The Fertility Diaries

The patient and I talk about the oddities of fertility. Over a lifetime, one womanmight have too much or not enough.

A sanurse practitioner, I help women negotiate fertility's many complex possibilities. One woman desires deeply to conceive, a wish that eludes her. Another finds herself unexpectedly pregnant. Yet another wants to have a child, but later, on her own terms. A woman might encounter any or all of these scenarios in a lifetime, and so fertility becomes a frustrating, elating, essential part of the dialogue between patient and caregiver. These portraits, each drawn from the experiences of many of my patients over my 25 years of practice, offer a glimpse into the varyingpaths that women take in deciding how to handle their own fertility.

"My husband and I have been trying for over a year." —ANNA

I t's so unfair," Anna says. "For most of my life, I've been trying not to get pregnant. Now that I want to, I can't."

Sitting on the exam table with a sheet wrapped around her, Anna, 29, seems anxious. She has thick blonde hair and an angular face. "My husband and I have been trying for over a year," she says, looking down and twisting her wedding band.

Although I've just met Anna, I'm not surprised by her straightforward manner. I see lots of women who struggle with infertility; most of them are emotionally exhausted, caught somewhere between hopelessness and blame, feeling they have no time to waste. Anna is trembling, evidence of how she must feel—like shattering into pieces.

"I'm glad you came into the clinic. Tell me about yourself," I say and sit on the chair nearest the exam table. Usually I don't begin with such an open—ended statement, but I want to hear Anna's story. I've learned that what a woman tells me about her life often reveals more than her symptoms or her chief complaint.

Anna had used the Pill for years, then stopped a few months before she and her husband, Jerry, started trying to become pregnant. She has now been off the Pill for almost two years. When I ask, she tells me that her marriage is fine, OK, but not as free as it was a year ago. She'd done all the responsible things: She started taking a daily multivitamin with folic acid to lessen the risk of a neural tube defect; she cut back on caffeine; she approached lovemaking with joy and anticipation. After six months, she and Jerry tried harder, and that brought a brittle edge to their conversations, to their relationship. Anna says they might be trying too hard now.

Although most medical studies say that stress shouldn't contribute to infertility, I'm not so sure. (And indeed, Alice Domar, Ph.D., a Harvard researcher, cites compelling evidence of an anxiety—infertility link in her book Conquering Infertility.) I've seen too many women juggle their lives—career, home, romance, social action—as if each activity were a flaming torch to be kept in motion. Infertility becomes one more thing to handle. At first, a woman is driven just by the simple desire to have a baby. Then it becomes complicated: the pressure to have sex, good sex, as if that might do it; questions from friends and family; questions people ask themselves but don't often say aloud. Is it my fault? What if we can't get pregnant? Sometimes, talking to patients about infertility, I almost feel guilty. I got pregnant easily, without a thought; I didn't realize the emotional impact of infertility until I began working in the clinic. Listening to Anna, I can't help but believe stress makes this difficult situation worse.

Anna tells me that her cycle, from the first day of one period to the first day of the next, is 29 days, like clockwork. Before each period, she has cramps and breast tenderness, signs of the hormonal shifts that accompany ovulation. She had read that most women with regular cycles ovulate about 14 days before the start of their next period, so she'd tried to catch those few days before ovulation when the chance of pregnancy increases to 30 percent.

"I always assumed I'd just get pregnant," she says. "The worst thing is, every time I turn around, one of my friends is announcing she's pregnant." The thought of this now brings Anna to tears.

It's humbling how quickly, in the quiet space of the exam room, a woman unveils herself. Women who can't conceive are often fragile, even angry, and Anna is no different. All around her, the world is in bloom. "When I go for a walk, all I see are other women wheeling carriages," she says. Even nature betrays the infertile woman. Spring arrives; everything ripens. Sometimes, unaware of the intricacies of fertility, a woman blames herself when pregnancy escapes her.

I put my hand on Anna's arm and tell her that in the United States, 15 to 20 percent of couples are infertile. The cause might be either a male or female factor. In fact, we always begin our workup with an examination of the partner's semen. In—fertility results from a problem with low or ineffective sperm as often as 40 percent of the time. Although infertility treatment can be humiliating, invasive and inconvenient, Anna is eager to begin the process. We agree to start with a physical to make sure her general health is good—a pelvic exam, Pap and cultures (to rule out cervical cancer and infection). She says she'll talk to Jerry about bringing in a semen specimen for analysis."I'll do anything to get pregnant,"Anna says.

I've seen women endure a multitude of tests, all the while clinging to the image of the child who might someday be theirs. Anna may require hysterosalpingography, an X—ray test to make sure her tubes are open. She might also need laparoscopy, an examination done through small incisions in the abdomen, during which a doctor checks the uterus, tubes and ovaries for adhesions or endometriosis (when the tissue that lines the uterus deposits itself elsewhere in the pelvis).

"What's the bottom line?" Anna asks. I feel her becoming more determined, and more frightened, with every question.

"Twenty percent of the time, no cause for infertility can be found," I explain. "Ultimately, you may have to take fertility drugs, have serial ultrasounds to determine when you're ovulating and have artificial insemination.

"I tell Anna I can offer her initial infertility testing, but once we see those results, she'll need to consult a specialist. Anna has the best chance of pregnancy if, after basic testing, she seeks the care of experts. I wish I could go on the journey with her. It's times like these that remind me of the dual nature of my role as a nurse practitioner: I'm privileged to share important moments in my patients' lives, but sometimes, my best gift is to urge them to seek a specialist's counsel and help them feel confident that they're making the right decision.

As I conduct the physical, Anna and I talk about the oddities of fertility, how a woman might have too much or not enough. We laugh a little. She doesn't ask me and I don't tell her that I've had three pregnancies. Two normal, healthy, easy deliveries. One miscarriage at five months, a loss that's haunted me, off and on, since it happened almost 30 years ago. I'm thankful for my pregnancies, even for the miscarriage. When my patients grieve for the children they don't have, I remember, and that awareness makes me a better caregiver.

I've developed a certain instinct about patients, a fluttering intuition that rises up, unbidden. I have a good feeling about Anna. Though I keep it to myself, I sense that she will return, round—bellied and smiling. I think, even if pregnancy eludes her, she will find a child to care for and then she will be a fierce and loving mother. For now, we will do her tests, wait for the results and do what we can to make Anna's hopes come true.

"I have three grown children already. I can't have another baby." —ELAINE

Elaine has been my patient for eight years. We've been through some hard times—her depression after her divorce, a mass in her breast that turned out to be benign. But, when I last saw Elaine, things were good. She'd been with her new boyfriend for two years, and her three teenage children were healthy, her oldest son off to college."I can't believe it," she says to me. "I've never forgotten to take the Pill. Never. I'm 41 years old. I can't have another baby." Her eyes are light brown, with the bright, direct gaze of a woman who has been weeping. A few creases etch her forehead. She rests her hand low on her belly and says she's here to discuss terminating her newly discovered pregnancy.

From the outside—from the picket line—the issue of abortion seems well defined, easy to approve or condemn. But I see how this issue changes people from the inside. I've seen staunchly anti—choice fathers bring their 13—year—old daughters in for pregnancy termination. I've seen women who are devoted mothers choose not to bring another child into the world.

Elaine starts to cry again when I begin to ask the series of questions clinic protocol requires me to ask: Is she firm in her decision to terminate? Has she considered carrying the baby to term and offering it for adoption? Has she thought about obtaining financial help, having the baby and taking it home? I ask these necessary questions with kindness.

"I'm going to terminate," she says. "I'm just devastated. I did everything I could to avoid pregnancy."

This is something that many people don't understand: It's possible to use birth control regularly and still become pregnant. It's also possible, although very unusual, to conceive without vaginal penetration, from semen deposited on the thigh or even the belly. In the United States, half of all pregnancies are unplanned.

Whenever a woman cannot, for whatever reason, continue a pregnancy, I discuss not only the technicalities of abortion but also the emotions surrounding it. I've done so ever since one patient, weeks after her abortion, complained to me: "No one told me I would be grieving ."

In Japan, statues called mizuko jizo stand outside Buddhist temples. Women who have experienced miscarriage or abortion tend these tiny stone babies; the mizuko jizo allow them to acknowledge their sorrow. Often, we caregivers don't recognize that women who end their pregnancies might feel that, because they have chosen to terminate, they don't have the right to mourn or that these feelings are a luxury they haven't earned. I believe that each woman experiences loss in her own way, and each has the right to lament.

After I've ticked off the list of risks associated with abor—tion (uterine perforation, bleeding, infection), I ask Elaine the difficult question.

"How do you think you'll deal with this loss?"

She looks shocked. For a moment, I worry that I've been too intrusive. Maybe I shouldn't have asked. I'm not a therapist, after all. Then again, if I don't ask, maybe no one ever will.

When she doesn't answer, I rephrase the question. "How can I help you?"

"Thank you," she says then, "for recognizing that, even though I've made this decision, I can still be sad."

I take her hand.

"I want to know what a seven—week pregnancy looks like," she says.

Elaine is not the first to ask me this. Some women want to identify the size and shape of their sorrow.

"At this stage, male and female embryos are indistinguishable," I say. "There are no eyelids or external ear structures." Although we date pregnancy from the last period, calling Elaine seven weeks, it's actually five weeks since fertilization. As I talk, I watch Elaine's face, trying to judge her reaction. I know I'm creating an image that she will carry in her mind's eye. I've also learned that there is only a word or two between just enough information and too much.

Elaine is not naive or coy. She is examining her options, from all angles, as if the answer were something she could turn over in her hand and hold up to the light. Like most women, she does not make this decision lightly. After her exam, she makes an appointment to return for an abortion in three days.

Elaine looks at me and says, "I already have three grown children. I'm choosing the living over the potential."

"I want my body to be ready when I am." —BETH

Beth, a new patient, is 33, a successful woman with her own small company, a long—term partner and a strong desire to have kids—on her own schedule. She's here to find out how she might successfully delay pregnancy.

"I'm totally confused by this big controversy," she says. "I read one book that says you'd better have your kids while you're young. Then I read an article that says it's OK to wait. I'm on the Pill and I don't want to get pregnant now. But I also don't want to hurt my chances later."

I think of Anna, who trusted that her body would be ready when she was. I think of Elaine, whose birth control failed her.

"I'm not sure I can guarantee anything when it comes to fertility," I say. In the clinic, I've seen both sides of the "When should I have my baby?" debate: women who've had successful pregnancies in their 40s as well as older mothers—to—be whose pregnancies were complicated by genetic abnormalities.

"No pressure here!" Beth says with a laugh.

She tells me she plans to stop taking the Pill when she's 36. Once, five years ago, when she forgot a few pills, she and her current boyfriend had an unexpected pregnancy that ended in miscarriage. I know how common this is—15 to 20 percent of all conceptions end in miscarriage—and once a woman has had a miscarriage, fear of recurrence lingers.

Today, as never before, women face the task of balancing waiting long enough with not waiting too long.

"Could that happen again?" she asks.

"Miscarriage is fairly common," I say. "Sometimes a pregnancy is lost early, during the first 14 days. A woman might be a little late, then have a heavy period and never know she was pregnant. If a woman has several miscarriages in a row, then we'd begin an extensive evaluation".

Beth is healthy, with normal Paps, no sexually transmitted infections, no surgeries and no family history of genetic disorders. But she smokes, drinks socially and, occasionally, takes sleeping medication—all habits that might adversely affect a pregnancy. I also learn that her boyfriend occasionally smokes pot; for some men, smoking marijuana or cigarettes can interfere with sperm production and efficiency. But what I'm most concerned about is her advancing age.

"Over age 35, the chance of having a baby with genetic abnormalities is increased significantly," I explain. "The risk of abnormalities associated with chromosomes increases with age. The risk of a fetus having these abnormalities jumps from about 1 in 400 when the mother is 35 to about 1 in 250 when the mother is 37." I want Beth to have the facts, but I also want her to understand that there are good screening tests available: detailed ultrasounds, a blood test that calculates individual risk, and more definitive procedures, like amniocentesis or chorionic villous sampling, a first—trimester procedure in which a tiny sample of placental tissue is obtained through the cervix and evaluated for genetic abnormality.

"My mother says I'll be sorry I waited. I'm not, but I do want my body to be ready when I am," Beth says. Then, confidence fading slightly, she asks, "Is it safe for me to stay on the Pill?"

Once Beth is 35, if she's still smoking while on the Pill, she will be at higher risk for stroke and heart attack. If she conceives and can't stop smoking, she'll increase her risk that the fetus could die before delivery, even very late in the pregnancy, or that the baby would have developmental delays.

"Could I switch from the Pill to the injection?" she asks. "I've read it only contains one hormone, progesterone, and no estrogen."

"Well, unlike the Pill," I tell her, "when you stop the injection, your cycles may not return to normal for months..."

"And that could delay pregnancy further, right?"

"Possibly."

Beth is silent, then says, "What should I do?"

Like many patients, she has come to me for the answers, as if I could plan her future as neatly as she plans a business strategy. I try to balance medical knowledge with support, always aware of the shifting boundary between patient and caregiver. I can't decide Beth's course; I can only give her advice based on statistics and experience. But I also know there are other things that enter into our decision making: timing, chance, habit, human vulnerability.

"I see lots of women who have healthy babies after age 35," I tell Beth. "It seems to relieve some anxiety if a couple decides, beforehand, how to approach a pregnancy. You and your partner might want to talk about the screening tests and decide if you'd want them. You could meet with a genetic counselor to go over family history and talk about age—related risks. You can also prepare for pregnancy now by staying healthy".

Today, as never before, women face the intricate task of balancing waiting long enough with not waiting too long. We have tests and medications that can help us avoid pregnancy or achieve it safely. Yet our fertility remains what it's always been: a shape—shifting entity, an unwelcome guest, an unrealized dream, a blessing. Whatever it is, it's ours. Some days, we might ignore it. Other days, it might change our lives.

Cortney Davis is the author of I Knew a Woman: Four Women Patients and Their Female Caregiver (Ballantine Books).