On Infertility, Definitions and Statistics, Part I
How does that work again? Some terms defined, explained, and stats shared
One of the themes of our journey with (in)fertility is how much there is to learn at absolutely every step of the process. I thought I knew a lot about reproductive health. I self-identify as a feminist, have a copy of “Women’s Bodies, Women’s Wisdom” on my bedside, and I’ve read it cover to cover for pete’s sake. And yet as we have waded into deeper water together, I find myself saying, “Wait, what?!” or “How does that work again?” Each step of this process has yielded its own learning. And even though some of that learning is specific to us (because all bodies are unique, and the interaction between two bodies even more so, and there’s no single path of diagnosis and treatment for (in)fertility), it feels important to share in case you or someone you know is quietly going through a hard thing in relative isolation. Years ago, I religiously read the blog of a college classmate who was experiencing infertility. This was before I’d even met Lucas. I couldn’t have told you why at the time, but I knew it was essential reading. So let’s get into it.
Roughly one in eight couples in the U.S. experience infertility. The number is closer to 15% globally. Someone you know is experiencing this. To start with, “infertility” is an umbrella term under which many factors fall. (Though actually, our clinic doesn’t even use that word. Instead, they are The University of Iowa Center for Advanced Reproductive Care. Advanced Reproductive Care is kinder and more holistic. It’s also a mouthful and an even bigger umbrella than infertility, so for the purposes of this essay, we’ll stick with infertility.)
Medically speaking, purely male-factor infertility accounts for roughly 20-30% of cases, purely female-factor for up to 50% of cases, and a combination of male-factor and female-factor infertility for 20-30% of cases. If you’re doing the math, you’ll notice that that adds up to more than 100% because in a very Rumsfeldian way, when it comes to infertility, you know what you know and you don’t know what you don’t know. You may have identified one factor that you’re treating for and there still may be unknown factors at play, you’ve just never gotten that far before. Infertility may be related to whether the acidity in the fluids in both bodies is compatible, to the number or motility of sperm, to endometriosis, to irregular ovulation or blocked fallopian tubes or competency of the cervix or a whole host of other factors. One couple experiencing infertility may easily become pregnant but struggle to carry a pregnancy to term. Another couple may have never shared the exhilaration of a positive pregnancy test.
I am almost ashamed to write this, but there was a season in which I envied women who had miscarried because at least they knew they could get pregnant. And I knew that statistically speaking, if you can get pregnant, even if you miscarry, you are more likely to carry a healthy pregnancy to term. This was also the season in which I doubted whether the language of infertility was really something we could claim because: what had we lost? There was a lot of quiet and denied grief during that season. I’ve learned and grown a lot since then.
As an aside, unless a couple offers the details of which factor(s) is/are at play for them, it’s not really info to inquire about. There’s stigma attached to it and shame can creep in when someone feels “at fault.” I really loved the perspective of an acupuncturist we were seeing for a while. He said “No one is to blame for not getting pregnant. It’s about getting your bodies and their juices in alignment and working together. Because it’s absolutely a together project.”
That said, regardless of what factors are at play, it is the female body that bears the brunt when it comes to fertility treatments. Just as it is the female body that does the heavy lifting in pregnancy. Regardless of what the factors are, the path forward is the same.
In order to qualify for infertility treatment, you don’t just have to be a geriatric case like me. (Any pregnancy carried over age 35 is considered a geriatric pregnancy. Not my favorite language.) You have to demonstrate that you have been “trying” for a year without success. What constitutes as “trying”? Regular intercourse during the likely ovulation window each month.
There are all sorts of strategies and products to help with identifying and tracking this window. Taking your basal body temperature at the same time each morning. (For most women, body temperature is lower the first half of their cycle and will go up after ovulating. If they become pregnant, it will stay up. If they menstruate, it will drop and the cycle starts again.) This strategy is not helpful for identifying when ovulation is coming, but it’s helpful to know it’s happened.
To anticipate ovulation, you might get into tracking your cervical mucus or you might use a period tracker app to get a view of your global trends (know the privacy info of any app you use!) or you might get ovulation test strips. We landed on ovulation test strips. These are pee strips that you use at a regular time each day that give you information about a spike in luteinizing hormone. When the luteinizing hormone spikes, your body is preparing to ovulate within 36 hours. This means you’re entering an ideal window for sex with a higher likelihood of fertilization. That is, if you can read the dang pee strips. Maybe because I hydrate so well, I always struggled to read the test versus the control. To the point that for a season I had a yellow tablet with weeks’ worth of old-dry-peed-on ovulation test strips taped to it to see if I was any more confident reading them when one day sat right next to another. If, after a year of “trying,” there’s no pregnancy, you get referred to a specialist for next steps.
Steps like a semen analysis. What do sperm numbers and motility look like? Steps like a vaginal ultrasound to count follicles. How many egg repositories are there on each ovary? Steps like a hysterosalpingogram. This is an x-ray test using contrast dye to outline the internal shape of the uterus and see if the fallopian tubes are blocked. After all these tests, there are more known knowns and fewer unknown unknowns.
At this point in the process, we were referred for IUI. Intrauterine insemination. In the past, I have referred to this procedure as one step up from a turkey baster. Compared to other potential fertility treatments, IUI is relatively low cost and low tech. Though it does include a stepped up, doctor specified ovulation test kit. No more eye-balling lines on test strips. Digital read gives you either a smiley face or an empty circle. Very little chance for user error. It may also include medication to ensure ovulation.
At different points in our treatment, I was prescribed both Clomid (clomiphene) and Femara (letrozole). These are drugs taken at the very beginning of your cycle to trick your body into thinking you have less estrogen so your pituitary gland will up the production of FSH (follicle stimulating hormone) and LH (luteinizing hormone) that can contribute to the production of a mature egg at ovulation. The few days of each month I spent on these drugs were not my favorite. Femara (which, incidentally, is primarily used to treat breast cancer) gave me at least one day each month with terrible thoughts that didn’t belong to me. I was miserable. The world was ending. And I knew that it was all thanks to the drug. Clomid was mostly fine. But when my dose was increased, I spent a day with lightheadedness and full-body shakes while writing a sermon. I literally had to speak to myself out loud, saying things like, You can do it. You’re almost finished. When you’re done you can rest.
After those experiences, and when we realized that I was ovulating pretty regularly on my own, we set aside the medications for our other IUI attempts. Then, instead of briefly grieving on day one of my cycle, calling the pharmacy on day two, and starting a prescription on day three, we could decide more in the moment whether this was a cycle that made sense to try IUI.
It still required plenty of us. I’d start peeing on test strips around day ten of my cycle. It couldn’t be first morning urine, but it needed to be before noon, and it was preferable if it was at a regular time each day. Super convenient. I definitely spent staff meeting breaks in single stall restrooms waiting to see if I got a smiley face or an empty circle. And set timers on my phone to remind me to run up to my office and grab the test for a quick bathroom stop between services on Sunday mornings. It was super weird to be surreptitiously doing this thing that had so much bearing on our future in the midst of everyday life. And it wasn’t exactly that I wanted to be talking to people about it. It was just another level of my everyday reality that most people didn’t know about.
That simple act of peeing on the test strip also felt weirdly loaded. A smiley face meant my body was doing what it was supposed to. Hormones were spiking. Ovulation was coming. Pregnancy was a real possibility. An empty circle felt…ominous. Even when I knew ovulation was still likely days away. Each day with an empty circle felt like a failure. No smile today. What’s my body doing? Just another empty circle. Empty like my womb. This may seem dramatic. And maybe it is. But conceiving life is dramatic. We were and are living the question of whether that could be a possibility for us each day.
Once the smiley face showed up, I put a call into our clinic. The surge in luteinizing hormone is time sensitive, so they wanted to see me the next day. We’d schedule an IUI for as early in the morning as possible. Lucas would provide his semen sample in a sterile cup provided by the clinic. They wanted it within 30 minutes of ejaculation and not more than an hour before my procedure was scheduled. Keeping it close to body heat was also a positive. Before the procedure, the clinic ran the semen through a wash and centrifuge process that concentrated the number and quality of sperm. Once complete, the prepared sperm was placed into a catheter. At procedure time, that catheter was threaded through the cervix and the sperm inseminated right into the uterus (intrauterine insemination). With less distance to travel, it had a higher likelihood of fertilizing the egg that would be descending the fallopian tube in the next 12 hours. But still, as the nurse at my first IUI attempt reminded me, the chances of success are only about 18%.
The IUI procedure itself lasts less than 10 minutes. It takes longer to get undressed for the procedure than it does to have it. And while there may be some discomfort and cramping, there’s no real reason not to go about your day afterwards. I’ve definitely walked into a staff meeting a little late with a hot pack after this procedure. The smiley face comes when it comes. And if this is your course of treatment, you smile and answer its call.
I mentioned that, as fertility treatments go, IUI is relatively low-cost. At the two clinics where we were seen, we experienced prices ranging from $400-$600 out of pocket for each attempt for those without fertility coverage as part of their health insurance plan. For a long time, this was us. Given that IVF adds a one in front and a zero behind that quote (even before factoring in the cost of medications), we were happy to stay in the IUI lane for a while.
“For a long time” means that now we do have fertility coverage thanks to a serendipitous twist of fate at my former church and thanks to LGBTQ+ community clergy and activists within the United Church of Christ whose health plan I am now (back) on. I’ll say more about why and how cis-het breeders like me are indebted to the LGBTQ+ community and details about IVF in another post. It’s way more involved than IUI.
If you read this far, I hope you learned something that was helpful or interesting to you. The science of reproductive health is super interesting, even as living through “advanced reproductive care” can be emotionally fraught, financially challenging, and physically demanding. One thing it reinforces for me daily is how awe-inspiring it really is that any of us are here at all!
I am in such awe of your honesty, your willingness to share, and the simple idea that you were enduring all of this in the midst of a global pandemic, while things at "the office" were more than just a little bit, let's just say, out of whack! The compartmentalization, the boundaries, the energy, all of the things that had to be going on while you went about your "normal day." It amazes me and makes me sad for you. I am glad this part of your journey is under different circumstances. I really understand your candor and honesty about feeling jealous of women who have had the experience of pregnancy, even if it ends in miscarriage. I had a miscarriage after we had Charlie and before Sarah. I was so devastated and feared I would never again be able to carry a baby full term. And yet I was also aware how much worse it would have been had I not had Charlie already. It makes sense and it is the simple truth of the process and experience. Continuing to send so much love and prayers for the intersection of science and care to result in your ultimate goal. You are not alone, not by a long shot. And yet your journey is still unique. Blessings!
Lindsey: Reading this essay brought me back to very familiar territory in an earlier chapter of my life. Back 25-30 years ago I taught anatomy & physiology at the college level. My master’s degree “elective” classes centered on reproductive physiology, but for horses. I assisted an equine veterinarian in developing a “stallion station”. In our practice, I handled the male part of the equation, and he the female. Our procedures for assessing mares, who ovulate seasonally, could vary wildly in their estrus cycles (different from human females). Like you and Lucas’ wild timing protocols, we were fighting God’s design for a successful pregnancy by trying to get a mare’s estrus to start earlier in the year than they normally did. This stupid practice was done because the breed registries for most of the equine breeds categorize foals (the babies) by the year they were born. So all foals born in the calendar year 2022 turn 1 year old on January 1, 2023. So, if you are showing or racing, a foal born in February of 2022 will be much more developed on January 1 than a foal born in June of 2022. Because breeders wanted earlier foals for competition, there was pressure to get mares pregnant earlier and earlier. Anyway, to get mare’s to cycle earlier we would use incandescent lights so that their eyes were exposed to the day/night cycle for June 21 to get their brains to believe it was summer and time to turn on the ovaries. This was sometimes so successful that a foal may be born in December of the year, which meant that in 4 weeks they would be a year old....those foals were usually kept hidden with their moms so that their “birthday” was say, on January 5th....
I share this so that you may laugh a bit and know that God is as much in support of your efforts as He (remember, I am LCMS...) loves and supports you and Lucas. The road you are traveling is challenging (no shit!) and very emotionally challenging, which of course has an effect on your cycles. Your humor and faith are great allies for you and Lucas on this journey. Please know that I hold you both (all 3 of you, actually) in prayer each day, and I know that the love of God in Christ Jesus permeates every part of your being, both physical and emotional.
If you want a visual to make you laugh: One evening I had ordered a shipment of equine semen from a stallion in North Carolina. The mare in Tucson was assessed by my partner that she would be ovulating in the next 36-48 hours, based on ultrasound examination of the ovary. The semen was scheduled to be delivered via Delta Airlines Freight at around 9:30 that night. The guys at Delta and UPS knew me as “Dr Sperm” after I explained what these blue ABS plastic containers contained in their cooled core. That evening I taught Confirmation at my church and decided to just hang out at the church till the shipment would be in. So, I walked into Delta around 9:15 and the guys at the counter started laughing....I was wearing my clerical shirt and one of them said “Father Sperm”? We laughed as I explained my then tri-vocational life. Knowing that the mare needed to be inseminated that evening, I drove across town in my big red crew-cab dually pickup and went to the mare owner’s barn, got the mare our of her stall, prepped her and inseminated her (intrauterine). The owner heard my truck and came out to chat and saw me with my plastic sleeved arm in the vagina of her mare with a large syringe attached to a 2 foot long catheter with the semen in it. She saw my collar (I guess she didn’t know I was also a Pastor), ran in the office and grabbed her camera and snapped a picture of the sight. Unfortunately, the picture didn’t survive. I had planned to submit it to The Lutheran Witness for a story on bi-tri-vocational Pastors.....God be with you, dear Lindsey and Lucas! Love ya, Padre.