“I totally masturbated in high school and I lied to my boyfriend about it,” said another girl, in jeans and a black top. “I was like, ‘No, only you. You’re the best.’ ” Around the table, eyes rolled.
On the topic of reproductive angst, several of the young women shared that they hadn’t ever had a pap smear, and a few had never been to the gynecologist—a fact that caused me to blurt out, “Wait, seriously?” even though I was trying to sit and mostly listen without interjecting.
Almost everyone at the table had a specific reason for believing her fertility had somehow been compromised—because of an eating disorder, or years running track and field, or Accutane (a strong drug used to treat acne), or PCOS, or fragile X syndrome (a genetic condition), or months in a row of missed periods. “I don’t even know if I’m fertile,” said Alexis, looking down at her hands. “Like, because I’m so reckless. I make bad decisions in terms of sex. I stopped taking birth control because I’m not good at taking medication. And I don’t remember the last time I used a condom with someone that I was seeing on the regular. So, I don’t know. I’m on a non-plan plan, I guess.”
“I’m going to put this out there,” a girl named Michelle said suddenly. She wore a pink blouse and nervously played with her dark hair. “I’ve had an abortion.”
At first, the table fell silent. And then:
“I have, too.”
“Me, too.”
“Yeah. Same.”
A few others murmured affirmatively, their eyes cast downward at the table.
Michelle shared her story of having an abortion at fifteen weeks. When she described walking into Planned Parenthood wearing a sweatshirt with the hood pulled up over her head, she began to cry. The girls looked at Michelle, then among one another. “There were old ladies literally throwing paper balls at me,” she said, referring to protesters who often stand outside abortion clinics and harass women entering them. I looked around and saw expressions of sad recognition on almost every face. It turned out that more than half of the group had had an abortion, and while their experiences were not all as harrowing as Michelle’s, they shared worries that the procedure had somehow impacted their ability to give birth in the future. When I asked why, no one could articulate why their concern felt as real as it did.[*5]
Even a couple of the women in the group who had already given birth to healthy babies were concerned about their fertility. For years, twenty-five-year-old Stefanie and her partner did not use protection while having sex. After a while, Stefanie assumed she was infertile. “It got to a point where I was like, ‘Oh, I can’t get pregnant,’ ” she said, leaning back in her chair. “It would have happened by now.” But it did; her son had just turned one. Still, she says, “I know I obviously can have a baby. But we didn’t happen to get pregnant until after three years of having unprotected sex. So I don’t know how long it’s going to take when I actually want to try to have a kid.” Kayla, another mother in the group, said that her first doctor’s appointment after getting pregnant at age twenty-six felt like a sit-down interview. The way the doctor phrased her questions made Kayla feel the need to defend her decision to keep the baby. At the same time, the doctor’s gentle probing gave Kayla pause. “I thought to myself, ‘Am I worthy of having a child right now?’ ” she said. Like Stefanie, Kayla and her partner did not use contraception. “I knew better, but I just got comfortable. We’d been together for eight years by the time I got pregnant.”
Am I worthy of having a child right now? Later, I’d consider Kayla’s choice of words, reflecting on the value judgments often wrapped up in young women’s perception of motherhood, as if having a baby is something one must earn and deserve. At the same time, not using birth control suggested a flippant attitude toward the possibility of pregnancy, a shrug at what could happen. It was a confusing juxtaposition, and normally I would have asked a challenging follow-up question or two. But at the time, Roe v. Wade was still in effect, and as our discussion came to an end, a certain tenderness hung in the air, so I chose not to press the point any further. I felt a kind of quiet kinship with these women, I realized, and wondered if that made me a less-than reporter, if it compromised my purported objectivity in some way. It was becoming more difficult to compartmentalize my work as a journalist from my work being a woman.
To me, the most striking aspect of our informal discussion was the young women’s shared frustration about the lack of open dialogue around so many topics related to sex, fertility, and reproductive choices. And not just with family members or sexual partners, but among their peers and friends. The conversation that evening wasn’t the first time those women had been confronted with this deficiency, but collectively airing their frustrations cracked something open. When the talk shifted to abortion and the women who’d had one shared their experiences, I saw a real catharsis happening. Shame was replaced with solidarity, and the feeling of acknowledgment and you’re not alone that played out at the dining room table was heartening to witness.
The Knowledge Gap
One winter night a few months into our relationship, Ben and I shared ravioli and a basket of bread at an Italian restaurant in Brooklyn. I picked at the red-and-white checkered tablecloth as I relayed details of my second surgery: the familiar pain I’d felt in my side, the doctors plunging their hands between my legs, the deep fear. I tried to keep my tone even and unemotional; after all, I was fine now, wasn’t I? But I felt compelled to explain how important this all felt to me. Still.
Ben listened, eyes wide. I couldn’t quite tell how much he was grasping; most men I explained my surgeries to—women, too, for that matter—began squirming at “transvaginal ultrasound” and “ovarian torsion,” which I’d take as my cue to wrap up quickly. As I talked, Ben sat very still, a look of concerned compassion on his face. “Do you think about these things when we’re having sex?” he asked when I’d finished, his voice quiet but not shy. I looked down at my hands, twisting my thumb ring, not sure how to answer.
My adolescence, that tender time of puberty and growing into one’s body, had been bookended by medical emergencies starring my ovaries. Ben’s question spurred flashes of memories from the years between and after those traumas: painful recollections of when my body felt as if it didn’t belong to me; moments that left me feeling exposed, alone, gone away. My list is long, my stories not particularly unique. Operations. Instances of sexual violence. Being the subject of medical studies, when I was just out of college and in need of cash, for which I received paltry amounts of money. A physician prying me open like a clamshell; a stranger forcing himself on me; a boyfriend’s hands on the back of my head while I was going down on him, pushing deeper without asking me first until I gagged. The truth was, from adolescence to my mid-twenties, my understanding of my body was marked by a sense of things being done to me. Those experiences no longer defined my relationship with my body, but they did—do—inform it.
But I wasn’t ready to tell Ben any of this. “No, not really,” I finally answered, my heart still in my throat. Ben hesitated before he spoke. “Because I don’t want to mess anything up,” he said. “I don’t want to hurt you.”
—
The sit-down conversation with the young women and my attempts to talk with Ben more vulnerably about my past medical traumas stirred familiar frustrated feelings about young women’s collective ignorance. Knowledge is power, and in the particular situations described by the women with whom I’d spoken, they had had little of either. The same had been true for me at various points in my teens and twenties. But it went deeper. At first I thought the knowledge problem centered around the troubling fact I’d learned about how college-age women are only cursorily informed about their cycles. But then I had to add the realities of age-related fertility decline to the list, as well as the basics about hormones, once I’d learned that most young women know very little about the birth control pills they swallow, the IUDs they have inserted, the reproductive parts they may rely on one day to have a child.
The issue was not merely what we weren’t taught or told but what came to exist in the vacuum. The implications of all this not knowing extended to an entire new chapter of obliviousness or misguidance when women reached their thirties. Sex ed was long gone, dusty and mostly unhelpful as it faded in the rearview mirror. Now the vast bubble of ignorance and silence centered around fertility—around two troubling facts in particular. One, too many women have unrealistic expectations about how long their bodies can biologically bear children. And two, too many women don’t understand fertility until they learn they no longer have it.
—
Like Will before he met Kati, I didn’t learn about fertile windows until well into adulthood. A woman can only get pregnant on the day she ovulates: false. A woman can get pregnant all the time: also false. The more I learned about ovulation and hormones, the more I realized that my newly gained knowledge about a woman’s ability to get pregnant meant untangling myths and misconceptions I’d long believed to be true.
Also like Will, I woke up to how little I knew when I first thumbed through Taking Charge of Your Fertility. The book is clear and comprehensive, but also warm and approachable. I’ve dog-eared the pages and scribbled question marks and exclamation points in the margins. There are pictures and helpful diagrams and straightforward, easy-to-understand explanations for incredibly complex things. My copy was a gift from my mother after I began writing this book, many years after the American Girl book. She inscribed this one, too. Dear Natalie, her familiar, comforting cursive reads. I’ve had this book a few days now, and yesterday, I set it out to write a note before giving it to you. Last night I dreamed I was breastfeeding my baby girl! I certainly must have “fertility” on my mind. Use this book to enhance your knowledge. Use the knowledge you gain to be a better informed, and more relaxed, mother-to-be. I have not a doubt in the world that you will be a mother…and a great mother. I’m so happy to be your mother.
It was becoming clearer to me now that my relationship to my body was not separate from my decision about egg freezing. The broader truth was this: How women learn or do not learn about the basics informs if and when they learn about fertility and circumstances impacting their reproductive futures. One of the common frustrations voiced by women over the years, doctors told me, is that they wish they had known how much egg quantity and egg quality matter—and they wish they’d learned this earlier, before they found themselves seeking fertility treatment in their late thirties and early forties. Doctors I spoke with also confirmed what I had heard anecdotally to be true: that many women undergoing egg freezing wish they’d realized earlier how big a role age plays in the ability to conceive, instead of looking to celebrities having babies in their mid- to late forties—often through donor eggs, surrogates, or gestational carriers, though their ART interventions usually go unmentioned—to guide their sense of what’s possible.
It’s not just younger women who are in the dark. It’s common for women in their forties to blithely assume they can get pregnant, merely because they feel young and healthy. It’s an easy trap to fall into. Women think that because we are looking younger and living longer, the expiration of our eggs should be extended, too. But as I discussed in chapter 3, the realities of a woman’s fertility have mostly remained unchanged; in this area of life, thirty is definitely not the new twenty.
Okay, so by this point I’d come to terms with the social and personal reasons women are procreating later in life. I’d learned about the sex ed we never got and begun to grapple with the long-term implications of Not Knowing. But what to do about the pesky problem of biology? Try as we might to ignore or discount it, this biological truth is not easily swept under the rug. ASRM’s Ethics Committee reminds us: “Older female age increases the risk of inability to conceive due to reduced oocyte quantity and quality, with increased chromosomal abnormalities leading to more fetal abnormalities and pregnancy losses.” Translated: As the years accrue, fertility diminishes. Healthy eggs are hard to come by. Miscarriages and babies born with developmental issues become more common.
“Fertility meant nothing to us in our twenties; it was something to be secured in the dungeon and left there to molder,” writes Ariel Levy in The Rules Do Not Apply, her memoir about the loss of her pregnancy, partner, and home. “In our early thirties, we remembered it existed and wondered if we should check on it, and then—abruptly, horrifyingly—it became urgent: Somebody find that dragon! It was time to rouse it, get it ready for action. But the beast had not grown stronger during the decades of hibernation. By the time we tried to wake it, the dragon was weakened, wizened. Old.”
Her words were a warning. Coupled with the words of NYU bioethicist Arthur Caplan that I quoted before—there is this notion that you can get pregnant whenever you want, the technology is here, we’ve got the answers, it’s in your control—they haunted me. For educated, middle-class women, the list of things in life we can control and succeed at is long and growing. We live in an aspirational age; very little today ever slows down or de-escalates. It should come as no surprise that the message as we get older is that fertility is something we ought to be controlling—preserving, protecting, investing in. And infertility, then, is in many ways the ultimate loss of control.
“We lived in a world where we had control of so much,” Levy continues. “Anything seemed possible if you had ingenuity, money, and tenacity. But the body doesn’t play by those rules.” And so we intervene before our bodies can betray us. Deploy technology to not only command but enhance our reproductive systems, what and when they will produce. Capitalize on the scientific advancements that have made it possible to exponentially expand our ovaries’ capacity to generate eggs, thereby improving our chances of having a biological baby only when we are ready, completely or at least mostly on our own terms. Take action now to mitigate against loss of control down the road. These are the solutions women are encouraged to embrace. The nature of the game has changed, and the savvy among us will realize we no longer have to shrug and accept our bodies skirting the rules.
At least that’s what our can-do society is promising us.
Egg Freezing Up Close
I had gotten some clarity on the basics, and why I hadn’t known what I didn’t know until now. The next step, it seemed to me, was to learn more about the mysterious technology that my fertility doctor and the physicians at the EggBanxx event all spoke of as being the solution to the hard-to-get-around biology problem. And to better understand the whole process, I needed to see egg freezing in action.
I paid a visit to a lab belonging to Extend Fertility, a boutique egg freezing clinic in midtown Manhattan. On a snowy winter day, I hurried along West 57th Street to watch an embryologist demonstrate the actual technique of freezing a woman’s eggs. It was my first time visiting a fertility clinic as a reporter rather than a patient, but the potential egg freezing customer in me took note of Extend Fertility’s warm and inviting vibe, the orchids at the reception counter, the sunny, window-filled consultation rooms. Privacy rules prevented me from watching a patient have her eggs retrieved, but Leslie Ramirez, an embryologist and the company’s assistant director of its embryology laboratory at that time, offered to walk me through a sped-up demonstration of the process.
Most of the conversation around egg freezing centers around the several days of hormone injections and the day of the egg retrieval. But while the day a woman’s eggs are retrieved is in many ways the end of her experience, the journey for her eggs is just beginning. The actual “egg freezing” part of egg freezing begins immediately after a woman’s eggs are no longer inside her body. Amid the hype surrounding the whole procedure, the all-important step of vitrification—the ultra-rapid cooling technique that significantly improves egg survival and pregnancy rates—tends to be overlooked.
A crucial component of egg freezing, the delicate process of vitrification occurs shortly after the retrieval. While the woman is waking up from anesthesia, her eggs are hand-delivered to the lab and placed in an incubator for a couple of hours. Then, an embryologist inspects the eggs under a microscope to determine which ones are mature before exposing the mature eggs to cryoprotectants, the chemicals that shield the eggs from the stresses of freezing and thawing. Next, the embryologist attaches a few eggs at a time to labeled plastic strips (each about the diameter of a piece of spaghetti), called straws, and dips them in liquid nitrogen, where they freeze almost instantly; all biological activity in the eggs, including aging, stops. Once the eggs are flash-frozen, the straws are attached to a longer piece of plastic, called a cane, and placed in a sealed tank that looks like a propane canister used for a barbecue grill. The storage tank, which has been filled with liquid nitrogen and maintains a temperature of –196 degrees Celsius (–320 degrees Fahrenheit), keeps the submerged eggs cold—and preserved indefinitely.
Decorative snowflakes on the embryology lab’s door matched the cobalt blue scrubs I had been instructed to change into. Ramirez gestured for me to come in. I pressed “record” on my phone and shoved it inside my waistband, hoping it wouldn’t slide down my pants leg and clank onto the white-tiled floor, then stepped inside, pulling the heavy metal door closed behind me. The brightly lit lab had the faintly metallic smell of hospital-grade disinfectant. High-powered microscopes sat beside micromanipulators that resembled videogame consoles and white machines with pink or blue labels that said things like TransferMan 4m and incubator c16. There were also custom air filters, designed specifically for an embryology lab like this one. Because eggs and embryos are exposed to open air when being transferred in and out of petri dishes, keeping the air as sterile and contaminant-free as possible is important; even a lab worker’s perfume can impact the quality and development of an embryo.
Ramirez, a thirtyish, petite, Mexican-born Harvard-trained scientist with a PhD in biotechnology, was looking down at a petri dish that sat on the counter. Inside the pool of clear liquid, she told me, lay two human eggs. I moved closer to get a better look, careful not to bump against any of the expensive-looking equipment. Most cells are too small to be seen without a microscope, but a human egg—0.1 millimeters in diameter, about as wide as a strand of hair and right at the level of visibility—can be seen with the naked eye, though it’s a lot easier to see a group of eggs than just one. I could just barely make out the minuscule eggs in the petri dish, each about the size of the period at the end of this sentence. “Ooh,” I exclaimed softly, looking up at Ramirez. She smiled back at me, then briskly returned to explaining. The liquid solution, or culture media, mimics the nutrient-rich environment the egg has in the female body while the embryologist inspects them to determine maturity. Usually, only mature, viable eggs—typically 75 percent of retrieved eggs—are frozen because they’re the ones that can be fertilized, hopefully, later on.[*6] The petri dish in front of me, labeled Discard in handwritten black capitals, held oocytes that had been extracted from a woman whose retrieval had yielded several mature eggs that had been successfully frozen. The patient had given permission for her leftover, unviable eggs to be used for training purposes.
Ramirez placed the dish on the stage of a microscope and, using a pipette, moved the eggs from their nutrient-rich bath into a different petri dish. The liquid solution in this dish is where the vitrification magic happens: In a series of chemical processes, the cryoprotectants in the solution draw out water from the eggs. On the monitor attached to the microscope—the image of one of the eggs blown up, making the action look more dramatic—I could see how it immediately shrank. In its dehydrated state, the egg, projected on the screen, resembled a small, shriveled pea. Then, the egg expanded again, as the cryoprotectant filled the cell. Almost instantly, the egg regained its normal, perfectly round shape. Ramirez stepped aside and motioned for me to look through the microscope’s eyepiece myself. A tank of liquid nitrogen hissed; a machine whirred and beeped. I squinted my eyes and peered into the petri dish at the tiny scraps of life it contained.
I once heard it explained that preserving eggs is akin to preserving the crystals of a snowflake—except the eggs are far more delicate and even more vulnerable. In the laboratory environment, as they are transferred from a woman’s ovaries to a plastic straw to inside a tank of liquid nitrogen, these smaller-than-small cells are incredibly sensitive to any variation in temperature. Fluctuations of a few degrees can destroy them. As I watched Ramirez demonstrate transporting and submerging eggs in their liquid nitrogen bath, the decorative snowflakes on the lab’s door caught my eye and I found myself smiling. A coincidence, a small irony, maybe, or both. I wasn’t sure I was firmly grasping what I was seeing—literally, a woman’s fertility put on ice—and what it meant. My last biology class was in eleventh grade, which was also the last time I fumbled around with a microscope. Back then, more or less pretending I knew what I was looking at and why it mattered amounted to a teenage shrug and an A-minus. But standing in the lab that day, wearing borrowed scrubs and scribbling unfamiliar words into my notebook, I couldn’t even pretend I possessed the robust scientific background required to understand the most intricate parts of egg freezing.
