infertile one. Both partners had trouble understanding what the prospect of infertility was like for the other one. Eventually, they decided to get a divorce.