Birth Control

Even with advanced family planning methods more readily available, working moms still struggle to have it all

Back Longreads Apr 25, 2017 By Amy Westervelt

“My story isn’t really the typical fertility story,” says Erika, an education researcher who lives in Grass Valley and telecommutes for a company in Menlo Park. Erika, who asked to remain anonymous, decided she definitely wanted kids about the time she turned 39. She had been married in her late 20s and divorced five years later. On her 39th birthday, she had been with her then-boyfriend for another five years.

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“I really loved the person I was with, but I was like I think I want to have kids and if you don’t we have to break up,” she says. “The following month I looked for a donor and less than a year later I was pregnant.”

Erika describes her journey as “easy” compared to other women she knows. She got pregnant with the first round of in-vitro fertilization (it’s not uncommon for women to undergo multiple rounds, up to five, before getting pregnant, while some never get pregnant with IVF), she didn’t have to deal with progesterone shots, and the oral medication she took didn’t affect her much. She was also in a financial position to qualify for a loan to cover the cost: $35,000 between medications, five failed IUI attempts, donor sperm and IVF.

“I had really good insurance, but it covered almost none of this,” she says. Erika was also at a point in her career where she could take time off and not lose her place in line.

That’s not necessarily the case for all women who have decided they want to balance a career with parenting. While reproductive technologies have given women and families more control and additional tools, having it all still seems a far leap. Treatments are expensive (most insurance plans won’t cover much), time-consuming and not always effective. Meanwhile, workplace politics have been slow to shift and accommodate a growing number of working moms.

The Ins and Outs of Fertility

Although no two women have the same fertility story, there is a typical trajectory: A woman tries for some time to get pregnant (usually about a year) and it doesn’t happen; she tells her gynecologist, who does a blood test to ensure the woman is ovulating and then prescribes Clomid, a follicle-stimulating drug that helps ensure her ovaries produce at least one egg per month; she may try that for several months, and if it still doesn’t work, she’s referred to a fertility specialist.

The specialist will do more tests, including testing the man’s sperm. The next step is intrauterine insemination, or IUI — depositing the sperm in the woman’s uterus while she is ovulating (for slower-moving sperm, this usually solves the problem). Most women will try IUI a few times because it’s far less expensive and doesn’t require all of the drugs that IVF does. Success rates can also increase with multiple tries, but remain in the range of 7-20 percent. Most doctors will recommend moving onto IVF after three failed IUI attempts.

The IVF process typically starts with injections of a class of drugs called Gonadotropins, which contain follicle-stimulating hormone, luteinizing hormone or a combination of the two. This helps the woman produce many more eggs during her monthly cycle than she would normally — because the more eggs produced, the more opportunities for a viable pregnancy. When the woman’s eggs (called follicles in medical parlance) are mature and numerous, a procedure is performed to remove the eggs, which are then fertilized with sperm in a lab. After three to five days, the healthiest embryos are transferred back to the uterus (though sometimes the embryos are frozen for a cycle if the woman has responded poorly to the drugs). In most cases, the woman then must take progesterone shots to thicken the uterine lining enough to support a fetus.

Some specialists worry the modern, drug-assisted IVF process is overused. When IVF was introduced in the late 1970s, eggs would be harvested as the woman naturally produced them, without most of the accompanying treatments. According to Dr. Geeta Nargund, an international fertility expert based in London, too many women who don’t need drug-assisted IVF are being sold on the idea. “In a lot of cases, the woman has no fertility issue, it’s their partner that has the issue,” she says. In fact, this is true in 51 percent of fertility cases in the United States. “There’s a significant population of perfectly fertile women who are having fertility treatment and they don’t need it,” Nargund continues.

Nargund counsels women who ovulate on their own and have no issue with their fallopian tubes to try “natural IVF,” which requires the patient to inject hormones only for about 5-9 days, versus the current IVF standard, which includes 4-6 weeks of daily injections.

“We tend to forget because the field is male-dominated and they often take the approach of, ‘Oh well, women are doing all these injections, but they don’t mind that,’” Nargund says. “Well, how do you know that? … Most women are working during this time and I’ve seen a number of them have to resign because of the intensity of this process — I think we owe it to women to make fertility treatments as safe and easy as possible.”

“It causes so many psychological emergencies in this country, women quit jobs, it causes relationship issues — it should not be taken as lightly as it is.” Dr. Aimee Eyvazzadeh, fertility expert

Side effects from fertility drugs  can vary wildly from woman to woman. Clomid, for example, is known for making some women feel everything from mildly depressed to outright psychotic, but some women experience no side effects. In many cases, doctors don’t discuss these potential effects with their patients. Some consider Clomid a completely innocuous drug, while others believe women are willing to put up with any number of side effects in order to treat infertility — which is true in many cases, but that approach can have a real impact not only on patients’ personal lives, but also their professional ones.

“It causes so many psychological emergencies in this country, women quit jobs, it causes relationship issues — it should not be taken as lightly as it is,” says Dr. Aimee Eyvazzadeh, a nationally recognized fertility expert who runs a practice in San Ramon.

Leticia McCann Murphy, an HR manager in Sacramento who had her first baby this year through IVF, had exactly that experience. McCann Murphy and her husband started trying when she was 28. After a year without getting pregnant, her gynecologist put her on Clomid. She was not told about any contraindications. “I got a blood test to make sure I was still ovulating but that was it — fortunately it didn’t make me feel crazy the way it did for a lot of women in my fertility support group,” she says. After a year on Clomid, McCann Murphy tried four cycles of IUI before finally doing IVF.  

That process is common, and also makes many women less likely to opt for “natural IVF,” which although far less expensive (typically about $5,000, according to Nargund), could take longer. Fertility is often described as a numbers game: It’s a world dominated by discussion of success rates, number of eggs, number of viable embryos and so forth. For many women seeing a fertility specialist, there’s a certain amount of panic involved, particularly if they’re over 35. It’s a high-pressure situation and one in which the quickest fix with the highest success rate — drug-assisted IVF —is very appealing.

Technology is Not Always a Silver Bullet

Success rates are a big deal in the fertility industry, but they can be hard to decipher. According to the U.S. Centers for Disease Control’s most recent report, the average success rate for IVF ranges from 20-30 percent, depending on the woman’s age. Some clinics boast much higher rates. The California IVF Center in Davis, for example, has a success rate of 50-80 percent. That wide range is due to a number of factors: Some clinics take more complicated cases, which drives their success rates down. Some women, and the clinics that serve them, are willing to undergo multiple rounds of IVF in their attempt to have a child, which also drives down success rates.

“People have no understanding of success rates,” Eyvazzadeh says. Most of her patients have quite low chances of success because she is a specialist who takes pride in tackling challenging cases. She’s seen as a sort of miracle worker for women from San Francisco to Sacramento who seek her out when other specialists have failed them. “I tell them they have a 23 percent chance and they think that’s low, but in the world of assisted reproduction, that’s actually considered high,” she says.

That’s especially true for the many patients who come to Eyvazzadeh because of her reputation for cracking tough cases. “My theory is that there’s no such thing as unexplained infertility,” she says. “There’s always a reason.”

Ferreting out that reason and addressing any contributing health issues is important to ultimate success, according to Eyvazzadeh.

“If we address any contributing factors, then if and when we do go ahead with IVF it will have the highest chance of success,” she explains. “I don’t want to, after the fact, say, ‘Oh we should have removed those polyps’ or ‘Oh your husband should have seen a urologist.’”

To Freeze or Not to Freeze, That is the Question

One potential tool for extending fertility and improving success rates is egg freezing. Heralded as a game-changer that could allow women to safeguard both their careers and their fertility, egg freezing has taken off in recent years, bolstered in part by high-profile announcements from Apple and Facebook that they would cover the procedure in employee health plans. In 2009, only about 500 women in the U.S. froze their eggs — in 2013, almost 5,000 did, according to data from the Society for Assisted Reproductive Technology. Fertility marketer EggBanxx estimates that 76,000 women will be freezing their eggs by 2018.

But it too is not quite the ultimate fix it’s been made out to be. Although the American Society for Reproductive Freedom removed the “experimental” label from egg freezing in 2012 because advancements had dramatically improved success rates, it still cautioned against overselling the procedure to women and giving them “false hope” of more control over their future fertility.

“Without verification of their techniques, places freezing eggs may not be offering any real benefit to patients.” Dr. Ernest Zeringue, founder; medical director, California IVF Fertility Center

Ernest Zeringue, medical director and founder of California IVF Fertility Center in Davis, has some advice for women envisioning egg freezing as a fail-safe. “Egg freezing services are relatively new,” he says. “It is no longer considered experimental, however that doesn’t mean that clinics are proficient yet.  There are many centers, I’d go as far as to say most centers that are freezing eggs, that have not yet thawed them and attempted pregnancy.” In other words, they don’t yet know whether the eggs will be viable once thawed — something the woman won’t find out until years later.

Zeringue explains that in his center, it took quite a bit of time and effort to come up with an egg-freezing process they know works: “We set up trials of different techniques and tested eggs after thawing to see if the fertilization rates and pregnancy rates were the same as with fresh eggs,” he says. “Using commercially available materials and protocols, most of the eggs failed to make good-quality embryos.”

It was only after several adjustments to their process that his center was able to ensure a higher survival rate following egg freezing. Still, about 75 percent of frozen eggs survive the freezing and thawing process. “Without verification of their techniques, places freezing eggs may not be offering any real benefit to patients,” Zeringue says.

In addition to not being guaranteed effective, egg freezing isn’t cheap. It costs about $10,000 to harvest eggs, a procedure that is typically done after a woman has taken many of the same follicle-stimulating drugs taken during IVF, which can cost up to $1,000 depending on your insurance. Then the storage fee is around $500 a year. If and when you decide to use the eggs, you’ll still need to go through the implantation procedure and, if you’re single, will need to pay for sperm. Women who undergo IVF often wind up paying for storage of fertilized embryos as well, which they will need to decide at some point whether to use, donate or destroy — a decision that carries increasingly uncertain legal implications.

For Erika, even though she’s quite sure she doesn’t want any more kids, “especially as a single mom,” it’s been hard to decide what to do with her embryos on ice. “Destroying them is a hard decision to make, and then donating to someone would be strange too — it would be a sibling to my kid, and related to me — and I’m pretty positive I don’t want to have any more, but I just keep putting the decision off,” she says.

The Career Question

Planning for a family as a career woman is complicated. Some women have bosses they can be open with and a schedule conducive to attending doctor’s appointments whenever necessary. But even if they have both of those things going for them (which tends to be a luxury), dealing with the fertility process can be tough on your professional life.

For McCann Murphy, the HR manager, she had a flexible schedule and her boss and closest colleagues were aware of her fertility journey. Still, “it’s different when you can say a week or two weeks ahead of time that you have a doctor’s appointment, versus this, which is ‘You’re ovulating so you need to come in immediately,’” she says.

And there’s another unforeseen downside to colleagues being intimately acquainted with your reproductive life. “There was no keeping secrets when things didn’t work out, or when they did — I knew already at five weeks that I was pregnant and then everyone else knew immediately too,” McCann Murphy says. “So rather than waiting the usual three months to make sure everything was OK and then telling people, we had everyone in on it right from the start.”

However, the support all but stops once the mother goes back to work. Neither McCann Murphy or Erika works for an employer that provides or subsidizes childcare (doing so is still so rare that companies will often send out press releases if they decide to offer such a perk to employees), and both struggle with how to balance motherhood and career. McCann Murphy is fortunate to have family in the area that helps care for her 4-month-old daughter three days a week, while she’s found a daycare nearby to cover the other two days. Erika pays for full-time daycare for her son, and says she relies on the other moms at work when her son is sick and she needs to care for him.

“We’re constantly tagging in and out covering work for each other,” Erika says. “But it’s really unfortunate when parents in the office offload night or weekend work to people without kids. It’s unfair, and I don’t feel good about it. There’s this whole secret burden they bear because no one has really worked out yet how to actually support working parents.”

Because there’s no government-paid family leave, companies often use other employees to cover the leave they pay for, which means mothers are typically expected to hit the ground running the second they’re back at work.

“Everyone loves a pregnant woman and everyone loves a baby,” Erika says. “But then it’s sort of like OK, you’re on your own now.”