Conceivability_What I Learned Exploring the Frontiers of Fertility

by Elizabeth L. Katkin

  It took me a few days to want to talk to anyone. At the office, I told only the office manager, Jackie, who was incredibly sympathetic, and my two new friends and colleagues, Susan and Kathryn, with whom I spent virtually all of my time at work. Susan was pregnant at the time, and it was particularly painful to tell her, especially as it was early in her pregnancy as well.

  I called my parents and could barely talk to them through my tears. Everyone was shocked. Everyone, that is, except my close friend Kathy, the ob-gyn. I could tell that she wasn’t surprised. When I pressed her, she hesitated and then confessed that she had been worried about me.

  “Why?” I asked, confused.

  “Because your due date kept slipping. Your due date should never slip by five days. The fetus wasn’t growing properly. They should have told you.”

  I was stunned. There were warning signs. She explained that at that stage of early development, a difference of five days was very significant, and that she had suspected that there was a problem with the embryo, very likely a chromosomal problem.

  The next part of our conversation, on the other hand, did surprise her. Kathy explained to me that the doctor would most likely be planning to test the chromosomes when he did the dilation and curettage, known as a D&C, but that I should ask about it and make sure that they were definitely planning to do so, so that we could learn from this loss. I told her that Mr. R had strongly counseled against a D&C when he had called a few hours after the scan, and wanted me to wait for the dead fetus to pass naturally, a process that sounded scary, painful, and messy. In addition to the physical horror, I did not welcome the emotional toll of walking around knowing that I was carrying a dead baby. It had been panicking me.

  “Whaaaaat?” Kathy exclaimed. “That’s crazy.” She thought I should get the D&C right away. Not only did she think it was emotionally better for me, but we were likely to get useful information about the fetus, and it would have physical benefits as well. I would know that I had been emptied of all the retained products and I would begin to heal and my cycle restart. She emphasized that I was at risk of infection from the dead tissue inside me, and that I had no idea if or when it would come out. We also knew from the ultrasound that the miscarriage, diagnosed at eleven weeks, six days into the pregnancy, likely occurred at approximately nine weeks. Her feeling was that if it had not spontaneously evacuated by now, it was not going to. I called the doctor several times. I practically begged him to do a D&C. He insisted that I wait two weeks. I grew to hate the sound of his voice, his repeated denials of my request for the procedure.

  Richard urged me to call another doctor. Kathy urged me to call another doctor. My mother urged me to call another doctor. She had never trusted a doctor that didn’t have a computer. I couldn’t act. I couldn’t explain it, but I felt paralyzed.

  Finally, the day came that Mr. R had scheduled the D&C at The Portland. I was relieved, almost strangely excited, to be getting this dead alien being out of my body after two horrendous weeks of waiting. I was not, however, looking forward to seeing Mr. R again. It turns out I needn’t have worried about it. He never showed up. He had a family emergency, and Richard and I waited anxiously for news of what would happen next.

  Eventually, a dashing, charming gentleman in a tuxedo popped in to introduce himself. He would be filling in for Mr. R. We must excuse him, he had been on his way to a gala of some sort, when he got diverted to perform my procedure. He would just scrub up and be with us in a jiffy. We were both relieved—he was wonderful. The procedure went smoothly, and when I woke my newest doctor, who happened to be the Surgeon-Gynaecologist to Queen Elizabeth II’s Royal Household, was there, regaling us with his stories. I loved him and wanted him to be my doctor. He politely declined. He couldn’t think of taking a patient from Mr. R. As suddenly as he arrived, he was off, and we were left alone with our reality—sitting in a recovery room in a posh maternity hospital surrounded by mothers and babies when we had just lost ours. It was time to get out of there and refocus on the future.

  Several weeks later, I received a fax at my office from Washington, DC. Not to worry about the toxoplasmosis, it said. It was a marker from an old infection and was not a threat to the pregnancy. I didn’t have long to dwell on it. It was September 11, 2001.

  Another two weeks later, I received the following letter from Mr. R:

  I have now received the Chromosomes results on the products of conception and these show that the fetus was abnormal. The chromosome showed an extra X chromosome which would be the cause of the miscarriage. This should not be repeated in a future pregnancy and is a one-off.

  I look forward to seeing you soon.

  That was our last communication.

  * * *

  The cause of my first miscarriage at the age of thirty-three was a chromosomal abnormality in the fetus, believed to be the culprit in as many as two-thirds to three-quarters of first trimester miscarriages.2 The most common cause of miscarriage, a chromosomal abnormality in the embryo is generally thought to be a random event resulting from errors in cell division in the egg, sperm, or just forming embryo. This kind of miscarriage is termed “sporadic” (as opposed to “recurrent”), and is experienced by a quarter of all women, the vast majority of whom will go on to bear healthy children.

  In my case, it likely wasn’t random at all but due to a whole host of factors that we had yet to discover. Neither was it to be a “one-off” event, as my doctor had assumed.

  * * *

  I. Doctors in the United Kingdom are referred to as Mr., Mrs., or Ms., as the case may be, rather than Dr., unless they have a PhD.

  A journey of a thousand miles begins with a single step.

  Lao Tzu

  5

  Baby Steps

  Minimally Invasive Treatment

  It was a new world order now. As my country back home marched its way to an invasion of Afghanistan in the fall of 2001, I set my mind on those things within some semblance of my control. The task now was not just getting pregnant—it was staying pregnant. And I couldn’t get pregnant soon enough. The doctors told me to wait three months before trying again. It seemed like forever. Friends I had grown up with, studied with, and worked with were getting pregnant, and it didn’t help my mental state that I suddenly seemed to be getting invited to baby showers or first birthday parties on a regular basis. My pregnant colleague, Susan, who was now a close friend, grew bigger and more beautiful each week. Her due date was a week before what had been my own. I was genuinely happy for her and her husband. But I feared I would not be able to get through the birth of their baby without unbearable sadness.

  When allowed to restart my efforts, I approached the task of getting pregnant with the zeal of the type A lawyer that I was. Encouraged by Susan, I was now in the care of her doctor, the affable and ever-so-handsome Mr. Jeffrey Braithwaite, also on the famed Harley Street in London. A bit of a cross between Hugh Grant and Colin Firth, he made visits to his office as comforting as reading a Jane Austen novel. As I sat in the Wedgwood blue chair in the elegant wood-paneled reception room, I smiled to myself thinking how pleased my mother would be; she had, after all, named me after Elizabeth Bennett.

  Not yet as convinced as I that there was something very wrong, at the start, Mr. Braithwaite was confident we would succeed together. The course of action he proposed was similar to the original course set by my first gynecologist in DC; the only difference was in timing. Because my period had never returned after my first miscarriage, Mr. Braithwaite decided to induce a cycle with norethisterone (a synthetic progestogen) and then begin Clomid, but his plan was for me to start the Clomid on day two of my cycle, continuing until day six, in contrast with the previous schedule of days five through nine of each cycle. Mr. Braithwaite felt that merely switching to days two through six of my cycle would produce a better result, which it did. Fortunately for me, he believed 150 mg was a bit excessive, and suggested we start at 100 mg to reduce my unbearable headaches.

  It was Nove
mber again, Thanksgiving upon us, when I restarted the Clomid. I couldn’t shake the feeling that I had lost a whole year in the blink of an eye. Dreading the side effects, I was determined that this time I would at least learn more about my cycle. Susan had given me a book, Taking Charge of Your Fertility, which became my bible. It explained so many mysteries of the human female body. How had I made it through high school and college and graduate school and law school and not learned any of this? The book was fascinating. One of its prime directives was for every woman to learn her own cycle through charting. Charting required me to take my basal body temperature every morning as soon as I woke up and to pay careful attention to my body and its relationship to what was going on in my life. Every day, I meticulously wrote down the time that I woke up, my body temperature, the state of my cervical fluid, and anything else that was going on that might be relevant—travel, exercise, illness, stress, alcohol, anything that might affect my cycle. Essentially Bridget Jones’s diary if Bridget were trying to get pregnant. The theory was that this charting would help illuminate the timing of my ovulation (essential information in the quest to get pregnant) and would also help to detect a pregnancy at the earliest possible moment through identifying changes in body temperature. Charting became an obsession for me, and an annoyance for Richard. For charting brought with it the demise of carefree, spontaneous sex.

  I was still using my Baby Computer, and the fact that the two sets of information coincided very nicely every month reinforced my belief and confidence in both. Mr. Braithwaite, on the other hand, didn’t place much faith in either. He placed far more stock in the ultrasound machine in his office that he used to scan my ovaries to look for growing follicles, starting about a week into my cycle and continuing every other day or every third day until ovulation. The triple-feedback loop further built my confidence in the Computer, which was infallible in indicating my ovulation, as well as my belief that I would soon be pregnant.

  One thing that most doctors fail to warn patients about is the toll that all these baby-making attempts will take on their romantic lives. When going to all the trouble, not to mention the expense, of taking Clomid or other superovulatory drugs, a couple cannot afford to be cavalier with their sex life. Intercourse must be carefully timed and sometimes rationed. Sex now has a purpose, and no shot at having a baby should be squandered. It took a long time for Richard to adjust to our new reality of sex as dictated by my ob-gyn. “I need you home Tuesday and Thursday this week, period,” are not the romantic words most husbands dream of hearing.

  Miraculously, thankfully, joyfully, it all worked on the third cycle. On February 5, 2002, I happily discovered I was pregnant again. Just six days later, one day before my ill-fated first due date, Susan and her husband, Rob, welcomed their beautiful baby Isabelle at The Portland. I went to see them and their new baby that afternoon. Isabelle was absolutely breathtaking. Susan looked exhausted but radiant, her smile peaking through her shiny black hair as she bent down to hand Isabelle to Rob. Clichéd as it may sound, Rob was beaming, his eyes sparkling as he gently lifted her tiny fingers, one by one. I was relieved to find that I was genuinely happy for them. And they were as thrilled—and I suspect, thankful—as I was that I was pregnant again.

  Five weeks later, filled with a strange blend of excitement and dread, Richard and I went for our first ultrasound to see the baby and hear the little pulsing heartbeat, which can usually be picked up at around five or six weeks after conception. As Mr. Braithwaite began the scan, the gray fuzz starting to take shape, his expression became as still as the screen. Although Richard had no idea, I knew right away. There was no heartbeat.

  It was my second miscarriage—or missed abortion—in less than six months.

  * * *

  After waiting the requisite three months, Mr. Braithwaite was ready to plunge back in. Clomid, cycle charting, ultrasound scans, Baby Computer, acupuncture. We did everything “right,” but this time there was no pregnancy.

  By New Year’s, even the eternally optimistic Mr. Braithwaite agreed that it was time to move on to intrauterine insemination (IUI). After three harrowing Clomid plus IUI cycles (including an exhausting and stressful 5:00 a.m. trip to Heathrow Airport with my husband so he could produce a “sample” in the restroom at the optimal moment, followed by my frantic rush back to my fertility clinic by train and taxi to get the precious vial there in time), like the vast majority of others trying to conceive with IUI, I was not pregnant.

  Intrauterine Insemination

  If sex on a schedule seems a romantic buzzkill, it feels downright utopian when instead a father-to-be is reduced to producing his contribution in a cup in a private room filled with girlie magazines, while his female partner lies on a table with her feet in stirrups. Welcome to the world of intrauterine insemination, or IUI, also known colloquially as artificial insemination, the first step into the world of assisted reproductive technology.

  When Clomid and superovulatory drugs alone fail to produce a baby, the vast majority of fertility specialists turn to IUI, largely because it is the least invasive and usually the least expensive form of assisted reproductive technology (ART).1

  The relatively low cost reflects the fact that IUI is a fairly simple procedure. IUI is almost always used in conjunction with ovulation stimulation (Clomid or superovulatory drugs) and close monitoring. The insemination will be scheduled twenty-four to thirty-six hours after the LH surge that indicates ovulation is about to occur (either naturally or more often, following a trigger shot). On the day of insemination, the hopeful dad (i.e., sperm provider) will preferably go to the lab or clinic to produce a fresh semen sample, which will then be washed and processed, separating the strongest and fastest swimmers from the rest. It doesn’t always go according to plan though. I’ve spoken with women whose partners have obtained their samples in restaurants, offices, and Starbucks restrooms, wherever he needed to be during the fifteen- to thirty-minute window the doctor specified. When timing is everything, there are few hurdles one won’t jump through to get the goods to the lab on time. After the sample is prepared, the star sperm are inserted into the womb through a catheter, in a relatively quick and painless procedure.

  While IUI is financially the only option available to many, unfortunately, it is also among the least successful of the procedures, with a success rate according to some studies of as low as 10 percent per cycle, even among women under thirty-five. According to Resolve: The National Infertility Organization, many studies have shown that the use of IUI in women older than forty, even when paired with Clomid, does not improve pregnancy rates over not doing anything at all. Similarly, in the case of women who do not ovulate regularly, compared to intercourse, IUI does not improve the chance of pregnancy. Recognizing its failure to significantly improve pregnancy rates, the British National Institute for Health and Care Excellence (NICE) no longer recommends IUI for women with unexplained infertility or for male infertility problems, unlike in the United States, where IUI is still seen as appropriate treatment. To the contrary, IUI is only recommended in the United Kingdom in very specific cases such as sperm donation, where a physical problem prevents intercourse, or when a parent is attempting to prevent passing on a communicable disease.

  I spoke with dozens of women who were experiencing fertility problems and turned to IUI. Only one had a baby to show for it.

  Once you put human life in human hands, you have started on a slippery slope that knows no boundaries.

  Leon Kass

  6

  The Big Guns

  Moving on to IVF

  Apprehensive, although also a bit excited, I went off to see Mr. P, the fertility specialist recommended by Mr. Braithwaite. Although just down the road, Mr. P’s office lacked the warmth I had grown accustomed to. The image Mr. P projected—with his carefully balanced combination of Hermès tie, Montblanc pen, office full of Louis IV furniture, and of course, the Porsche 911 out front—reinforced my misconception that financial success must correlate with
fertility success. After a very brief conversation, Mr. P told me that he thought IVF was “the only route for me.” He suggested, however, that prior to beginning my first cycle, I go for testing at the world renowned Recurrent Miscarriage Clinic at St. Mary’s Hospital for further investigation and to rule out potential complications. Of course, as with all things fertility related, despite being armed with a reference letter implying a sense of urgency, I had to wait months for my appointment.

  I had never heard of antiphospholipid syndrome before the day I was diagnosed with it by Mr. Raj Rai during our first visit to the Recurrent Miscarriage Clinic. This time, I had insisted that Richard cancel a business trip so that he could come with me. The wait had made me so tense I was afraid I wouldn’t be able to think straight or retain the salient information. It hadn’t occurred to me that I wouldn’t even understand the words. I repeated after Mr. Rai, “antiphospholipid syndrome,” which he proceeded to tell me was a fancy word for blood clots. I had a condition in which my blood clotted too much, and this was associated with higher rates of miscarriage. Brilliant, as they say in England. We had an answer, again. As with the charming doctor who performed my first D&C, I begged him to be my doctor. But no, he could only pass along treatment recommendations and assure me that he was optimistic that our next pregnancy would be successful without further need of him. He warmly shook our hands as he offered to summarize his diagnosis and recommended course of action in a letter to Mr. P, and then bade us farewell.