On April 10, Stephen Yunis let his wife hold the brown paper bag. Normally he carries it himself, arriving early at the squat office building in Rockville, having done everything just right. Each time, he gives up drinking beer and makes sure not to use any strange medicines or turn on the seat warmers in his car. And at the appointed hour of the appointed day, he deposits his “sample” into the little cup, screws on the lid and drops it into the paper bag provided for discretion.
That’s what the good people inside the building call it: a sample. They never call it “sperm” or “semen.” And they don’t call it “your dream of having a family,” though everyone knows that’s what it is.
Stephen has mastered the sample dropoff. This is his fifth go-round in less than a year. Once he gives it to the receptionist, his sperm is washed, analyzed, graded and manipulated. Then it’s transferred to his wife, Jennifer, in hopes of producing a child. So far, it hasn’t worked.
The doctors are trying a different procedure this time, so of course Stephen and Jennifer are praying this will be the one. But they’ve learned the danger of getting their hopes up. And they know they could be stuck in this strange, secretive parallel universe known as “Fertility Treatments” for a long time.
That’s okay, Stephen says. They’ll stay in it until someone tells them, “We’re sorry, but you just can’t have kids.”
So Stephen will keep giving Jennifer painful nightly injections and finding ways to come up with money for each attempt. He’ll help his wife off the floor each time she’s capsized with bad news. He’ll keep trying to make her laugh.
He’ll keep trying.
- At home with the Yunises
Of course he never thought he’d be here. No one does.
Stephen, 32, and Jennifer Yunis, 31, were both born to young mothers and raised in homes where money was scarce. In the late 1990s, the two became online pen pals, but didn’t meet until Stephen borrowed his aunt and uncle’s car to drive from his home in Wheaton to hers in Poolesville. Soon the trip was routine. The pretty brunette who giggled at all his jokes became his best friend and the center of his world.
There was a short stretch during her college years in Baltimore when they decided to see what else was out there. But they weren’t good at breaking up: The two still spoke daily and saw each other all the time. After college they moved into an apartment together, and in 2006, they exchanged vows by the South River in Riva, Md.
Stephen and Jenn wanted children, but were intent on making sure they were ready and financially secure. After a series of unstable jobs, Stephen landed a sales position with Boland, an HVAC parts and supplies company, four years ago. He signed up to coach a youth wrestling squad at night, and Jenn started a career with a contract research organization. Throughout their 20s they diligently saved money and in 2011 bought a townhouse in Germantown. They painted the walls in calming tones, arranged their DVDs in the living room and put up a climbing tree for their two cats.
Then they were ready. And nothing happened. Month after month, Jenn bought ovulation predictor kits, downloaded fertility predictor apps and made sure they had sex on the right days. They watched as one home pregnancy test after another turned up negative. Meanwhile, their friends started having children and posting ebullient pregnancy photos on Facebook.
They did not want to believe anything was wrong. Jenn’s doctor gave her a referral for a fertility treatment center, but she let it expire. Online they found a sperm analysis company and sent Stephen’s sample off. It came back okay.
After two years of disappointment, they agreed it was time to get things checked out. Soon they were sitting in the Rockville office building, Stephen sweating as a doctor talked about what might be wrong, about cycles and uteruses and eggs and estrogen and other “womanly things.”
And all he could think was, Um, should I leave the room? I can just go.
By the time women end up at a specialist, they usually have at least watched an “Oprah” show about the trials of infertility. Perhaps they’ve read a People magazine article about a celebrity’s struggle to have a baby or listened to a friend talk about going through it.
Men? Maxim and “SportsCenter” don’t spend a lot of time covering fertility issues. And even if a guy knows that a buddy and his wife are undergoing fertility treatments, he’s apt to leave the subject untouched when they meet for beers.
No one is prepared for this, but least of all men.
“They are typically totally shocked,” says Sharon Covington, a Rockville therapist who specializes in helping couples through the fertility process.
After years of trying not to get a girl pregnant, they suddenly find that they can’t. Fertility is almost never talked about as a man’s issue. Yet, of the 7.3 million people grappling with infertility, approximately half are men. If a couple can’t conceive, it’s often assumed there’s something wrong with the woman. But just as often — in about a third of cases — the problem stems from the man. Another third of the time, there are issues on both sides, or the difficulty remains unexplained.
These healthy, strong men become trapped, along with their wives, in a medical mystery where doctors test one potential solution after another. A new language swirls around them: Nurses rattle on about “Clomid,” “morphology,” “cryopreservation.”Schedules are overrun by morning doctor visits, evening injections and the ever-precarious development of follicles.
Infertility becomes not just the ruling fact of their life, but a desperate problem they can do almost nothing to solve. Women are transformed into human pincushions, riding waves of unpredictable hormones, while men watch helplessly, waiting until it’s time to deposit their samples.
“They are the forgotten mourners,” Covington says. “Men really get marginalized in this whole process.”
- Inside a fertility center
Phyllis Martin is a Fairfax counselor who began focusing on couples facing infertility a dozen years ago after experiencing it firsthand. When she considers what men go through, she thinks about rapper Jay-Z. At an awards show soon after wife Beyoncé announced her pregnancy, cameras panned to the expectant mother proudly rubbing her growing belly. Men sitting near the couple jumped up to slap Jay-Z on the back and offer high-fives for a job well done.
“It was like he made a touchdown,” Martin remembers. “Imagine if you can’t be the guy who made that touchdown.”
Throughout time, a man’s ability to produce heirs has been seen as a reflection of his virility, masculinity and power. When something goes wrong in that department, “it becomes extremely shameful and humiliating,” Covington says. “They can feel depression; they can feel very, very anxious. They have panic attacks around having to perform.”
Sometimes, Martin adds, they fear that infertility will change the way their wives’ view them. She often hears from men wondering, “Am I enough to keep her if we can’t have children?”
The issues are compounded because while many women confide in friends and family, men often aren’t comfortable talking. They can end up feeling isolated, even from their wives.
“Men have such tremendous pressure on them,” Covington says. “And they’re kind of conditioned to keep their feelings inside.”
Although there are plenty of fertility support groups, it’s rare to see men attend. Every once in a while, someone will request a men’s group, the therapists say, but they never have enough guys show up to sustain it. To get around the stigma, Covington has the clients in her women’s group bring their partners along for several sessions. Once they’re in the door, the floodgates open.
Friends would joke he must be doing it wrong. “It’s always a guy thing, like a sexual guy thingAnd they think it’s hilarious. Most of them are just kidding. But it’s like, ‘You don’t have any idea.’ ”
“Given the opportunity to talk, they really run with it,” she says.
One issue that always comes up is bafflement on how best to support their wives. It can seem as if everything they say or do is wrong. “They really feel very helpless in seeing their wives in such distress and not knowing how to help,” Covington says. Usually women in the group chime in to say they just need to be listened to or simply held.
Men will talk about how the dynamic has changed in their relationship. Sex has become “babymaking” and ceased to be fun or spontaneous.
And while some pairs become closer under the strain, others are driven apart. Barry McCarthy, a Washington counselor who specializes in sex therapy, says the issue couples come to see him about most frequently isn’t erectile dysfunction or affairs. It’s the effect infertility is having on their relationship.
Couples routinely argue about how to proceed and the lengths they’re willing to go to conceive. Is donor sperm an option? How many cycles of in vitro fertilization do we try before thinking about adoption?
Couples can try for years without success. The Centers for Disease Control and Prevention estimates that in 2010, 30 percent of attempts to conceive with the help of reproductive technology led to a live birth. The numbers vary greatly according to age: For women younger than 35, 42 percent of attempts resulted in a baby; it was only 12 percent for 41- and 42-year-olds, and the figures dropped from there.
Infertility can be a financial nightmare. On average, a cycle of in vitro fertilization costs $12,400, according to the American Society for Reproductive Medicine. Although some insurance plans cover much of the cost, others pay for little to none.
Once the fertility process gets underway, men’s lives are set on a roller coaster as much as their wives’. It’s just that they suffer in the shadows.
Stephen Yunis tried talking to his buddies once. He was coming in late and missing work occasionally because of the procedures and decided to give his colleagues an explanation.
The response: “Oh, you must be doing something wrong.”
“It’s always a guy thing, like a sexual guy thing,” Stephen says. “And they think it’s hilarious. Most of them are just kidding. But it’s like, ‘You don’t have any idea.’ ”
Stephen is stocky and strong from years of wrestling and landscaping, and at first he might seem like a tough guy. But look closely at the tattoos on his forearms, and you’ll see they’re the names of his grandmother and grandfather, who helped raise him and whom he took care of in their later years. It was Stephen who, when the fertility treatments were failing, pushed to get a third cat, one that would cuddle next to him.
Step one was testing. The first time Stephen brought in his sample in June 2012, he found himself glancing around, hoping no one was watching him make the dropoff at the front desk of the Shady Grove Fertility Center. He and Jenn both did blood work, and she had an ultrasound to make sure there were no blockages in her reproductive system.
Everything came back pretty much okay. One of Jenn’s hormone levels was slightly depressed, which might indicate a low egg reserve, but it was nothing drastic. Stephen was relieved his side of things checked out. Their struggle to conceive was one of those frustrating “unexplained” cases.
“For a guy it’s like, ‘What if it’s my fault?’ ” he says. “I was like, ‘Phew, now nobody can make fun of me.’ ”
Jennwas put on a low dose of hormone therapy. Doctors watched as her ovarian follicles developed. When the time was right, Stephen dropped off his sample, which was “washed” to remove chemicals from the semen that might interfere with conception. Finally, it was inserted into Jenn’s uterus through a catheter.
For 14 agonizing days, they waited. Stephen wouldn’t let Jenn do any cleaning or heavy lifting. “I’d read that stress could play a part in it,” he says. “So I was like, ‘We’re going to do everything we possibly can to make it work.’ ”
He was at his job when he got the call from Jenn, crying happy tears. The blood test was positive. They told her mother and sister and a close friend. They started talking about buying a new car that would be more reliable for a baby. Jenn had seen so many home pregnancy tests turn up negative that she bought a few just to see them turn positive. Sure enough, the second line was there. It was faint, but it was there.
A few days later, she was back at the fertility center for another blood test to make sure her hormone levels were increasing as they should. But the levels had dropped. This pregnancy, the nurse said over the phone a few hours later, wasn’t going to last. Jenn fell to the kitchen floor in devastation. She dialed Stephen’s number.
He is a resolutely positive guy by nature. Even in his darkest moments, thinking about the possibility that they may never have children, he’d say, “Well, we’ll be sad and we may never get over it in the long run, but, you know, we could go on cruises every weekend.” When Jenn told him the news, he was upset mostly for her. He didn’t want to talk about it as much as Jenn did, but when he did, it usually went along the lines of “It’s okay; we’ll do it again.”
Which was nice, but it wasn’t exactly what Jenn needed to hear. “At first he was wanting to fix it, and I just didn’t need him to say anything. Just listen and say, ‘That sucks,’ ” she remembers. “And with his not talking as much, I thought, ‘Well, maybe he doesn’t care.’ ”
But he did, of course. He couldn’t have cared more intensely — about Jenn and their future and the family they both desperately wanted. He just wasn’t as verbal about it.
A couple of months later they were back for Round 2. Jenn’s insurance covered most of the cost, but there were still hundreds of dollars of expenses with each attempt, so they put their tax refund into a savings account and skipped a vacation. Jenn was put on higher doses of hormones, and they tried to find a balance between optimism and raised expectations. “I always felt bad,” Stephen says, “because I was like, ‘I don’t want my hopes to get up,’ but if I start not having high hopes, then I’d be like, ‘Who cares? Why even bother?’ ”
Two weeks after insemination, the blood work came back. Negative.
The third attempt also failed. Injectable medications were added to the regimen, and because Jenn could not stand the thought of giving herself the shots, Stephen did them. But this go-round, Stephen’s sperm quality was not as strong as in previous attempts. “Then you start feeling bad. I was like, ‘Well what did I do when I was younger?’ ”
After three failed rounds of intrauterine insemination (IUI), their doctor suggested they move on to in vitro fertilization (IVF), in which the woman’s eggs are fertilized outside her body. But because their insurance covered six IUI procedures, Stephen and Jenn decided to give it one more try.
This time Stephen’s sperm count was low.
Doctors call it “male factor infertility.” They might as well call it a waking nightmare.
If guys don’t chat about their fertility issues with friends, they sometimes seek the anonymous comfort of online message boards.
One man wrote: “I feel, on some level, totally inadequate. It’s not mental. It’s not chemical. It’s a depression in my very core. I almost want to take my penis and testicles and throw them away.”
Another posted: “I wanted my wife to leave me, find a man she can love AND father her child. It was like, ‘What’s the point of marriage?’ I literally wanted to just disappear.”
Jeremy Roop refers to his condition as “low and slow.” His sperm count is low, and the sperm he does have don’t get around so well. When he found out, he wondered if he’d done something wrong — drunk too much Mountain Dew or rode a bike too often. He thought maybe he could change something in his diet and the situation would improve.
He was 21 when he married his high school sweetheart, Kia, and for two years they had tried to conceive. They were working as Christian missionaries at children’s group homes in Michigan when they got the diagnosis. In addition to Jeremy’s issues, Kia had endometriosis and a malformed uterus. They were given a less than 1 percent chance of getting pregnant on their own.
Kia wanted to be a mother with the same passion that Jeremy wanted to be a minister. “She had these motherly instincts and had been desiring a baby for two years now, and to know that I was contributing to that — it’s just disheartening,” he says. He prayed that God would make him fertile.
Kia had surgery to reshape her uterus and, after a tough recovery, they decided to try IVF. In winter 2010, she drove two hours every day to a clinic in Flint. They had little income, and the process cost thousands.
Doctors were able to fertilize two eggs that were transferred to Kia. Two weeks later, they got the call. Neither embryo survived. While Jeremy cared for five kids in a group home, Kia locked herself in a bedroom and cried.
- At home with the Roops
Kia was inconsolable, and Jeremy wanted nothing more to do with IVF. “To see her go through all that pain — the injections and everything she had to go through — and all that money. And then for a ‘no’? ”
In 2011 they moved to Westminster, Md., where Jeremy started working as a youth minister and Kia took courses in child and family welfare.
All around them, people were getting pregnant. “One of the hardest things about going through infertility was finding all of our friends having children,” Jeremy says. “Every birth and every pregnancy is just a constant reminder of what you’re not able to do.”
Kia wanted to try IVF again; Jeremy didn’t see the point. But she had supported him in reaching for his goals, and he wanted to do the same for her. He agreed to an appointment at Shady Grove. After hearing about the center’s “shared risk program,” he was on board: The doctors would do six attempts for a flat fee that Jeremy compares to the cost of a new car, and if none worked Jeremy and Kia would get all their money back.
When they were ready to transfer the first time, Kia hyperstimulated and her swollen ovaries didn’t allow them to go through with the procedure. The next month, the facility was closed for sterilization the week she was scheduled to go in. Finally in August, doctors transferred one fertilized embryo to her.
Specialists tell women not to take home pregnancy tests, but Kia, now 24, couldn’t wait. She came back from the bathroom shaking. After four years of trying, she was pregnant.
“Once it hit me, I just started crying,” says Jeremy, now 26.
He uses the word “sterile” freely now and sees it as part of his testimony of God’s grace. “It’s just like my height. There’s nothing I can do to change my height,” he says. And while he used to worry “that people were going to look at me and think less of me,” now he thinks, “If you do, you do. This is who I am.”
He hopes that by talking about infertility, he will make it easier on other men. “It’s nothing you can control,” he says. “But you have to accept it.”
In their living room sits an image of their baby from an early sonogram. The frame is inscribed with a poem: “Before you were conceived, I wanted you. Before you were born, I loved you. Before you were an hour, I would die for you. This is the miracle of life.”
On May 13, Judah Zion Roop was born. The name means “Praise God in the Highest.”
Stephen Yunis wore his Boland shirt to the Rockville office building on April 10. He wasn’t working that day, but he didn’t have any other clean laundry. Jenn was in her coziest sweats. She’d have to go under anesthesia to have her eggs extracted and knew she’d be groggy and uncomfortable upon waking.
Their fourth attempt at IUI was unsuccessful, so it was on to IVF. Against their wills, they’d become infertility pros. Stephen developed tricks to ease the pain of injections. They got better at talking and letting each other deal with the process in their own way. They learned to laugh at it all.
Sometimes Stephen called Jenn “an inefficient drug mule,” because she was pumped so full of pharmaceuticals.
“If this one works,” Jenn said, “it’ll be that doctor who got me pregnant. How do you feel about that, guy?”
When the umpteeth person asked when they were going to have a kid, they responded, “It must be on back order.”
Making a baby is “supposed to be free, and it’s supposed to be fun,” Stephen says. For them, “it’s neither of those things. So we make a joke of it. I think you have to.”
After dropping off Stephen’s sample just before 10 a.m., they sat in the beige-on-beige waiting room with half a dozen other couples. Almost everyone silently stared at their phones while HGTV played on a flat-screen in the corner. Jenn had found solace in Shady Grove’s Facebook page, where fertility patients eagerly offer advice and cheer one another on, but in the office there is an unspoken rule that no one talks to each other.
Up to that point, things were looking good. There was no explained reason why Stephen’s sperm count was low during the last round and no reason to think it wouldn’t be normal this time. On past attempts Jenn had only a few follicles develop, but in the previous weeks doctors were able to detect a couple dozen. Still, the two were anxious.
“Jennifer?” a nurse called. Together they walked down the hall, hoping yet again that this would be the one that worked. Jenn put on a cap and gown and sat on a hospital bed surrounded by curtains. There was little for Stephen to do but hold her purse.
By 12:30 p.m. it was over. As Jenn woke up, Stephen came back to the waiting room looking excited. They had retrieved 21 mature eggs. After they left, Stephen played nurse while Jenn rested.
In a few days their doctor implanted one fertilized egg. The following week ticked by with excruciating sluggishness. Signs of early pregnancy: fatigue, shortness of breath, heightened sense of smell. Could be something, could be nothing. All they could do was wait.
Blood work was scheduled for April 29. It was drawn in the morning, but results don’t come in until the afternoon. Normally, each second in between takes a decade to pass.
Not this time. In the week leading up to the appointment, Jenn took one home pregnancy test after another. The “positive” line grew darker each time. Blood work made it official, and 10 days later they were back for an ultrasound. The monitor resembled the fuzzy screen of an old black-and-white TV. But in the center was a dark spot and in the middle of that was a white ring. And just off of that was a tiny nub. Just a speck.
But in nine months, if all goes well, that speck will be their baby.
Ellen McCarthy is a Washington Post staff writer. To comment on this story, e-mail firstname.lastname@example.org.