By Belle Boggs
In February our tap water still smelled of chlorine tablets disinfecting the well we drilled the month before, giving our tiny house the damp, close feel of an indoor public pool. I was running load after load of white laundry, trying to flush out the chemicals, when the UPS driver arrived with my first shipment of IVF medication. I signed for the three large cardboard boxes, marked PERISHABLE OPEN UPON RECEIPT. They were surprisingly light, like props, and I waved off the driver’s offer of help and carried them inside.
After the truck was gone, I sliced open each box to find rounded Styrofoam coolers and frozen gel packs protecting my cartons of Lupron, Follistim, and Menopur. I set the medicine, the syringes, the sharps container, and the alcohol swabs on my kitchen table: more shots than my body had ever received, more medicine than I had ever taken. I photographed the eleven cartons of drugs, the three sizes of needles, the pages-long lists of instructions and precautions; then I put them all away where I wouldn’t have to see them.
The phrase my doctor uses to describe the way IVF works is take over—We’ll take over your whole cycle, he told me enthusiastically. As in, Don’t worry about your short luteal phase, your thin uterine lining, or predicting when you might ovulate. Your body will not be trusted to perform any of its biological tasks. We will do it all for you. To you.
On YouTube, if you search for “Follistim injection” or “Lupron injection,” you’ll get hundreds of results, most of them recorded by women in treatment for infertility. This is useful for new patients, like me, who have never self-administered shots, and some of the videos have thousands of views. The injections are given in kitchens and living rooms and dining rooms, in front of bathroom mirrors, sometimes by the women themselves and sometimes by their partners. Before starting IVF I watched dozens of these videos, not to learn to do my own injections but to feel a kind of kinship with these women as they tap their syringes free of air bubbles, swab their bellies, and hold the needle at just the right angle. In the backgrounds of the videos I watched were the messy signs of daily life you might find anywhere—piles of mail on the table, a television left on, houseplants growing toward a window—but there was a formality to their voices as they slowly narrated each step.
My husband, Richard, injected me between six and seven every evening. Preparing the injections—measuring and mixing the medication, drawing the solutions into the needle, tapping out the air bubbles—took about twenty minutes, and during that time our kitchen table was cluttered with papers, boxes, vials, and syringes. He spread out the instructions from our clinic each time, watched the online tutorial, checked and double-checked the amounts before saying, “Okay, ready?” As with the well drilling, there was an element of excess and surrender to this experience that felt unfamiliar and frightening, but it was too late to turn back.
I’d turn my head as soon as he swabbed my stomach with alcohol, biting into a piece of dark chocolate—a trick I learned from a friend, another woman who never imagined conception this way. The shots didn’t take long; I’d feel the needle pierce my skin, then a stinging, and then it was over. Each one left a pink mark that quickly faded, and sometimes a small, faint bruise. Afterward I’d look for the injection sites under a strong light, even though it was too early to know what was happening beneath the skin.
It is not just the takeover of your body that makes IVF so challenging, but the takeover of your schedule, your life. Every-other-morning appointments, waiting by the phone for news about the results of blood draws, timing injections precisely, ordering more medication or procuring discounted or free leftovers from women finished with their cycles: it all takes time. While Richard came to every appointment and performed every injection, I knew that if he had a sudden work emergency, he would be able to step away. Infertility was our problem together, but it was my body being treated, my body that had to attend every appointment and accept the shots. I handed over my insurance card. I ordered the medicine and dealt with the pharmacy and changed my workout routine. I was dimly aware that if I became pregnant, this imbalance would still exist, and would become even more pronounced with a breastfed newborn.
More than my body and my schedule, it took over my mind. I was always thinking of my possible pregnancy or looking out for superstitious tricks to bring it about. I watched the clock for 11:11, walked until I found good-luck clovers, prayed though I don’t believe in God. I was always desirous and worried, never at peace. If it didn’t work, we’d have more tries: six at most, three using fresh embryos and three with frozen embryos, if there were any left over from our other cycles. And if those didn’t work—what then?
I tried not to think of what then.
Few studies have examined the effects of involuntary childlessness after medical treatment, but some psychologists have suggested that the myriad treatment options make it difficult for women to know when to stop. If Clomid doesn’t work, maybe your ovaries will be more receptive to Femara. Or maybe you need an injectable gonadotropin and estrogen patches? If one IVF protocol fails, there are others, and if those fail too, you can try donor egg or surrogacy, provided you can pay the increasingly hefty bills. There is also the choice of clinics—a woman in Raleigh might interview doctors at four different practices; a New Yorker could see more than a dozen.
The availability of choices is known to decrease our happiness: gathering the information necessary to select among a range of options creates a sometimes paralyzing anxiety, and once we’ve chosen, we are prone to second-guessing and remorse. Reproductive medicine presents a twist to the choice paradox: while in treatment, patients report feeling hopeful, even excited, but each treatment cycle is just a few weeks long. Even the most advanced and expensive treatments offer a poor success rate: a thirty-five-year-old woman, on average, has a 31 percent chance of having a baby through a single IVF cycle. If unsuccessful, she must decide: try again? Try something new?
The abundance of options also makes it more likely that she will blame herself, fearing that she has made the wrong choice or has taken too long to settle on the right one. Though I heard women in my support group state firmly that after the next cycle, they’d be done, studies of women who have completed unsuccessful courses of treatment suggest otherwise. The desire for a biological child does not fade into ambivalence or deepen into wise acceptance, post-treatment: it only grows stronger.
The nurses at my fertility clinic were gentle, but my veins were small, or they rolled to the side, or my blood pressure was too low. Kim, my favorite, humored me as I swung my arms to increase my heart rate, and still it took several tries to get a good stick. Kim was monitoring my estradiol, a measure of the estrogen secreted by my ovarian follicles. In an unmedicated cycle a woman might produce 200–300 pg/mL of estradiol from a single mature follicle. Thanks to my daily injections, I was superovulating, and we were waiting for my estradiol to rise above 2,000 before triggering ovulation.
In the afternoons I waited for her phone call, when she’d tell me the result and whether I should adjust the dosage of my medication. Everything about my cycle was artificial and controlled, from the follicle-stimulating hormones that swelled my ovaries to the shot of human chorionic gonadotropin that would complete the maturation and time the release of my eggs so that the doctor could aspirate them into a hollow needle. Even the meeting of egg and sperm would be assisted by a doctor’s steady hands—our embryologist would select “the fastest, strongest, best swimmers” and inject one into each mature oocyte.
In the exam room, I opened to a fresh page in my notebook and lay back on the table as the doctor stretched a condom over the transvaginal ultrasound transducer. “You’ll feel my touch,” all of the nurses and some of the doctors would say before touching me. “Some pressure,” they’d say, before turning the transducer’s wand to the left or the right.
Everything that touched me, as gentle and respectful as the nurses and doctors were, was nevertheless heavy with symbolic, perhaps inaccurate, meaning. The wand was a symbol of control and power; lying prone, feet in stirrups, I was the picture of submission. Watching the black-and-white images of an ultrasound machine, Richard and I were hopeful future parents. I wrote down the thickness of my endometrial lining (6 mm) and the approximate sizes of the six follicles on my right ovary (ranging from 11 to 12.5 mm), the four on my left (10 to 12.7 mm). The numbers meant little to me in real terms, but I knew from scanning message boards until my eyes burned that they were reassuring.
By the time Kim took my blood for a final estradiol level, a few days later, there was scar tissue on my veins. Even this was a metaphor, for the addiction I feared would take hold once we started down the path of assisted reproduction. One more cycle, one more treatment, until all our money and emotional resources were spent.
On the morning of our last scheduled ultrasound, my estradiol was 2,248 pg/mL, and a doctor I’d seen only once or twice, known in our support group for her brisk bedside manner, counted ten large follicles. This would be a win for most of the women on the message board, but I worried it wouldn’t be enough. The doctor said things looked “good” but didn’t elaborate. We were given precise written instructions about how to measure out the hCG injection that will mature my eggs so they can be retrieved. “Pay attention,” she said, tapping the page as if we might be daydreaming.
Two mornings later, the day of our retrieval, it was raining and cold. We arrived at 7:45am with a plate of cookies for the staff and were led to a part of the clinic we’d never seen before, which looked reassuringly medical—more like the presurgical area of a hospital than a hotel. They gave me a gown to change into, and a nurse named Lenora attached my IV. It took her three tries to find a vein; I turned my head while she searched, and didn’t complain.
A few minutes later I was clutching my gown closed behind me, wheeling my IV to the retrieval room. It was very much like the image I feared for years—a long hallway, all the doors closed, with IVF at the end. But I was far from alone, and it didn’t feel routine or workaday or cold. Kim helped me onto the table. Dr. Young was there, and Dr. Ramos, the effusive Brazilian embryologist I interviewed when we first seriously considered IVF, greeted me with a jaunty wave that morning. Richard waited just one room away; he’d be there to help me back into my clothes and drive me home. I lay down, counted backward, and fell asleep.
Michelle, our embryologist, called with news the next morning—of the thirteen eggs they retrieved, eleven were mature and ten fertilized. She told me they wouldn’t check the embryos again until day three, when I could choose to transfer or to wait until day five. I recorded this in my notebook, then went for a walk by the river and found four four-leaf clovers. I saw a bald eagle perched in the huge pine tree across from our neighborhood easement, near her nest. I recorded these things too, and pressed a single clover into the notebook.
Richard and I had a phone conference with Dr. Young two days after the retrieval. The standard number of embryos transferred by someone my age was two, but I was eligible, Dr. Young mentioned, to transfer three. We told him about our desire to transfer a single embryo, a choice made then, at our clinic, by only 3 percent of patients in my age bracket. We wanted to avoid the risk of twins—not so much of twin car seats and double strollers and double college tuition bills, but the risk to my body, the risk to the fetuses carried within.
Waiting until day five would make it clearer which of the embryos was most “competent,” or likely to develop normally. Not every embryo makes it to day five—some divide perfectly, into round morulas on day four and complex blastulas on day five—but others short-circuit somehow, dividing unevenly or stopping division entirely. Waiting would allow us to choose the best one, I insisted to Dr. Young, who countered that my uterus—part of the reproductive system he spent weeks taking over—was actually the best place for the embryos, which was why most women my age chose to transfer two embryos on day three. Their natural environment, I think he said. Richard scribbled notes in red pen on plain white paper, but he didn’t write this part down.
Dr. Young had a formula: if three times as many embryos as we wished to transfer (for us, that meant three competent embryos) were developing normally on day three, we could wait.
Here is what I wrote down when Michelle called on day three:
4 look perfect
4 look almost perfect
1 has 1 slightly bigger cell but is appropriately celled
1 is 5-cell (may make it to blast on day 6)
I wondered which one they would transfer. I wished I could see photographs. I wished they could do all their development inside the laboratory, which I had come to trust more than my body.
Our bodies are miracles is a message most often given to two groups of people: children entering puberty and women preparing for childbirth. It makes sense to lie to children facing years of bodily inconvenience (monthly bleeding, wet dreams, unexpected erections) or to women facing many hours of agony, but evolutionary biology suggests that our bodies are not really the miracles we proclaim them to be but jury-rigged compromises.
On the day of transfer, Dr. Young brought us a photograph of the blastocyst they chose, “the prettiest one,” the embryologist reported, that she had seen all year. This handing over of image (or images, for women transferring two or more embryos) is part of the ritual of ART; if you get this far, it is the proof of what the takeover accomplished, the closest thing to those fetal ultrasounds posted to fridges and Facebook pages. I wasn’t sure how I would feel looking at a mass of cells in medium—let down? ambivalent? motherly? But I clung to the embryologist’s words; I wrote them down in my notebook before I even looked at the photograph. At the bottom of the image, he had written my last name and the date.
It was quiet enough to hear the humming of machines, and there was a strange formality as Dr. Young read my name aloud—an oddly low-tech precaution, given our circumstances. I held as still as I could while he threaded a thin catheter past my cervix. Kim, standing next to me, pressed an ultrasound wand into my stomach so he could select just the right spot. There was a spark of light on the monitor.
“There it is!” said Dr. Young. “Your embryo.”
Richard and I squeezed hands. Nothing about this experience had been what we expected when we thought of having children, or even when we first guessed that the road to parenthood might be a long one. It was more uncomfortable and expensive than we imagined, and less private—there were three other people in the room with us, plus family and friends who would want to know, in less than two weeks, if our IVF was successful.
Then the doctor, the nurse, and the embryologist all left, and it was just us: two people who might never have met, had these struggles, and made this embryo. A clock ticked on the wall, but we knew that no one would rush us. Though we were usually talkative with each other, even in examination rooms with my feet in stirrups, a shyness and reserve came over us as we considered the seriousness of what we’d done. We might have a baby in nine months, or more choices to make. For now we waited, again.
Abridged excerpt from “Takeover” © 2016 by Belle Boggs. Reprinted from The Art of Waiting: On Fertility, Medicine, and Motherhood with the permission of Graywolf Press, Minneapolis, Minnesota. All rights reserved. www.graywolfpress.org.
Belle Boggs is the author of Mattaponi Queen, a collection of linked stories set along Virginia’s Mattaponi River, and The Art of Waiting: On Fertility, Medicine, and Motherhood. Mattaponi Queen won the Bakeless Prize, the Library of Virginia Literary Award, and was a finalist for the 2010 Frank O’Connor International Short Story Award. The Art of Waiting was a finalist for the PEN/Diamonstein-Spielvogel Award for the Art of the Essay and was named a best book of 2016 by Kirkus, Publishers Weekly, the Globe and Mail, Buzzfeed, and O the Oprah Magazine. Boggs’s work has been supported by fellowships from the National Endowment for the Arts, the North Carolina Arts Council, the Bread Loaf Writers’ Conference, and the Sewanee Writers’ Conference. Her stories and essays have appeared in The Paris Review, Harper’s, Guernica, the Oxford American, Slate, Orion, Ecotone, and other publications. She teaches in the MFA program at North Carolina State University.
IVF embryo testing, by Emma Bell
This essay is part of a Motherwell original series on Motherhood and Waiting.