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Our triplets—three boys—were born at exactly thirty-three weeks on September 15, 2007, after I’d been on bed rest since the twenty-fourth week of pregnancy, thanks to an “incompetent cervix” (a preposterous term) that was reluctant to support a triplet pregnancy. Nonetheless, modern medicine handed us three breathing, bleating, squirming newborns to bring home after three weeks in the neonatal intensive care unit, or NICU. I felt simultaneously giddy and guilty; many of the other pregnant triplet moms I met instead brought home heartbreak.
Our IVF cycle and treatment decisions have had lasting effects on me, my marriage, my career, and every other aspect of my life. That fateful phrase approving the embryo transfer—“Let’s do it”—has come to mean an affirmation of life, love, and a willingness to encounter the unknown. As a result of making this affirmation, I also developed a strong and enduring appreciation and respect for REs and high-risk obstetricians, and a fascination with how medical decisions are made, which led me to incorporate reproductive technology and its legal consequences into my own teaching as a law professor. While preparing lecture materials for a related course, I was stunned that some experts suggested that women and couples experiencing infertility were “desperate” to conceive, implying that emotion imperiled their capacity to consent to treatment. Others suggested that fertility professionals exploited their vulnerable patients. But none of these characterizations matched my own experiences or those of other women I knew.
It wasn’t that I hadn’t been desperate—of course I had. It is nigh impossible to miscarry a wanted pregnancy and experience subsequent infertility without some feelings of anxiety, anguish, hopelessness, and despair. Instead, I suspected that experts’ definitions of desperation didn’t match mine. Far from the stereotypical desperation experience of paralysis and powerlessness, my emotions galvanized me, pushing me to seek answers, research treatments and providers, and speak to others about their experiences. Other women I had met described similar experiences.
The more I examined these characterizations of infertility and affected individuals, the more curious about their accuracy I became. Mainstream stereotypes of women with infertility depict a conglomerate of broken souls: selfish older career women, whiny and annoying mothers of multiples on reality television, and sensational stories about a woman on public assistance who birthed IVF octuplets, adding to a brood of six—a woman who is often denied her name—Nadya Suleman—and referred to as “Octomom.” I didn’t see my own face in that crowd, or those of my friends. These images increased my determination to investigate their accuracy, if necessary replacing them with fresher, more accurate and diverse portrayals of what infertility was, whom it affected, and how it changed lives. I wanted to destigmatize, even normalize infertility and its treatment, moving it from its social margins to the center of mainstream discussions about family and reproduction. In an echo of women who sought the right to terminate their pregnancies, I wanted to be unapologetic about my own choice to initiate one through reproductive medicine. Thus, in addition to triplets, my IVF cycle sowed the seeds of this research project, of which this book is the fruit.
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This book begins with my own story, but focuses primarily on those of others, representing the diversity of experiences and perspectives that both enriches and challenges those who experience and explore this subject. Conceiving a child, watching it grow in the womb, and ultimately giving birth can rank among life’s wonders. For many, pregnancy simply happens, often in unplanned or unexpected ways. But for others, an inability to conceive creates anxiety, frustration, and sometimes despair, and for centuries, people simply had to live with those emotions. Since the birth of Louise Brown in 1978—the first baby born through IVF—the reproductive medicine industry has flourished, injecting hope into reproductive attempts—hope that one’s failure to conceive can be overcome, hope that it just requires sufficient determination, money, and medical skill.
This hope is increasingly in demand as more women defer childbearing. And these technologies, and the hope they create, are subject to few safeguards. In America, the reproductive medicine industry is still largely unregulated, and there are few federal or state restrictions on embryo transfer or cryopreservation.1 Though many clinics belong to professional associations like the Society for Assisted Reproductive Technology (SART) or the American Society for Reproductive Medicine (ASRM) and agree to follow their clinical and ethical guidelines, these guidelines lack legal effect, with minimal consequences for noncompliance. If there are few policy incentives to regulate ART, there are even fewer motives for popular culture to accurately represent its patients. As women become more likely to defer childbearing, more celebrities, media characters, and public personas—from Celine Dion to Friends’ Monica and Chandler, from Kate Gosselin to Nadya Suleman and her octuplets—represent what fertility treatments might offer. These representations matter to individuals seeking medical intervention to achieve motherhood, whether they’re professionals who have surmounted every other life challenge, or women whose primary ambition has always been starting a family.
Although IVF is more affordable and available to a wider range of women (hence the importance of this book), it is not right for everyone. Deciding to try IVF involves a series of potentially gut-wrenching decisions, starting with the question of whether to try at all. IVF is expensive. The initial consultation often costs hundreds of dollars, and the first round of treatment will amount, on average, to $8,158, with medications costing an additional $3,000 to $5,000.2 Insurance likely won’t cover many expenses, even in the fifteen states mandating insurance coverage,3 and out-of-pocket costs may be high. Deciding to undergo IVF may therefore compel people to mortgage a house, max out credit cards, or use savings for a down payment on medical treatments instead. It may involve going hat in hand to relatives, describing reproductive troubles and then asking to borrow money. It may mean postponing other dreams—starting a business, switching jobs, or reaching the point where monthly bills don’t produce anxiety. And it may mean mortgaging the future, using funds intended for college tuition or retirement.
Treatment decisions also include which fertility interventions to pursue and what risks are acceptable—and these choices are influenced by informed consent disclosures. These treatments may involve surgery, drug regimens with potentially serious risks for mother or child, and novel procedures with uncertain consequences. Even routine treatments and medications have side effects; treatments may entail discomfort and sick leave, and medications alter hormone levels, change moods, and unsettle emotions. Some doctors recommend procedures of undetermined safety and efficacy. And there are no guarantees that these efforts will yield the longed-for pregnancy or live-born, healthy child.
Even standard treatments may pose difficult ethical choices. IVF increases the odds of getting pregnant with twins, triplets, or more and having to decide whether to undergo selective reduction. Some religions like Catholicism oppose IVF altogether; others mandate that believers follow guidelines, like using all fertilized embryos. Some couples who have no objection to producing embryos in a lab find it difficult to choose among those they create, or object to letting a doctor choose for them. Others might find that they can’t reproduce without using donor eggs or sperm, meaning any resulting child is genetically related to only one of its intended parents. Then there’s the question of what to do with surplus frozen embryos: should they be destroyed, transferred to another couple for reproductive purposes, donated to research, or frozen indefinitely?
Working through these choices raises profound questions about decision-making capacity, encompassing not only a patient’s ability to choose appropriate treatment, but the nature of the industry guiding that choice. Doctors providing emergency services or advising cancer patients may not know the cost of recommended treatments or payment mechanics. But fertility specialists can’t afford to ignore such matters. Most patients pay out of pocket, and Congress bars the use of federal research dollars for the very procedures that would most advance reproductive treatments. The reproductive medicine industry has been called the “Wild West” of the medical profession and, while not all criticisms are deserved, clinic professionals need to compete for patients and must remain cognizant of what their clients are willing and able to pay.
At its best, therefore, the world of reproductive