During our Two Week Waits, my husband and I often take walks to the river near our house. Among couples trying to conceive (or TTC, as it's known among people who have been trying for a while), the Two Week Wait is the wait between ovulation and a positive or negative pregnancy test. Online message boards are filled with advice about what to do during the Two Week Wait—go to the movies or out to dinner, take a yoga class, get a massage, anything to get your mind off the question of pregnancy. We have never been good at taking our minds off of anything.
We've also been TTC for long enough that we don't expect a pregnancy, not really. For a while, particularly when we were treating our infertility with oral medications and intrauterine insemination, it seemed like every river walk involved a conversation about what if: What if this is the month? What if our child is born in January, February, March? The months fly by, 47 of them, and it's time to make decisions about our next step.
Last month I did something different during the Two Week Wait: I visited an embryologist in her university laboratory. It has become clear to me, to my husband, and to our reproductive endocrinologist that IVF is the treatment most likely to overcome our infertility. But there are big questions: about the cost, about how we will feel if we try and fail, about the ethical considerations of spending so many resources creating a life that has not happened naturally, the way it does for most couples.
Even though IVF is still relatively uncommon—less than 5 percent of infertile couples are treated with IVF—everyone seems to have an opinion about it: what it does to the woman's body, what one should do with leftover embryos, whether the treatment should be covered by insurance companies. Rational, loving friends and family have told me all kinds of unhelpful things: that a child I conceive through IVF will be more likely to have autism; that IVF will give me cancer; that I would be better off with acupuncture, herbs, or drinking more whole milk.
So it shouldn't be surprising that politicians, too, are involved in the debate. In December, Personhood USA challenged Republican presidential candidates to sign a pledge to protect human life "at every stage of development." This protection, if enacted through Personhood USA's legislative proposals, would severely limit the practice of IVF. Five candidates—Rick Santorum, Michele Bachmann, Newt Gingrich, Ron Paul, and Rick Perry—signed the pledge, and Gingrich, a converted Catholic, expressed concerns specifically about IVF: "If you have in vitro fertilization you are creating life; therefore we should look seriously at what should the rules be for clinics that are doing that, because they are creating life."
"I bet a lot of politicians have never stepped into an IVF clinic," said Dr. Silvia Ramos, senior embryologist at the University of North Carolina School of Medicine, when I asked her about the personhood debate Gingrich was referencing. Born in Brazil, Dr. Ramos speaks with an accent that becomes more pronounced when she gets excited, and nearly everything about her work—from treating and interacting with patients to performing research on mouse ovaries and embryos—excites her. But about politicizing her lab, she is dismissive: "You need to have an understanding of science to know what goes on here. You need to have biological knowledge."
My biological knowledge about embryo development was rusty, mostly comprised of half-remembered facts from health class, but Dr. Ramos patiently and enthusiastically described the process of IVF, which begins when she receives the eggs retrieved from a woman's ovaries by the reproductive endocrinologist. In a sterile laboratory, she observes each egg, or oocyte, under a microscope and determines if it is mature enough for fertilization. If the patient has chosen intracytoplasmic sperm injection, a procedure designed to overcome male infertility, Ramos will carefully remove the cloudy masses of nurse cells surrounding each mature oocyte, and will inject the oocyte with a single sperm selected for optimum morphology and motility. This process can take an hour or more, and often she will listen to Brazilian bossa nova CDs as she works. "You have to be in peace every day to do your best at this," Ramos said. "Music helps."
After so many months of TTC, I found Ramos's step-by-step description soothing, even appealing, for its order and predictability, for the way it makes conception—that long-elusive goal—visible. If the oocyte is fertilized, Ramos will see the formation of two pronuclei, then the fusion of the diploid cell, or zygote. Over the next few days, as the zygote is incubated at 98.6 degrees, she will track its development in the lab. Ideally, the zygote will form four even, smooth cells, then eight. Sometimes, Ramos can wait for the embryo to become a morula, which looks like a blackberry, or a blastula, which looks like a soccer ball, before transferring the embryo to the woman's uterus. "Look! How beautiful!" Ramos said, showing me images of embryos she had worked with. She had folders and folders full of these images, and they were, at every stage, strangely beautiful, as were her tools: the polished steel and glass pipet used to move the embryos, the tiny, needlelike cryoloop used to cryopreserve the leftover embryos using vitrification.
"What happens here in my laboratory is a lot like what happens in the woman's body," said Ramos. "No one sees it."
Except they do. The day of transfer to the uterus Ramos gives each couple or individual a set of images of their embryo or embryos, plus a description of the embryos' condition and likelihood of implantation. I can imagine that these blobby, black-and-white images are precious to anyone who has experienced years of trying. Women on TTC message boards, women with screen names like Babybound or Tryn2BMommy, will send each other "sticky vibes" or "baby dust" in the hope the embryos will "take."
But in the clinic they practice a cautious optimism. Sometimes patients cry, Ramos said, but they never name or otherwise personify the embryos. There are too many things that can go wrong—the embryos, still months from viability, may not implant, or they may implant but stop developing. Extra embryos are frozen, and patients at UNC have three options: They can store the embryos for future tries, they can donate them for research purposes, or they can destroy them. Destruction of a stored embryo is accomplished by thawing. "The embryos belong to the parents," said Ramos. "They have the right to decide."
And they are the ones who know, ultimately, the impact and import of IVF, a treatment that is so expensive, invasive, and fraught that it is rarely—if ever—begun lightly or heedlessly. Dr. Ramos often has to call her patients to give them disappointing, even devastating, news: embryos, especially those from the oocytes of older women, sometimes have fragments or stop developing, and it is difficult to tell which ones will implant successfully. Despite this uncertainty, Ramos's discussion of IVF was punctuated by frequent, enthusiastic exclamations about the great love she has for her job. "It's so delicate," she said. "It takes the right combination of skill and personality to do it well. I create life. This is what is magic."