—

It’s only as an adult that I’ve come to understand the chain of events that led to my second surgery and how the stakes got so high. Piecing things together only happened after several long afternoons on my hands and knees, sifting through my medical records on the floor and trying to understand their contents. I’d emerge dizzy from doctor notes and jargon I could barely comprehend. One day, I called the hospital where I’d had my first surgery. I was pleasantly surprised to learn they still had my records—seventeen years after the fact—and would be happy to mail them to me. My college’s health center had kept my records, too; they emailed a copy to me when I asked. Looking them over, I noticed that the nurse who prescribed the Pill to me that day had made a note about the fact that I only had one ovary, but I don’t remember us talking about my girlhood surgery. It didn’t occur to me at the time to ask her to describe in detail the connection between ovaries and birth control. But I wish the nurse had mentioned, even briefly, that the Pill did other things besides prevent pregnancy.

Now, of course, I’m clear: The pill I swallow each morning prevents most cysts from growing too large or even existing at all. And so for women concerned about troublesome ovarian cysts, birth control pills are extremely helpful. In my case, having only one ovary makes the Pill’s risk-reduction power especially important. My doctors agree, and they’ve explained that I need to stay on the Pill until I am ready to become pregnant. I went back on it over a decade ago, almost immediately after my second surgery. These small pills are a daily reminder of my surgeries, my missing ovary, and my promising though uncertain fertility future.

But at the core of my complicated feelings is some degree of confusing self-blame. I realize that if I had lost my ovary—and with it, my ability to have biological children—it would have been at least partially my fault. I simply should have known better than to abruptly stop taking a prescribed medication without consulting a doctor (who hopefully would have consulted my chart or asked about any surgical history and advised me well—though there’s no guarantee that would have happened). My surgeries were the result of much that was out of my control. And yet. I should have known something, anything, about how hormones work, about my ovaries—the one I’d lost and the one I’d kept. Something, anything, about the basics of birth control. It’s my body, after all. As a woman, as an educated medical consumer, I should have known better. In hindsight, chucking that pack of pills in the trash was reckless. But I have sympathy for this younger me. How could she have known if she didn’t know what to ask, and whom?

—

Messing with my hormones and birth control pills had consequences. If there is a moral to my story, it’s that. Not every woman has such a complex saga when it comes to her ovaries. But many have a muddled relationship with birth control, a personal story about going on or off hormonal contraceptives. A gruesome IUD insertion story. Getting pregnant despite having a contraceptive implant. Being prescribed the Pill as a teenager to make painful periods more bearable. Finally getting off the Pill and feeling so much better.

My story is just one extreme example of how surprisingly little women know about birth control. Whether or not a woman uses hormonal contraception, and whether or not she wants to have children, understanding how hormones regulate her body and impact her fertility is important.

Pills and patches and rings—oh my. There are so many ways a woman can suppress her reproductive system. Here’s a non-exhaustive list of the myriad contraceptive methods women use (some being much more common these days than others):

Surgical sterilization procedures: tubal ligation (tying, clipping, or blocking a woman’s fallopian tubes) and partial or total tubal removal (completely taking out the fallopian tubes)[*10]

Fertility awareness–based methods (more on these in chapter 6)

Oral contraceptives (broadly known as the Pill)

Intrauterine device, or IUD (two types: hormonal and non-hormonal)

Patch: a thin beige square that looks like a bandage and is adhered to the skin; it delivers hormones and is changed once a week

Shot: a progestin injection once every three months

Implant: a plastic rod the size of a matchstick that contains progestin, is placed under the skin in the upper arm, is invisible, and typically lasts three years

Vaginal ring: a small, flexible piece of latex-free plastic that delivers hormones and is inserted into the vagina once a month

Spermicide: products that work by killing sperm and are placed in the vagina just before sex; come in several forms (creams, gels, suppositories, and more)

Diaphragm: a flexible, shallow, saucer-shaped cup (typically made of silicone) that’s inserted in the vagina before sex; reusable; must be used with spermicide

Cervical cap: a deep, bowl-shaped silicone cup (smaller than a diaphragm) that’s inserted into the vagina and fits snugly over the cervix; reusable; must be used with spermicide

Sponge: a small round piece of thick, soft plastic foam that’s inserted in the vagina before sex; disposable; must be used with spermicide

Female condom (also called internal condom): a small nitrile (synthetic rubber) pouch that’s inserted in the vagina before sex

As for available birth control options for men, there are three: condom, withdrawal[*11] (“pulling out,” which works until it doesn’t), and surgical sterilization (vasectomy).[*12]

About 65 percent of reproductive-age women in the United States use contraception. Interestingly, four in ten women also use contraception for reasons other than avoiding pregnancy, such as managing a medical condition or preventing STIs. The most common birth control methods are ones that rely on hormones—the Pill and long-acting reversible contraceptives (the IUD, patch, implant, shot, and vaginal ring)—as well as male condoms and female or male sterilization. Besides surgical sterilization, the Pill is the most widely used form of birth control in the United States, but the IUD is increasingly popular, as well as one of the most effective contraceptive methods on the planet. The idea of being on little to no hormones is what makes the IUD such an appealing alternative to the Pill for so many women; more than six million women in the United States have IUDs. It’s a T-shaped piece of plastic, about an inch long, that’s inserted into the uterus. There are two kinds. The hormonal IUD—Mirena is the most common—releases a type of progestin into the uterus; the device stays in a woman’s body for about eight years. The non-hormonal IUD, called Paragard, is effective for about ten years; it’s often referred to simply as “the copper IUD” because of the copper wrapped around the T-shaped flexible plastic. Sperm, as it happens, don’t like copper; Paragard’s copper ions change the way sperm cells move so they can’t swim to an egg.

Despite their prevalence, we don’t talk much about why hormonal contraceptive methods make many of the hundreds of millions of women around the world who use them feel crummy. That’s partly because we don’t know a whole lot about their myriad psychological and behavioral effects.[*13] Hormonal contraception is known, however, to precipitate or perpetuate mood disorders, including depression, in some women. And, in addition to its impact on a woman’s mental state, hormonal birth control—estrogen-containing oral contraceptives, in particular—is associated with a few more serious health risks, including breast cancer, blood clots, and strokes. Less serious but more common are spotting, headaches, acne, and cramps. Needless to say, these aren’t inconsequential side effects. Not that women are complaining. The less serious but still unpleasant side effects are sure more manageable than an unplanned pregnancy. I once saw a meme that put it like this: “Birth control be like well do u want depression or do u want a baby” and, honestly, that just about sums it up.

When a woman freezes her eggs, she injects fertility drugs that generally work like the body’s natural hormones that command ovulation. It’s these pricey hormone shots that run the entire operation. Most reproductive technologies rely on the ability to manipulate hormones, and it’s this ability that also makes it possible to have this totally new, but increasingly mainstream, conversation about egg freezing and fertility preservation. Consider, for a moment, just how incredible it is to be able to regulate your fertility. What was once a story about contraception and prevention, about Sanger and her fellow birth control revolutionaries, is now a story about intervention—and about more. More eggs, more control, more time.

Remy: Handle with Care

A few weeks after her egg freezing orientation, a box of fertility medications arrived on Remy’s doorstep. FedEx, overnight from Florida. Red Fragile, handle with care stickers on every side. The package happened to come just as Remy was getting home from an overnight shift—which was lucky, since a few of the medications needed to be refrigerated right away. She thanked the delivery person and, yawning, fished for her keys in her bag. Her long blond hair hung in a low messy ponytail, her moss-colored eyes smudged with mascara she’d hastily applied fourteen hours earlier.

Remy was ready to start. She’d tossed and turned the past several nights, her mind racing with possible scenarios of how the whole freezing procedure might go. Thinking through logistics usually calmed her, but there were too many unknowns right now to feel good about the process. Anticipating how she was going to manage fitting in the daily shots during her upcoming weeks of night shifts at the hospital was activating her brain’s control-freak wiring. Walking into her house, though, soothed her, as it usually did. Remy had begun to nest as soon as she moved in, intent on making the small one-story house feel cozy. Now it felt like her bohemian sanctuary. Shoes stacked neatly in the cubby by the door. Peloton in the office, in front of her framed diplomas. White shag rug. Small bottles of essential oils. Several sets of blue scrubs in a chair, neatly folded. A gigantic wall calendar made of glass, covered in writing from dry-erase markers: Injection Day 7 scrawled in red, Egg Retrieval Day! marked with hearts, squares labeled Bills and Budget off to the side.

She carried the box to her kitchen and opened it, pulling out the contents item by item: vials of fertility drugs, pills in orange bottles, ice packs, syringes, alcohol swabs, needles, a red sharps container, and a receipt. For most women freezing their eggs, the sight of these medical supplies could be daunting. For Remy, though, the wow factor was zero. Still, there had been a bit of a learning curve, getting clear on the medications and how exactly she’d be injecting them into her body.

With the arrival of the fertility meds, egg freezing suddenly felt more real than ever. Remy already thought of her eggs as her future babies. Maybe it was her faith in the universe talking instead of her faith in medicine, but a few weeks earlier, when a pregnant patient asked Remy if she had kids herself, Remy had replied: “Not yet—but they’re getting frozen shortly.” Blond, blue-eyed babes, she hoped they’d be. She even had names picked out.

The sound of birds chirping outside the window above the kitchen sink meant it was past time for her to be in bed. She opened the fridge and pushed aside a few things to make room for the egg freezing drugs and, one by one, carefully placed the cardboard boxes of meds inside. On the counter, she arranged the non-refrigerated meds alongside the syringes, alcohol swabs, and sharps container, and surrounded the pile with four small crystals—black, light green, orange, purple. Gotta let these meds marinate, she thought. Her injections were here. She was nervous—but so excited.

Skip Notes

*1 Name has been changed.

*2 Meaning “intramuscular,” referring to a shot administered directly into a muscle.

*3 Sedation options can vary depending on the clinic and the resources available to them. In some cases, stronger medications are used to create a deeper level of sedation, including up to general anesthesia.

*4 Along with producing hormones and nurturing the developing egg, granulosa cells play a role in deciding which eggs live, which die, and which are ovulated.

*5 The orchestra’s other sections: the liver, skin, immune system, kidney, heart, lungs, and muscles.

*6 For more on this remarkable feedback loop of intercellular communication involving the brain, eggs, and ovaries—and for a fascinating exploration of female anatomy in general—I highly recommend the book Vagina Obscura by Rachel E. Gross, in which she describes the ovary as being, beyond just a basket of eggs, “a crackling network of communication, alive with signals that pass back and forth between follicles.”

*7 It does not, however, affect a woman’s fertility long-term. That’s a myth—a pervasive one, I’ve found. While it makes sense that many women believe that years and years of being on the Pill and suppressing their ability to conceive would, surely, have some sort of enduring impact on their fertility once they stop taking it—it doesn’t. Using hormonal contraception, regardless of the type or duration, does not have a negative effect on a woman’s ability to get pregnant after she stops using it. Among the many large studies on this topic, one that looked at almost nine thousand planned pregnancies found that those who had never used oral contraceptives (birth control pills) conceived at the same rates as those who had used oral contraceptives for five years or more.

*8 The body’s natural forms of estrogen and progesterone make the uterus a hospitable place to grow a fetus; the synthetic forms of these hormones override the system, doing the opposite.

*9 Placebo pills—part of some but not all regimens—are placeholders; the idea is that if a woman stays in the habit of taking a pill every day, she’ll be less likely to forget when she needs to take the real thing. Even though she’s taking placebo pills, she’s still protected against pregnancy as long as she’s been taking the active pills as prescribed. Some women opt to go on a continuous-cycle birth control pill and skip placebo pills and having a light, fake period altogether.

*10 I was surprised to learn that female sterilization is the most popular birth control method for women—more popular than the Pill, even—both in the United States and worldwide. For most women who opt to have their fallopian tubes tied to prevent pregnancy, they’ve had all the children they want to have.

*11 There’s a lot of room for error with “coitus interruptus,” aka the withdrawal method, when a man withdraws his penis before ejaculating. It is not as effective at preventing pregnancy as most other forms of birth control; about one in five people who rely on the withdrawal method for birth control becomes pregnant. It also doesn’t protect against STIs.

*12 Researchers have created a birth control pill for male mice, which proved 99 percent effective in preventing pregnancy, but experts say male birth control pills won’t be available anytime soon. An injectable hydrogel that’s marketed as “the IUD for men” recently completed clinical trials.

*13 But we do know that many women struggle to find any form of hormonal birth control that they’re happy with and often stay on hormonal birth control despite the way it makes them feel.

5 Why Women Freeze

Egg Freezing Appointment #2

Like many people, I’ve spent much of my adult life trying not to get pregnant. And like a lot of people with uteruses, I’ve long been nervous about it happening accidentally. But at the same time, I’ve been anxious about the fact that I’m not certain I can have biological children, since I’ve never been or tried to become pregnant—and the only true test of fertility is conceiving a baby. I’m aware of this continual contradiction: I want to protect my ovary, but I do not want to let it do what it was made for. Not now, anyway. These connected yet contrary worries have troubled me for more than a decade.

A memory: It’s the middle of the night, the summer after college. I wake suddenly and sit up in bed, clutching my side, the cramp sharp and hot. I’m twenty-two and halfway across the world, traveling through Sri Lanka with my boyfriend of six months. We’re in a house on the outskirts of Colombo. He’s asleep next to me, his feet pushing against the mosquito net. I sit up, reach around for my headlamp, then slip out of bed and walk barefoot into the bathroom, where I swallow a couple of over-the-counter pain pills. In the kitchen, I put the kettle on for tea and boot up our laptop. My surgeries have left me hypersensitive and somewhat distrusting of my body; for me, pain is often indicative of a deeper problem. I’ve had cramps for the past two days but don’t know if they are related to my cycle on the Pill or if they are the less frequent but more painful cramps caused by the scar tissue that has built up since my first surgery.