SUZANNE'S first pregnancy ended, 120 days after conception, in a hospital, while she was drugged on morphine.
Suzanne and her husband were married when both were 25. For five years, they dutifully praciticed birth control, abandoning it five years ago when they decided to start a family. "I waited, I admit, until I was older to start a family because my mother was only a mother, and I felt I owed it to myself and any children I might have to have interests beyond them."
The doctors have never been able to pinpoint why she has trouble conceiving.
Though she is 35, her tall, slim body, conditioned by yoga and yogurt, hardly reflects it. She is a psychologist, and when she speaks, she sometimes relies on the jargon of her trade, using terms like "denial" and referring to this or that stage of grief. But mostly she speaks as a civilian, directly from the heart. Her dark eyes are the dominating feature, intense, direct. Two brown accusers, the charge they make is simple and ancient: life is a mystery, no more, no less.
Her story is this: a few months ago, she got her wish. It finally happened. She was pregnant. But she is a sensible person. She is a psychologist. She knows something about medicine. She readily understood that infertility patients run a greater risk of problem pregnancies. She talked of setting up a support system in case anything went wrong. She told her family. Her husband told his. Together they told close friends. At work she kept it quiet, informing only one colleague. She says: "Of course, I wanted to bask in the rounds of 'that's wonderfuls,' but I also wanted to play it safe."
The caution was justified . . .
Infertility is defined as the inability to conceive after one year of trying, or the inability to carry pregnancies to a live birth. It affects one out of six couples of childbearing age in the United States today - at least ten million people. And in a career-oriented area like Washington, where many couples postpone decisions about childbearing until professional goals have been met, the ration of one in six is probably on the conservative side. Yet it is rarely discussed, and understood even less.
For almost all couples the condition comes as a surprise. And no wonder. It seems as if the whole is on its guard against producing unwanted children. Every day. 19.9 million women in this country wake up and remind themselves to take the Pill. In China, a woman with more than three children is considered an enemy of the state. In India, population experts fear the country may end up at century's close with four times as many people as it started with - up from 250 million in 1900 to one billion. The huge nation has resorted to quickie vasectomies and cash rewards at commuter train stations. "Two will do" posters are everywhere.
The problem is simply not taken seriously by those unaffected by it. It is possible in 1977 for the executive secretary of an agricultural association to suggest that workers might enjoy working around a sterility-causing pesticide - dibromochloropropane (DBCP): "Some might volunteer for such posts as an alternative to planned surgery for a vasectomy or tubal ligation, or as a means of getting around religious bans on birth control when they want no more children."
Man. Woman. Child. It's basic, it's biblical. And the presumption, based on an overwhelming amount of good evidence, is that it is automatic. But the miracle of reproduction is not just the end product; it also includes the complicated processes leading up to the infant. Many scientists, acquainted with th thousands of things that could go wrong with each conception, are amazed we are not extinct.Yet thousands of things go right, routinely, for eighty-five per cent of humanity.
"I got pregnant the first month we tried," reports one woman, while friends tease her husband, "We knew you had the stuff, Al."
Things "go right" for all sorts of couples for whom it may be catergorically said it would be better it they didn't. They "go right" for the 14-year-old girl who gets pregnant "the first time." Things "go right" for the couple in Wichita, Kansas, recently charged with child neglect for trying to swap their infant for a 1964 used car.
Things go so right in general that in 1968 the voices of doom organized - Zero Population Growth. But even ZPG has no problem allowing each couple who chooses to replace itself: man, woman, boy, girl.
Ten years ago American couples were producing an average of 2.47 children. In 1976 the rate was down to reasonably unapocalyptic 1.8 per couple. In this country, it seems most people are willing to settle for two children, if not out of long-range deference to some demographer's theoretical ideal, then out of short-range respect for their own pocketbooks. (The estimates vary, but it is said raising a child to the age of 21 costs anywhere from $100,000 to $250,000.)
As the decline in the birth rate indicates, more couples these days are choosing not to have children at all; it is, in fact, often presupposed that anyone childless is so on purpose. For the fertile majority, what seems fantastic is that anybody has trouble having children, and that, given the price tag from diapers to diploma, anyone would seriously struggle to have them. But the struggle they do, in varying degrees, a good fifteen per cent of the couples in this country, often for years. For those couples, a simple question at a party, like "Do you have children?" evokes a painful history of doctor's appointments, surgical procedures and failed expectations.
Although infertility may effect people of all social classes, the childless poor usually have neither the time nor the money to undergo a lengthy series of tests - commonly called an "infertility work-up" - to determine the cause of the problem. There may also be class differences in a person's willingness to endure many sacrifices so that a long-range goal can be realized. For these reasons, the inability to conceive and bear children seems to be a middle and upper middle-class problem.
The anguish of infertility will strike increasing numbers of couples in the next few years, however, as the children of the baby boom reach their late twenties and early thirties. Many who till now have postponed marriage and childbearing for their careers will turn to both to round out their lives - and find child-bearing not possible.
The men, after years of enjoying what they consider a healthy sex drive, will be shocked to learn that their sperm are too few in number or perhaps not active enought to effect a conception. The women may be given a finding of endometriosis, a condition in which parts of the uterine lining seed themselves in various places along the reproductive tract. Unknown in cultures where women marry young, it is a common finding in American women past 30. Or the women may be part of the 10.9 million who took the Pill every day whether or not previous gynecological abnormalities should have warned the physician against a prescription.
A generation ago, before the current explosion in medical technology, many couples who could not produce children were told there was nothing wrong with them: either it was all in their heads or God's will. There was also smirking ignorance on the public, the insinuation they weren't performing correctly in bed.
In fact, male impotence is the source of less than five per cent of the cases of male infertility, and the sources of impotence are extremely varied, from diabetes to perineal nerve injury to psychogenic causes.
These days the rate of cure for infertility is fifty per cent. In ninety per cent of the cases doctors can point to a concrete physical reason preventing pregnancy. Twenty per cent of the time both partners have a problem; in forty per cent of the cases the difficulty is with the female, in thirty per cent with the male and in ten per cent doctors cannot detect a disorder.
A big reason for a distorted understanding of the problem are the infamous fertility drugs, Clomid and Pergonal. It is widely understood that these drugs promote the growth of eggs, and that sometimes they are too effective - hence the multiple births. What is not understood is that these drugs are of use only among that small percentage of women diagnosed as "anovulatory," meaning their ovaries rarely or never discharge a ripened egg for fertilization by sperm. There are many other conditions which prevent women from conceiving, including cysts in the reproductive tract, tubal adhesions, enlarged ovaries, tipped uteruses, cervical abnormalities. In many cases surgery is required.
Involuntarily childless couples often feel victimized by the common myth that the problem is totally psychological in origin. Even husbands who accompany wives for their first consultation with a doctor are prey to this myth; it is rare when they don't take the doctor aside and complain, "Look, if she'd only calm down." (Wives, on the other hand, often worry about the psychological problems husbands may experience after an adverse report on the sperm analysis; they have been known to contact urologists secretly and ask, usually in vain, that untoward findings be kept from the husband. "I know it sounds like a martyr thing," said one wife, "but I also know I can handle it better than he can."
"It's all in your heads. Relax. Take a vacation" goes one round of advice."We did," says one woman. "We went on vacations in the Bahamas, Europe, the West Coast. If that worked, we'd know by now."
Relaxation, while a noble ideal, has only a remote bearing on infertility. All specialists in the field have noted a slim self-curing rate among their patients; it is almost as if conception occurs because attention is being paid and the problem is being treated as a problem. This happens in about five per cent of all cases, frequently enough to give credence to the notion that the inability to conceive translates itself into somatic difficulties. It has also been noted that in women receiving A.I.D. (insemination by an anonymous donor), four per cent of those who don't conceive after six months become anovulatory.
Another common bromide: "How can you miss something you never had?" One woman's response: "That's like saying you'd never miss a mother or the sunshine if you never had them."
Another: "Don't worry. If you adopt, you'll have one of your own."
This happens in only three to five per cent of the cases, and it is cruel to suggest it to the other ninety-five per cent, many of whom know beyond a doubt that the birth of a biological child is impossible. Adoption as a means of promoting fertility is not only morally debatable; it doesn't work.
In most cases, couples who find themselves unable to bear children were in excellent health when they decided to start a family. Cheerfully, they abandoned the birth control devices, pills and spermicidal gels. They were filled with typical high hopes; their concerns were the same as most prospective parents.
A typical couple might begin their efforts to start a family with a celebration; the wife, a teacher, quits her job one June, and she and her husband blow her retirement fund on one last fling, a trip to Europe. Six years later, all they have to show for their plans is a dog-eared photo album of them at the Eiffel Tower, them with the changing of the guard, them at a bullfight. All they have is a photo album and the growing conviction that if having a child changes a couple's life, not having a child when one is desired revolutionizes it.
The struggle for an answer and the cycles of false hope can be excruciating. Sarah had two ectopic (misplaced) pregnancies, but her third, the doctors confirmed, was in the womb. She bought smock tops for her slowly swelling belly before it was really necessary. On a business trip to New York she stopped off at Saks Fifth Avenue and bought an $80 maternity dress. One day, at work, she noticed her belly didn't seem to be getting any bigger. If anything, it seemed smaller. She locked herself in the ladies room and gave herself a pep talk: "You can't flake out. Especially here at work.Nothing's wrong. Calmly go back to your desk and call the doctor."
Rising expectations, swiftly dashed, account for much of the burden. There is much illogic in the situation.The goal, a successful pregnancy, hardly seems mean or greedy; if anything, it seems altruistic. There are many sacrifices made along the way to trying to realize the goal, and in most human dilemmas there is a logical link between sacrifice and reward.
For many people, infertility may bring on psychological problems rather than result from them, sometimes evoking feelings of chronic sadness, rage and anger. A 26-year-old woman, the victim of a massive pelvic infection of unknown origin, complicated by severe diabetes which weakened her body's retaliatory resources, recalls: "Why is it me? I had accepted and lived with diabetes for years. How could God let this happen to me too? Had this happened to me as payment because I'd practiced birth control or had premarital sex or even because I'd had my car neutered? Then the doctors told me there was no way to cure my infection, and the only way to stop the pain was to remove both tubes and ovaries and the uterus. The feelings that tumbled through me . . . ran from 'not me' to 'why me' and finally to . . . 'I'll be just an 'it'. 'I was only 24. I considered suicide very seriously. Somedays I was very close to doing something . . . my only fear was failing."
One local psychiatrist, Robert Hirschfeld, head of the program on clinical studies in depression at the National Institutes of Health, says that a couple involved in a prolonged fertility work-up should seek professional counseling somewhere along the line: "The ability to conceive is a basic fact, a part of life. There is an irony in that we are raised to be constantly on our guard against one false move in the back seat of a car, where with infertility many right moves don't lead to pregnancy. It is an extra hard thing in a marriage. Sex is no longer an expression of intimacy; it's now work, scheduled, done at certain times in certain ways. There's nothing fun about it. There's no way it doesn't lead to resentment. There's already plenty of blame floating around in even the best of marriages."
When the question of childlessness drags on for years, it can rob sex of all its pleasure. The woman who had the hysterectomy due to pelvic infection: "For a time, I lost all desire for love-making. To me, it was just re-opening a wound."
In addition to sexual harmony, these couples give up money. Sometimes it amounts to no more than a few hundred dollars here and there, like money spent so one spouse can accompany another on a business trip. (If they were to actually explain such seeming closeness, the response would be blunt and all business. She: "I'm here to ovulate." He: "I'm here to produce sperm.") But, depending on the generosity of a couple's health insurance policy, the stakes may rise: "Look, we have some money set aside, about $5000. If we didn't spend it on this, we'd get another car. But, please understand, under the circumstances, a second car is meaningless to us."
Attempts to solve the problem take time, often resulting in a woman quitting her job: "You go to the doctor two, three times a week. There are few bosses that understanding."
It means the haunting passage of time: "When we first got started on this, a plain cotton receiving blanket at Woolworth's cost sixty-nine cents. Now they are two for $3.98."
Social patterns change: there are more sports, more hobbies, more pets with human names, more attention to projects like remodelling the house, longer hours at the office. There is more of everything and anything as long as it translates into less and less socializing with peers with young children.
Involuntary childlessness may damage a person's self-image, and that negative feeling is fed when the individual, or both members of the couple, start thinking and behaving in uncharacteristic ways, ways normally considered unworthy. A husband, arriving home from work before his wife, opens a letter addressed jointly. It is from an adoption agency, informing them that due to their advanced age (both are 35), they cannot even be considered as potential adopters. The husband rips it up, and puts the scraps in the ashtray, lighting a bonfire to their one last alternative.
A certain amount of human dignity is sacrificed: "I know a woman who thinks Pap smears are humiliating. She should try being examined in the genupectoral position . . . Or she should talk to my husband, who is very sick of masturbating into little bottles.
Discretion goes, the sense of being able to make rational decisions: "There is not a drug I wouldn't submit to, although I do wonder sometimes whether it is worth it. Sometimes I wonder whether by taking Clomid, someday I'll be one of those women testifying on Capitol Hill, asking why Clomid, just like DES in the Fifties, was disturbed so wantonly in the Seventies. I mean, even if I have a kid, will I be around to raise it?" (Diethylstilbestrol, given to women during the Fifties to prevent miscarriage, was recently shown to have a casual link to uterine and cervical cancer among offspring.)
Health suffers in all sorts of ways. "Pregnancy is supposed to be the most joyful experience of you life, but I'm in bed the whole time," says a woman who has had five miscarriages. The common side effects of one fertility drug alone, affecting varying patients in varying degrees, include: transient hot flashes, blurring of vision, increased nervous irritability, depression, loss of head hair, galactorrhea.
If it were possible to make even more sacrifices, they would be made.
But the hitch is obvious: there is no guarantee that all the sacrifices will yeild the desired results. In attempting to cure infertilily, medical science often relies as much on black magic, roulette, sheer chance as it does on proven medicines. Therapy is often empirical. Ironically, Clomid, known to be effective in preventing conception in rats, was shown by a control group of humans to have the opposite effect on people. And no matter how much a person tries to load the dice - like the woman whose doctor advised her to prop up her legs for thirty minutes after intercourse and who habitually threw in an extra fifteen minutes for good measure - it often makes no difference.
Suzanne, the woman who became pregnant after fives years of trying, was rushed to the hospital after several days of spotting escalated into frank red blood: "When I got to the hospital, they put me on a liquid diet. A doctor came in, not my doctor, but another one, and he felt my uterus. He said, almost in passing, that I seemed smaller than twelve weeks. I lay in bed, thinking: 'What does he know. He doesn't even know my uterus.' Evening came. I felt cramps. I told the nurse I had gas pains and asked for Tylenol. How's that for denial? Then it got worse. I was crampy, restless, nauseous, perspiring. I ran for the nurse and told her I thought I was going into shock. In my pain, I said, 'Let it be over with.' They gave me a morphine i.v. That quieted my whole system down. When the nurse came in during the night, she would monitor my sanitary napkins but I was too out of it to ask what was happening. Then sometime around dawn, I felt I had to go to the bathroom. I felt something warm ooze out. I called for the nurse and I told her something had dropped out and she said, 'It's over. You passed the fetus.' They gave me some Pitocin to make the uterus contract."
Adjustment varies. Some couples go on, hardly troubled. They say their marriages don't suffer, their sex lives don't suffer, their marriages seem secure. Other couples, in an effort to inject some guise of choice in the childlessness, deliberately undergo a sterilization procedure, vasectomy or salpingectomy, tube-tying in either sex.
If the problem is exclusively male, there is always the possibility of artificial insemination by an anonymous donor. It is not a new idea. The first recorded mention of the procedure goes back to the fourteenth century when an enemy injected some fine Arab mares with the sperm of an inferior strain. Still, the idea seems strange, and even for the couples who choose this route, it is an unpleasant alternative in some ways. For one thing the majority of all children born this way are kept ignorant of their biological paternity.
Doctors view the process on an ethical par with a blood donation. "With artificial insemination," says Dr. Jay Grodin of Bethesda, "the woman gets a child with her genetic input. She gets the experience of pregnancy. The donor sperm is carefully screened for health history and heritage and intelligence. She doesn't have to wait years and years for adoption. The only things missing are her husband's forty-six chromosomes."
But despite the advantages, the thought sometimes plagues a woman: "I am carrying the baby of a man other then my husband." Legally, the courts have always held that any offspring resulting from this procedure is the legitimate heir of the couple, but some religions, such as Orthodox Judaism and Catholicism, view the process as adultery.
Adoption is a common choice of many, but because of increased use of birth control and abortions, the number of children available for adoption in no way meets the demand.
In the most difficult situation, in some respects, are the ten per cent without an answer. They go on hoping because that is all they can do. "It would be so much easier if the doctors could just tell us why we can't conceive," said one woman. "The other day, in utter exasperation, I told my doctor, how can it be that I moved to Washington, I found a beautiful old farmhouse in Maryland for under $90,000, forever bordered by parkland, less than fourteen miles from the White House, 13.2 to be precise, and no one can tell me why I can't conceive."
There is much sadness; usually it is sorrow of a diffuse sort, pain without focus. In the extreme, these couples are in constant state of grief. They are bereaved parents without ever having been parents. They see normal healthy infants as seven or so pounds of tomorrow, and until the crisis has been resolved, in one way or another, there are no normal healthy tomorrows. There are many solutions couples choose; the happiest they don't choose, but if by chance, karma, accident, mystery, God's will, and, of course, medical technology, they happen to be delivered of a healthy child, there is a tremendous surge of relief, not just at the birth of a child, but also that the struggle has ceased.
Joe and Carol tried for over six years to have a child. Though they live in Washington, Carol saw a specialist in New York, one year spending over $1000 in train tickets, taking the Metroliner up to get there on time, and the slow train back to save money. After experiencing one miscarriage, they waited until the seventh month of a second pregnancy befor remodeling the guest room into a nursery. Carol: "I didn't want to commit an act of foolish faith."
During delivery, Carol remembers: "I was very high, very excited. As the baby was being born, I remember shouting, there were about twenty people in the room, and I shouted, 'It's over.' A nurse corrected me - she was probably thinking about how it is for most couples - and she said, 'Oh, no, it's just beginning.' And all I did was shout some more and I told her she didn't understand: 'It's over, it's over, it's over."
There is help for infertile couples seeking medical advice and an arena to discuss their problems in the form of a support group called RESOLVE. For further information, call Josie Rattien at 363-2190 or Arlene Cohen at 333-6119.