The women pick their way through the winter-chinked parking lot of Hampton Mall, dodging puddles until they reach the door to Everlasting Life, a health food store in this Prince George's County strip mall. Inside, a few Saturday morning errand runners are circulating through the aisles, scooping up organic produce and Luna Bars and packaged tofu. The women arriving just now, however, have not come to Everlasting Life to shop.
circulating through the aisles, scooping up organic produce and Luna Bars and packaged tofu. The women arriving just now, however, have not come to Everlasting Life to shop.
Instead they go to the cash register, pay $10 and receive a ticket. They proceed down a dim corridor to the rear of the mall, where double doors open into a large, badly lit meeting room. They strip off their cabled sweaters, their stretch jeans, their boots, peeling off layer after layer until they are down to T-shirts and leggings. Barefoot, they sit down on dirty carpet the color of shirt cardboard, stretching their hamstrings until, at 11:30, a voluptuous woman arrives in a cloud of exotic costumery.
The woman's name is Sunyatta Amen. She is a medical doctor, naturopath and specialist in unconventional solutions to infertility. In her practice, Amen addresses unwanted childlessness by helping patients change their diet, urging them to forsake fatty foods in favor of raw vegetables and aromatic spices and pregnancy tea, the idea being to "put the best possible seed in the best possible soil." She also encourages them to engage in abdominal exercise designed to transform, unblock, and generally stir and vivify the internal organs.
Which is to say, Sunyatta Amen teaches women who want babies, and are having trouble making them, to belly-dance.
To that end, Amen pops in a CD and assumes a position in the center of the room, cheerful, resplendent, wearing a coin-encrusted skirt-and-bra ensemble. She herself is four months pregnant, something that cannot help but motivate her students, most of whom have heard about her class from friends or relatives, or run across it (www.sexualhealing.com) on the Web. "Let's do some stomach work, since the stomach is what holds it all together!" she tells the women, who are still arriving, 40, 50 women now, casting off their coats, forming a big circle around the room. She instructs them to think of their bellies as divided into two sections: one just below the rib cage, and one from the "navel down to the land of milk and honey." She encourages them to practice rolling their stomachs from one section to the other, and back again.
"What if you've only got one big section?" calls out one woman, and everyone laughs.
The specific condition this two-hour class is designed to ease is uterine fibroids, a troublesome kind of tumor. Though they are not cancerous, fibroids cause pain, heavy bleeding and often -- because their growth obstructs reproductive passages -- chronic infertility. Amen figures that 90 percent of the women in her class suffer from fibroids. Some are older women who developed them after having children, but many are younger women who are worried about their fertility or are having problems conceiving. Of these, some have jobs and health insurance, but others make low salaries, or have no health insurance, or are unemployed. They are in no position to pay for the expensive medical fertility treatments available to more affluent or better-insured Americans, though their desire for a child is no less intense. For these women, belly-dancing is fertility treatment, the only treatment within reach.
"I just want to have a child, you know, to be able to have a child of my own," says a slim, shy, short-haired woman, describing what another student calls "that hunger for a baby." The women are following Amen's gyrations, bending and shaking, arching and circling, trying to get the blood flowing through their abdomens, with the hope that this will shrink the fibroids or cause them to change positions. The short-haired woman has been trying to conceive a child for three years. At 36, she worries that she doesn't have much time left.
"People ask: Where are your children?" she says, drinking from a water bottle during a break. She feels that her infertility is embarrassing, deeply private, which is why she asks that her name not be used. She comes from a Caribbean culture where children are naturally expected, where children are an integral part of the pride and achievement of adult life. When friends ask when the babies are going to start coming, she doesn't know what to say. She and her husband are both self-employed, and neither has health insurance. She has paid to visit two gynecologists. They recommended in vitro fertilization, the Cadillac of fertility care, in which eggs and sperm are extracted, fertilization achieved in a lab, the resulting embryos reimplanted. The price tag for the average IVF procedure: $10,000, for a single try.
She and her husband have talked about it, but 10 thousand, for them, might as well be 10 million. So she gyrates and shakes, trying not to let herself be paralyzed by anxiety or sadness, one of countless -- uncounted -- people for whom money is the chief thing standing between them and the baby they want. If nothing else, dancing is relaxing. Dancing is doing something. Dancing is hope. Dancing is cheap.
"Come on!" Amen calls, reminding them that in the past year, three members of the class have gotten pregnant. "Let's get those hormones flowing!"
"Infertility is just treated cavalierly. People think: You're breeders anyway. They think: You already have too many children," Amen reflects afterward, summarizing a persistent myth about lower-income communities. The myth is that the less money a person has, the more babies a person has: that the poor are unstoppably fertile, popping out baby after baby that they cannot afford to clothe or educate or feed. The flip side of the myth is that only the rich have trouble conceiving. In the modern American version of that myth, infertility is the affliction (some would say, the comeuppance) of ambitious, upper-income working women who have delayed childbearing until their thirties and forties. The curse of the female litigator, the high-powered woman broker.
Real-life infertility, however, doesn't discriminate by race or class. It strikes between 10 and 20 percent of Americans of child-bearing age: supervisors with a window office, yes, but also car mechanics, immigrants, students. And there is some evidence that the less money you have, the more likely you are to be infertile. Among poorer patients, doctors say, sexually transmitted diseases often don't receive good medical treatment, and untreated STDs can cause all sorts of damage to reproductive organs. The poor frequently suffer from morbid obesity and diabetes, both of which create hormonal imbalances that can lead to infertility as well. And there are conditions like fibroids, which for unknown reasons more often affect women in minority groups, who in this country are more likely to be lower-income.
Patients at a high-end fertility center are offered long, sit-down consultations and painstakingly designed, obsessively monitored medical regimens that often cost around $1,000 a month; patients on Medicaid, the federal insurance program for the very poor, are offered a spectacular variety of contraceptive devices, but no fertility treatment. The poor fare no better when they seek their care at, say, nonprofit clinics: In D.C., Planned Parenthood offers abortion as well as contraception, but people seeking fertility services are sent away with a referral and a wish of good luck. "We see many, many low-income people who would love to have a family," says Jean-Gilles Tchabo, an ob/gyn at Virginia Hospital Center in Arlington. "Then you do your evaluation and find out maybe they're infertile because their tubes are blocked, or they have a condition that would require stimulation of the eggs [with fertility drugs] or in vitro fertilization."
And if his patients don't have money for that treatment, Tchabo says, all he can tell them is: "Bye-bye."
"The whole emphasis is on preventing birth," says Mairi Rothman, a midwife at the D.C. Birth Center, which treats low-income women. "Preventing pregnancy, actually. Medicaid is not going to pay for someone to get pregnant who can't even afford health care."
Fertility care for the poor is hard; it's confusing. Where do you come down if you're liberal? If you're conservative? Pro-choice? Pro-life? If you're against abortion for the poor, should you be in favor of IVF for the poor? It's a hard argument to advance: that public medicine should actively assist the poor in having children, particularly when there are so many other urgent medical needs. And even then there remains the question of what, if anything, to do for the completely uninsured, that is, the working poor and almost poor who have no private insurance, and do not qualify for Medicaid; people who are obliged to pay full price for their medical procedures -- or, frequently, to forgo them. To a certain extent, the infertile poor are a relatively small group of bottom-bunkers in America's vast two-tier medical system, a system where tens of thousands of people are denied medical insurance and, with it, a whole array of treatments.
So in a way there's nothing new, nothing surprising here. The poor are denied babies, or rather, the poor are denied costly solutions that might help them have babies. By definition, that's what it means to be poor: to be denied expensive things. Somehow, though, there seems particular cruelty -- a particularly cruel irony -- in being denied children. Part of the myth of the fertile poor, after all, is that children are your riches, your solace. In that sense the infertile poor are doubly impoverished.
Because that fundamental longing, that feeling of incompleteness, that desire to love and be loved by some tender smaller creature -- none of these are confined to any one social class. No one class lays claim to our biological urge, as a species, to reproduce; no class lays claim to that core human emotion, family feeling. The power of that feeling is the reason people will go to surprising lengths to have the family they want. When middle-class and wealthy people are infertile, they lobby Congress for better insurance coverage for fertility procedures; they pay for in vitro fertilization, donor sperm, donor eggs, cryogenic embryo storage, surrogate mothers. They travel to Russia, China, South America to adopt babies. When the poor are infertile they belly-dance; they get credit cards and max them out; they beg for help from scattered, unlikely patrons. When it comes to that hunger for a baby, the poor aren't different from the rich. They just have to be more creative.
"Sometimes I ask myself: Am I going to die on this earth and never have children?" says a woman nicknamed Sam, sitting in the immaculate basement of her home in Prince George's County, a home that contains no hair bows, no castoff shoes, none of the happy clutter that comes with having a child. It's Sam's day off. Forty hours a week she gets up and goes to work as a security guard, but because she is officially a "contract worker," the company that employs her is not required to provide health insurance. Which is okay: Sam would gladly buy her own policy, if she could find one that's affordable. But she has a preexisting condition, diabetes, so when she recently attended an "open house" held by Blue Cross and Blue Shield of Maryland, the monthly premium she was quoted was $500. On her take-home pay of about $25,000 a year, she says, it just isn't feasible to pay $6,000 a year -- plus deductible, plus copayments.
"I've just always wanted a child," says Sam, a small, round, forthright woman who grew up in D.C. When her friends started having babies, Sam naturally expected that she would someday have them, too. She attended college; left; started working; used drugs, a habit she regrets and one she has vanquished. But the babies never happened. Now, at 33, Sam feels she has worked her life into a good place, a place where she is married, settled down, clean. She met her husband in recovery; neither has used drugs for five years. Her husband, a construction worker, is also uninsured. Recently he fell off a roof, so he's home now on worker's comp, going to school to be a locksmith. No more roofs, he says. He wants a safe, comfortable life. A life with Sam. A life with children. When they married, last year, Sam's mother gave them a daybed. "For my granddaughter's room," she said.
"It would be wonderful to have a child with her," says Sam's husband, who has adult children from a past marriage, something that subtly adds to Sam's own problems. Infertility is a sadness that affects and complicates every interaction: When Sam argues with any of his children, she asks herself, afterward, "Is it because I don't have kids myself?" Does not being a mom make her a less loving stepmom?
Sam's husband dismisses this idea; he hasn't been the best of fathers; his own children aren't perfect. But now, like Sam, he's ready to settle down and do this parent thing right. "This is the beginning of a dream," he says. "I have a wife I'm madly in love with; I have a home; I feel stable." He and Sam talk about the child they would like to have. Often, in their conversations, she is a girl. She follows them around, fills the house with disembodied longing. Meanwhile, their friends ask: "When are y'all going to have children? You haven't had any babies yet!"
Sam talks about her infertility with only a few people, among them a cousin who has had two children and has lost custody of one, who is now being cared for by the father. "I think in actuality, she really didn't want to have those kids," says Sam, who feels the irony acutely. Sam's cousin has children and doesn't seem to want them; Sam wants them and cannot have them. They have discussed, from time to time, the cousin having a child for Sam, but an arrangement like that seems complicated, and risky. She's thought about foster care, but the idea of caring for a child only to see that child relinquished back to a birth parent -- a situation that foster parents are trained to expect -- is too wrenching to contemplate. She wonders about private adoption, but fears that her past drug use would doom her chances. Plus, what adoption agency would release a child to a parent with no health insurance?
So Sam is pursuing the only angle she can think of. "I don't like doing what I do, but I don't know what else to do," she says. Though she lives in Prince George's, she quietly crosses the line into D.C. to seek basic fertility care, showing an old food stamps ID and using her maiden name. There exists some low-income care in Prince George's, but it's scattered, and Sam (whose nickname is being used, at her request, to avoid exposing her) fears she earns too much to qualify. D.C., in contrast, has a relatively generous safety net that helps the working uninsured by allowing them access to public health clinics. As Sam's husband puts it, she is stealing her health care.
In truth, though, there's not much to steal. Like most public medicine, the D.C. system covers little fertility care. Doctors can do some diagnostics; if blood tests show that Sam has, say, a thyroid deficiency, she can get medication. If she's not ovulating, the doctors can oversee a regimen of Clomid, the mildest and cheapest of the fertility drugs that stimulate egg production. But if she needs more powerful drugs, or medical treatments to, say, open her fallopian tubes, no public health system will help her. "I think I was pretty hopeful until maybe a year ago," she says. "Now, I'm like, well, I'm not sure." Not sure she will satisfy that fundamental desire, that lifelong expectation to become a mother and raise a child, just raise it, doing all those ordinary, unimaginably pleasant child-raising things: "Watching it grow, watching it bloom. Spoiling it. Disciplining it."
"I'm doing that with the dogs now," she adds, referring to two 100-pound dogs that are rustling around in their crates in the laundry room, dogs her husband brought home against her wishes. She fussed at him when he called her at work to tell her what he had done. What was he thinking, bringing dogs into the house? Who would take care of them? Now it's the dogs she fixes breakfast for, the dogs she tucks in at night. "But they're dogs," Sam says, and starts to cry. "It's not the same."
She recently gave the daybed back to her mom. "I wasn't using it," she says.
This is not to say that it's easy for the middle class. Fertility treatment is expensive for everybody; it's stressful and sad; it removes any sense of control over your life, your basic biological processes. In recent years, however, advocacy groups have done an effective job of persuading some private insurers to pay for treatment, and many fertility centers have begun offering "money-back" guarantees that help the uninsured middle class. The thing is, even the most sophisticated treatments often don't work. The logical next step -- for the poor, the middle class, the rich -- is adoption, and here the poor are still at an overwhelming disadvantage. "One of the criteria that many birth mothers use is: They want the baby with a well-off family," points out Norman Hecht, a banker who specializes in adoption loans. "To give the child some of the benefits they never had."
Over the years adoption has become surprisingly expensive, Lexus-level expensive, costing $15,000, $25,000, $40,000, or even more. Meanwhile, in the last 30 or 40 years the pool of babies has dwindled, owing largely to cultural changes. Now, many single mothers feel it's okay to keep their babies, or, sometimes, to abort them. Time was, an "unwed mother" who called an adoption agency from her childbed might be turned away as having applied too late; these days, an agency would practically send a limo to pick up the baby before another agency gets there. Adoption is competitive, and entrepreneurial, and those competing aren't just private agencies. Three-quarters of infant adoptions are now achieved quietly, independently, by couples who place an ad directly in a newspaper, setting up a hot line; paying for their own lawyer, the birth mother's lawyer, if necessary the birth father's lawyer; paying for travel, paying for the delivery, paying for Caesarean sections; paying as well for not-strictly-necessary things, like birth mother gifts. You can't pay a woman for her baby, but you can express your appreciation.
"Well, we'll just have to play to our strengths," says Brian Poole to his wife, Amy, as they sit cross-legged on worn, putty-colored carpet in their apartment in Hershey, Pa. They're surrounded by a pile of old snapshots that they're hoping to assemble into an adoption dossier that will win the heart of some unknown birth mother, somewhere, who is preparing to put her child up for adoption.
Brian Poole, 27, is a graduate student at the Milton S. Hershey Medical Center, the medical school for Penn State University. He and Amy, 26, are poor, close-to-federal-poverty-level-poor, a temporary student poverty but one that's acute and will last for quite a few more years, until Brian finishes his PhD program and post-doc training. Mornings, Amy works for a publishing company that pays her $11 an hour. Days, Brian does his research work. Nights, he works as an auditor at a Best Western motel. For their efforts they bring home around $1,700 a month after taxes, of which at least $170 goes to pay their tithing to the Mormon Church, and $750 goes to their rent in this two-bedroom walk-up, leaving them with less than $800 to get through the month.
And here they are, trying to spin all this into something positive, something desirable; here they are, trying to persuade a birth mother to bet her baby's future on them. Here they are, contemplating a snapshot of Brian standing at the sink, laughing and washing dishes with their son, their miracle boy, 2-year-old Ethan. What the photo communicates -- Amy hopes -- is not that they're a poor household, poor enough that they don't have a dishwasher, but, rather, that they're a happy household, a wholesome household.
"Our strengths are a husband who does dishes, and a long history of being together, dating, doing fun things," says Amy brightly, wearing cotton pants and a flowered shirt and glasses, sitting on carpet that may well be older than she is.
Brian and Amy's poverty has defined every aspect of their baby quest, and may well be part of the reason they are infertile. Brian, a tall, brown-haired man with the shy demeanor of a person who is most at ease among close family members or interesting lab smears, grew up in a Utah household with lots of siblings, a love-rich upbringing but one that left no money to spare for his education. He received a full scholarship to Brigham Young University, but paid his living expenses by laboring in a factory that made gun safes. His job was gluing strips of carpet on the rack that would cradle the guns.
"I would glue things all day long, and you could tell I was inhaling all sorts of things," says Brian, leafing through photos of Amy and him in high school, Amy and him in college, Amy and him being married in the Mormon Temple in Salt Lake City. "There were buckets of solvent; you'd put the glue on the rack, and if it got on anything, you'd have to use the solvent to get it off. You could tell there were chemicals pretty much pervading." Like much infertility, his was impossible to diagnose with certainty, but doctors suspect that big buckets of solvent may have a lot to do with the fact that for three years when he and Amy were trying to conceive, his sperm count was so low their endeavors were hopeless.
"My biggest fear was always that I wouldn't be able to have children," says Brian. "Being a dad has been my whole goal for my life for my whole life." During high school he was interested in being a doctor, but doctors, he feels, must put their families second. His compromise was to pursue a career as an immunologist, a goal that has the added benefit that, maybe someday, he will discover a cure for the sort of autoimmune disease that afflicts Amy, who has lupus.
He came to study here, in Pennsylvania, where exactly 90 days after he got away from solvents, Amy found she was pregnant. Nine months later she delivered Gordon Ethan. "The nurse called him a sucker baby," says Amy, a baby so sweet and easy that he suckers you into wanting another. Which she does. As does Brian. They'd like a big family, an aim that's fueled not only by the wonderfulness of Ethan but by her own solitary childhood. "I was an only child, and being an only child is a lonely life," says Amy, who never knew her own father; she was raised by her mother, an alcoholic, and her stepfather, an unemployed truck mechanic. When her mother's drinking was too bad, she would live with her grandparents, a difficult childhood that she endured without sibling companionship.
For months she went to church and prayed for the Lord to give her another child. Now she prays to the Lord to help her accept the fact that this probably won't happen. Because now, the infertility seems to be hers. Brian's sperm count is slightly better, though still not high, but she herself now ovulates only irregularly. It could be the lupus; it could be the steroids she takes to control the symptoms, which have been virulent in the past year, her disease brought out of remission by pregnancy and childbirth; it's hard to know what's wrong, exactly, and now nobody can tell her. When Ethan was born, she had health insurance through her part-time job, but like many private insurers, her insurer would pay for infertility diagnosis but not for treatment. She paid for three regimens of Clomid, but all three failed. Then her premiums got so high -- $300 a month, just for her -- that she switched to Brian's state-provided insurance, which excludes any fertility treatment at all, including testing.
So who knows, anymore, what's going on inside her? It's true that several years from now, they'll have more money to pay for fertility treatment; but Amy's lupus has already wrought such damage to her body that each passing year makes a pregnancy more risky. Her time frame is much shorter than most women's. Which is why they are where they are, on the floor of their apartment, leafing through the photos, while Ethan looks over their shoulders, sometimes clambering into Brian's lap. "Which piece of stationery do you like best?" says Amy; they've shelled out $30 for a variety of paper samples decorated with teddy bears or rainbows, on which they will print the missive to prospective birth mothers. The letter and photomontage will be on file in the family services division of the Church of Jesus Christ of Latter-day Saints, which has a branch office in Frederick. They could never afford an independent adoption, or most private agencies, either, so thank God -- literally -- for the Mormon Church, which, like many religious charities, runs an extensive adoption agency, and offers a sliding scale. In theory, you are required to pay no more than 10 percent of your annual income, but the rock-bottom price is $4,000. With the cost of a lawyer, and travel to pick up the baby, Brian and Amy expect the total to be closer to $5,000.
But to get that baby, they have to compete with other deserving, loving Mormon couples, hundreds of other couples, smiling, upstanding young people, many of whose dossiers can be viewed on the LDS Web site. Technically, there is no place to state one's income, but there are ways to write a personal statement that communicate a certain degree of, shall we say, material comfort. "We are an adventurous family who likes to go swimming and soak in the Jacuzzi," says the statement of two would-be parents named Brian and Leslie, who are pictured seated, in a manicured yard amid fresh-clipped grass and carefully watered perennials. "We've had lots of opportunities to travel and see wonderful things around the world," say Dave and Lorraine, who are pictured underwater in Hawaii, wearing scuba gear. "We just built a house last year," say Christopher and Leslie, who have posed in a formal portrait. "Our home is very comfortable and there is a whole bottom level that we plan to make into a family room and playroom."
Brian and Amy don't have a Jacuzzi; they don't have scuba gear; they don't have a house or a yard. What they have is warmth, and wit, and words. "Brian is an amazing man," writes Amy. "Amy is the strongest, most loving and most giving person I've ever known," writes Brian, and they sit there writing and rewriting, hoping that some woman somewhere will read these words and connect.
But should a birth mother choose a poorer family? Are poor people a good bet, as parents? It's a question that very few people wrestle with. There is no organized campaign to help the impoverished infertile; no advocacy group holding walkathons; no Ronald McDonald House, no Oprah show.
Instead, those advocates for the poor who do exist, exist quietly and on a very small scale. Twenty years ago a wealthy Cincinnati woman named Madeleine Gordon was going through anguished infertility treatments during which, like many rich people, she stopped at nothing to conceive. "If I were told that there's a specialist here who peels the egg and therefore can inject the sperm right into the egg -- at that time, that was on the cutting edge -- I had the ability to see that doctor," says Gordon, for whom none of the treatments took. Instead of sitting around feeling sorry for herself, Gordon was struck by her great good fortune. "What if you didn't have the money?" she found herself wondering. "What if you were denied the opportunity at all?"
Soon after her 50th birthday, Gordon persuaded the University of Cincinnati's medical center to join with her in founding a modest philanthropy called the Gordon Gift of Life, which pays for five poor people each year to receive two rounds of IVF. Every year, there are hundreds of applicants. People send long, descriptive letters laying out their case; they come for interviews; they are considered by a board. The lucky five must meet strict criteria. They must be from the Cincinnati area. They must have no alternative except IVF. They must be married. They must be childless. They must be a male-female couple. ("We live in a very conservative city," says Gordon, somewhat apologetically.) They must be relatively young: A 29-year-old is more likely to be picked than a 40-year-old. They must be poor, but not problematically poor: i.e., they must be sympathetic and well-spoken and attractive. "We look for nice, articulate people," says Michael Thomas, the doctor who administers the program. So far 13 babies have been born, with two more on the way; each year the petite, girlishly voiced Gordon sends out a Christmas card with herself, looking immaculately groomed and deeply satisfied, among all these babies whose lives she enabled.
The Christmas card is part of drumming up money, trying to expand the program, which remains tiny and, as far as anyone knows, unique. Because it is a challenging thing, helping poor people have children. What about the really poor poor? What about the unmarried poor? What about the poor whose life, in part because of poverty, has not been blameless? What if IVF technology were to become cheaper, the way, say, DVD players have? How would we, as a society, feel about full, unfettered access for the poor? On the other hand, how do we feel about full, unfettered access for the rich, who can walk into a fertility center and buy treatment without any scrutiny at all? What about selfish people? What about white-collar criminals? Do you have to approve of the person you help?
"This has been an issue that has bothered me for years," says Michael DiMattina, another person who, like Gordon, does what he can. DiMattina, who with another doctor runs Dominion Fertility, a clinic in Arlington, is talking about the question of helping, and judging; the quandary of knowing that you are helping only the affluent; the issue of whether, and how, to help the poor.
"I really and truly do feel committed that all people in this great country we live in should have health care," says DiMattina, who has thought about setting up a foundation to help low-income patients. "I feel it's a right. The problem, as you know, is who's going to pay for it, and when you have people dying from AIDS, cancer, all the ailments that exist, and there's limited dollars, they prioritize what they're going to be paying for, and not. And it's very noble to treat people who are infertile, but if they're poor and can't even take care of themselves, some would say, 'Gee, they can't take care of themselves and be able to finance that, why should we help them have more children?' I think it's a legitimate question."
It's an ongoing discussion DiMattina has with himself, because there are always low-income people who do somehow get in to see him. "I don't know how they find me," he says. "But they do." And he quietly, from time to time, helps them. The thought of even this much information appearing in a newspaper fills him with anxiety. Each month he volunteers his basic ob/gyn services at Arlington Free Clinic, where patients are not told he's a fertility doctor. If they knew, he figures, the pent-up demand would break down his door.
And the question of how the people he helps will manage, after the baby is born, is real. It's a question faced by James and Teri Simpson, a couple from Southern Maryland who two years ago did find their way to DiMattina. James, a self-contained 28-year-old, has light brown hair and an air of not expecting anything from anybody. He grew up on a farm, where he learned to work, and work has always been the thing in life that interests him most. In seven years, he has not taken a vacation.
"I've always been more mature than the people I went to school with," says James. "When I was in school, I always had jobs, I worked all the time, worked on a horse farm, worked after school, during the weekends; that's really all I ever did, was work." Now he works installing heaters and air conditioners, bringing home about $500 a week after taxes. When he married Teri, a bright, vivacious woman who works for a paper company in Prince George's, making slightly less than he does, she had a child, Jordan, from a previous marriage. Teri and James moved in together, and one day when Jordan was visiting her grandmother, James remarked on how quiet the house seemed and how much he missed her. "I knew then," says Teri, who is 33, "that he was ready."
"I just want a child," is how James puts it. Like most people, he has a hard time saying exactly what it is that he wants, or expects, from that child. It's something like: Having someone else to think about besides yourself. Having a goal in life beside working and partying and hanging out. Growing up. Fullness. Noise. "To make my life complete," he says. "To finalize that chapter in my life, so I can finally feel like an adult."
They never suspected anything would get in the way, so after they married they bought a house in Pomfret that they planned to fill with kids, a brown, vinyl-sided four-bedroom, pretty much the smallest house you can get in one of the new developments. They tried to keep it as cheap as possible, turning down options, such as cathedral ceilings, which James knew are expensive to heat. They'd been told the total mortgage payment would be $1,600, but then the financing fell apart, and when it came back together, the new payment had bloomed to $2,100. They bought some furniture on financing, and James bought a new Dodge Dakota on which he was also making payments, so Teri, who doesn't work in accounts receivable for nothing, consolidated the bills into a second mortgage to get the tax deduction. They'd both keep working, and slowly get themselves out of debt, and wait for a baby to happen.
But the baby didn't happen. After a year or so, Teri's ob/gyn directed them to DiMattina, and they drove up to Arlington to see him. Maryland, in theory, is one of the best states to live in if you're infertile and insured; it's one of a handful of states where private insurers are required to pay for treatment. But in Maryland as elsewhere, there are loopholes: Both Teri and James work for companies small enough to be excluded from that requirement. When they met with DiMattina, he found that they both had fertility problems. In the years since she'd had Jordan, Teri's fallopian tubes had become blocked, and there was no point giving her an operation to open them since James had low motility, which means his sperm were both scarce and -- there is no pretty way to put this -- weak. In the ensuing months James would come in for a lot of ribbing from his colleagues, who would say things like, "Can't knock your old lady up? Want me to do it?"
Because of the motility problem, DiMattina recommended that in addition to IVF they get ICSI, or intracytoplasmic sperm injection, in which the sperm is assisted in penetrating the egg. The price for IVF was $7,800, ICSI an additional $2,000, plus there were costs for the consultation and screening. They didn't have the money. All they had were material objects -- a couch, a bed, a house, a truck -- on which they were making payments. James didn't hesitate. "I wanted the kid," he says. "So the truck had to go." He sold his brand-new Dakota, taking about a $9,000 loss, but ending up with enough cash, about $14,000, to cover a single round of treatment.
On appointment days, the routine would be the same. In the evening Teri would get her shots: Some of the fertility drugs she injected into her stomach, but most had to be injected into her backside by James, who was initially nervous about doing it. "I was like, I didn't want to do this, this is crazy," says James, but then a nurse came out and showed him where to put the shot, literally drew a circle in permanent marker on Teri's rear, and by the time the marker wore off he'd gotten so good that he now thinks, sometimes, about becoming a nurse himself. In the mornings they'd leave the house together at 6 a.m.; drop Jordan at before-school care; drop James's work vehicle at his shop; then ride together to Ar-lington, where DiMattina conducted blood tests and sonograms, monitoring the drugs' progress in stimulating Teri's follicles to produce eggs. Then they'd drive back to Maryland, and Teri would drop James off at work -- he'd have to stay late to make up for the hours he lost -- and go on to her job an hour away in Capitol Heights.
When Teri's eggs were mature, DiMattina extracted them. James gave his sperm; DiMattina's lab washed it, treated it, implanted one sperm in each egg. All in all, 12 eggs were retrieved. Of these, eight were successfully fertilized. Three were transferred to Teri's uterus. One took. They saw it on the sonogram. One was enough. One was all they needed! One would give them a baby! But when they drove back for the next sonogram, they saw that what they had was not a baby but something called a blighted ovum. The sac was growing, but the embryo wasn't. Teri soon miscarried.
"It's like your whole life has ended," says James, who was going to work every day and installing heaters and air conditioners to pay bills on a truck that no longer existed, because he sold the truck to get the baby, which no longer existed either. "Everything you had worked your whole life for, everything you'd wanted all your life, you couldn't have," was how it felt, he says. Now, when his colleagues started in with the jokes, he told them to stop it. "I put an end to it," he says. "I told them, It's not funny anymore. Y'all done wore it out."
They took a couple of months to regroup and recover. Then, when they met with DiMattina, he recommended that they give it another try, since Teri seemed such a good candidate for a pregnancy. This made sense, except for one problem. Explaining that their insurance was not covering treatment, James said: "We don't have another vehicle to sell."
DiMattina offered to give them a break on the next attempt, which he would perform for $6,000. When she heard that, Teri realized that she had a $6,000 limit on a credit card. They could charge the next round of treatment. "This is how poor people think!" Teri says now, laughing. "We're already poor, so we'll just spend our last dollar."
So they charged the procedure, and the discount helped, though there were other expenses. James's company had changed insurers. The old insurer would at least pay for the fertility drugs, which run about $3,500 per IVF regimen; the new insurer wouldn't pay for anything. Disgusted, Teri said to hell with both their policies, and went out and bought Blue Cross and Blue Shield (now known as CareFirst of Maryland), which costs them a little more than $1,000 every three months. When she spoke to the representative, Teri asked if they covered infertility. The person asked if she had a preexisting condition, and Teri said yes. She was told, she says, that the company would cover up to three IVFs per live birth. But when the policy arrived in the mail, it contained a rider excluding fertility treatment. Teri signed it, returned the policy, and -- suspecting the exclusion was a violation of Maryland law -- contacted her state senator, whose office initiated a legal challenge.
Meanwhile, they charged the treatment on their credit card, and James's aunt lent them money for drugs. Teri spent time each day with an Internet infertility chat group, and some of her chat-room friends sent her drugs and needles that they no longer needed. In the Internet underground, these are known as "leftovers." One woman mailed her the Lupron; another shipped her the Repronex; another gave her some leftover Gonal-F. They would arrive in gift-wrapped packages, complete with teddy bears and good-luck cards. And the whole process started again.
James gave Teri the checkbook. He didn't even want to look at it anymore. He didn't want to be able to buy anything. "It was like, go for broke," he says. "We figured, hey, if she doesn't get pregnant, we'll be broke. We'll figure something out. If we have to get out of the house, we'll get a townhouse, till we get back on our feet again."
The thing is, Teri did get pregnant. She's five months along now, well into what her nurse practitioner calls a "premium pregnancy," a pregnancy so costly and hard-won that she's not going to take a vacation between now and delivery day, for fear that something might happen while she was away from her doctor. The pregnancy is great; it's what they wanted, but in some ways it makes things even harder. They can't move into a smaller place, not with a 9-year-old already and a baby on the way. They are so deeply in debt that they've canceled their trash service. Instead it accumulates in the garage until James takes it to the dump. They can't buy a rocker for the baby's room. When Jordan wants a small luxury -- a T-shirt from school, dues for the soccer team -- they have to think hard about whether they can afford it.
"We could be like a lot of people: Get ourselves a lawyer and declare bankruptcy," James says. "Get a deal with a finance company so we can stay here. But we're not that kind of people." It seems to him a real possibility that they might lose the house.
They've gotten a bit of good news, though: Sitting on their dining room table is a letter from the Maryland Insurance Administration declaring that CareFirst must pay for the second round of IVF. Even so, they feel the company will inevitably appeal. While waiting to hear, they're still making credit card payments -- with interest -- and there's an unpaid bill, $160 for blood work. Plus, there are the costs of the first round of IVF, which they're still making payments on, and no insurance will ever pay them back for that.
"We have no savings," says Teri. "What little bit of savings we ever had is gone." When the baby is born, Teri would love to be able to stay home, or work only part time; she dislikes the fact that, now, she must drop Jordan off for before-school care, work all day, leave Jordan in after-care, too. They'll have to find a similar all-day arrangement for the baby. Teri isn't even sure how she will swing her six-week maternity leave, during which she'll be on disability at half-pay. When it's cold, they set the thermostat as low as they can stand. Each night, James checks Jordan and Teri, to see if they're covered with enough blankets.
They've exhausted themselves to get this baby; they're poorer than ever; the baby is closer to reality than ever; raising the baby will only make them poorer. But the baby exists; the baby is real; and for them, that's the only thing that matters.
Liza Mundy is a Magazine staff writer. She will be fielding questions and comments about this article at 1 p.m. Monday on www.washingtonpost.com/liveonline.