Battling the biological clock

NEW YORK—On a recent Thursday evening in SoHo—an upscale neighborhood in lower Manhattan, New York City—young women packed a reception room at the ritzy Nomad Hotel, fresh from work and dressed sharply. Servers brought glasses of sparkling white wine and tiny appetizers, cheese pastry puffs and hamachi on rice crisps.

A sign outside the room with a woman raising her arms in triumph read, “Smart women freeze!” On tables literature proclaimed, “Break free from your biological clock.”

Eggbanxx, a network of egg-freezing fertility clinics, organized this happy hour event, as it does in major cities in the United States every few months to encourage women to freeze their eggs. That way, the women can wait to have children until later via in vitro fertilization (IVF).

In career-driven Manhattan, women often wait until well into their 30s. Double strollers filled with twins, often a result of IVF, are a common sight. The fertility industry boom in Manhattan is likely to move out to the rest of the country as more and more women delay child bearing because of career or later marriage, and as the various technologies like IVF become more available.

The first IVF clinic opened in the United States in 1983, but only in the last decade has the practice become mainstream. Few consider the ethical problems and high failure rates of IVF and other assisted reproductive technologies until they are in the throes of infertility and desperate for a child.

From 2000 to 2012, the rate of 35- to 39-year-old women having their first child rose 24 percent nationwide, and 40 percent in New York, according to the Centers for Disease Control & Prevention. Over the same period that “first birth rate” rose by 35 percent among women aged 40 to 44. According to the CDC’s latest report, women gave birth to 67,996 babies in 2013 as a result of in vitro cycles.

In New York, a fertility boom is underway for those who have money for the expensive IVF process: In 2013, TriBeCa, one of the wealthiest neighborhoods in the city, had one of the city’s highest birthrates. That same year, the highest rates of multiple births occurred in wealthy neighborhoods, and among women over 40, which the department of health said “is likely attributable to more frequent use of assisted reproductive technology.”

A few of the 100 or so women at the SoHo happy hour had on wedding rings, but most women I met were single and in their late 20s like me. Several had recently gone through breakups and were discouraged about meeting a partner in time to have children naturally. A few representatives from a genetic testing company chatted with the women.

One of the doctors at the gathering said the women she sees for freezing are younger and younger. That’s the fertility clinics’ goal: The younger women are when they harvest their eggs, the higher the quality of the eggs, which boosts the clinics’ success rates when they fertilize the eggs and implant them via IVF.

Fertility doctors in cocktail dresses mingled and answered questions. Egg harvesting, and IVF, are physically intense processes for women and have low success rates. IVF has a 28 percent success rate in the United States, with success defined as live births per IVF cycle. Egg freezing is still a relatively new technology with low success rates, but the fertility doctors argued that new freezing and thawing methods were increasing their success.

A few women talking afterward expressed reservations about the cost: Through Eggbanxx, two cycles of egg harvesting costs $13,000. Then egg storage costs, at a minimum, $500 a year. Then women would need to go through IVF to use the eggs, another few thousand dollars per cycle.

“We hope you’re empowered,” said Dr. Fahimeh Sasan, the chief medical officer at Eggbanxx and an OB/GYN at Mt. Sinai Hospital in New York.

“It’s such false hope,” said Chris White, the director of research and education at the Center for Bioethics and Culture (CBC), a nonreligious group. CBC does not outright oppose IVF but thinks women should be informed of its low rates of success and the health risks to the mother and the child. CBC does oppose involving donors or surrogates in the reproduction process.

Hank Greely, a law professor at Stanford University who directs the school’s Center for Law and Biosciences, gave a talk in 2014 titled “The End of Sex,” in which he argued that sex would be used less and less as a means of procreation, and that in the next 40 years most babies in wealthy nations would be born via IVF. “The biological clock could even disappear,” he said, according to the Duke Chronicle.

As more and more couples turn to fertility treatments, few couples consider ethics or the physical and emotional costs. IVF can create complicated legal situations: In California, a divorced couple is currently fighting over the custody of their five frozen embryos. The mother, Dr. Mimi Lee, wants to keep the embryos alive and have the children through a surrogate. She’s infertile and 46 years old. The father, Stephen Findley, wants the embryos destroyed. Courts have few precedents on such cases.

Christian bioethicists and couples who have gone through IVF are arguing that the church should speak about infertility more as it becomes more of an issue, and that infertility should be a topic in premarital counseling. Few Protestant denominations take a position on assisted reproduction technologies like IVF.

CARSON AND KATE ROYAL married in their mid-20s and then found out they were infertile after a year of trying to have children. Following counsel with their parents and their pastor in Chattanooga, Tenn., they decided to try IVF. They now have three boys through IVF, a 5-year-old and twin 3-year-olds.

After the Royals did their first round of IVF, which resulted in a pregnancy, some of their acquaintances started questioning the ethics of the practice. Kate had thought her pastor and her parents’ endorsement was enough, but then realized they needed to ask more questions. Before the Royals did the next round of IVF, they met with Bill Davis, an ethicist at Memorial Hospital in Chattanooga.

In his day job, Davis is a professor of philosophy at Covenant College, the denominational school of the Presbyterian Church in America (PCA), but he’s also an ethics associate for Catholic Health Initiatives. The Catholic Church opposes IVF entirely on the grounds that babies should only be conceived in the marital act of sex. But Davis sketched out a Reformed approach to the technology for the Royals over an hour-long lunch.

“There are biblically permissive ways to make use of the technology,” Davis said later. “We have to be equipped to deal with the temptations to recklessness. But we do that with lots of other things.”

Fertilize only the eggs that you can implant, he tells couples. Implant only the embryos that you can safely carry to term. He recommends not freezing any embryos, but if you do, commit to implanting all the embryos you have. Don’t do selective reduction, the fertility euphemism for aborting an embryo if multiple implanted embryos develop into a pregnancy.

On introducing third parties into reproduction—sperm donors, egg donors, or surrogates to carry babies—Reformed theologians, Catholic leaders, and the Center for Bioethics and Culture generally agree: Nope.

“Once you’ve agreed on that principle, the only really hard part is to find a fertility specialist who’s willing to do it within the limits that you set,” said Davis. “And even within that you need to be persistent in asking questions.”

The reproductive endocrinologists at the clinic the Royals found in Chattanooga were accommodating, never suggesting selective reduction of their twins. Of the 10 embryos the Royals created and froze, they have five remaining after having three children. When we talked, Kate was about to go in for another embryo transfer.

“We decided we were going back to get all of our embryos even if it meant we were going to have 10 kids,” Kate said. “So that’s been the hard part at times, when you’re overwhelmed with three little boys—we’re going back and doing this five more times, six more times. But that’s something we decided we couldn’t get around. How do you put an embryo up for adoption when you have no guarantee that they’ll ever hear about Jesus?”

Kate and Carson told their doctor to treat each embryo “like this is our only shot.” Kate said some people will go back and have an embryo put in without taking all the right medications “just to kind of be done.” At her clinic, “They call things off if things aren’t perfect or close to perfect.”

Carson said the discussion about how to do IVF the right way amounted to three minutes of their hour-long lunch with Davis. The bulk of the time Davis spends with couples is counseling them through their sorrow. He tells the people he counsels, “The world is broken. It has a Redeemer. And between now and the full realization of that, the misery is not spread around equally.”

“I went to get answers about the ethics of it,” Carson said. “And I left feeling very cared for. … We’re hurting. In vitro is not easy.”

The church’s resources to address infertility appear to be mostly organic rather than official. The Royals didn’t know anyone who had done IVF when they started, and they recalled googling “infertility” and “PCA.” They found emotional support from their church friends, but it was awkward to talk about initially. Davis said most of the couples he counsels find him via word of mouth.

Sometimes years of IVF attempts never bring children. Pamela Mahoney Tsigdinos, the author of Silent Sorority, spent more than a decade doing fertility treatments, including IVF, without having any children. By age 39, she was emotionally, physically, and financially exhausted. She and her husband decided to stop trying. She says more people should be talking about the difficulty of fertility treatments like IVF and their low success rates.

“I really, truly felt like a lab experiment,” Tsigdinos said. “People are under the illusion that reproductive medicine is a sure thing.”

In Tsigdinos’ first meeting with a reproductive endocrinologist, the doctor recommended that she go straight to IVF. Tsigdinos likened that experience to having chest pains and a doctor immediately recommending open heart surgery.

“This has become the go-to procedure,” she said. “It completely turns your life upside down.”

Tsigdinos said clinics don’t prepare women for the “emotional gymnastics” of going through the motions of pregnancy on a regular basis. She recalled going in for an embryo transfer, only to receive a call from a nurse two weeks later saying she wasn’t pregnant. The embryo hadn’t survived, but the nurse’s response was, “Call next week if you’d like to schedule another cycle.”

Tsigdinos said women should seek advice from their primary care physicians or OB/GYNs, who have no commercial ties to fertility treatments. She urges couples to think through their boundaries before “you are emotionally under pressure.”

CBC’s White says questions about infertility should be a part of premarital counseling. Davis teaches bioethics courses at Covenant College, and he’s noticed that most students haven’t considered the question.

“My experience in trying to talk to younger people about it is they all assume it doesn’t happen to very many people, and it won’t happen to them,” Davis said. He tells them, “Twenty percent of couples will go at least 12 months of trying to conceive and not conceiving. So look around the room, one in five of you. Do not assume that’s not going to happen to you.”

How it works

The in vitro fertilization (IVF) process varies depending on the patient’s needs and approach. Generally, an IVF cycle starts with the woman taking daily hormone injections for a week or two before her monthly ovulation. The injections stimulate the follicles in her ovaries, so that she will create multiple eggs in that cycle instead of the usual one. During that time she must visit the doctor regularly for monitoring.

When the eggs are ready, the doctor will give the woman a shot that triggers ovulation. The next day the woman goes under anesthesia and the doctor surgically removes the eggs. The clinic will mix eggs with fresh sperm from the father, and the fertilized eggs will develop in a dish for the next several days. After a few days, the ones that survive and develop will either be placed in the woman’s uterus (what doctors call an embryo transfer) or be frozen. Then the couple will wait two weeks to do a pregnancy test.

“The discomfort burden is wildly disproportionate for the man and the wife,” said Covenant College’s Bill Davis (see main story). “Men need to think about that.” —E.B.

Emily Belz discusses her cover story on The World and Everything in It.