Sticky Situations

Infertility is not easy on so many levels. Physically it is challenging and demanding. Financially it is draining. Emotionally it is exhausting and difficult. But it is also rife with ethical issues. A lot of really, really hard questions, choices, and decisions are considered and made during the process--especially at the IVF level. Because this adds another layer of complexity to this experience, I thought I'd share some of the ethical concerns I've personally grappled with on the journey.

ProChoice and IVF'er?
I have always been Pro Choice. I believe that a woman's body is her business, and that the choice to have an abortion is not by any means an easy one but that it can be lifesaving in many ways. I have spent a lot of time carefully using words like "fetus" and "embryo" and have tried hard NOT to personalize a cluster of cells as a baby. A potential baby, yes, but actual baby? No. So now I wrestle with that, since the cells clustering (or not clustering) are our potential babies, I can't help but personalize. I get excited to see how many embryos I might have, because those embryos would be my baby/babies. And if I was successful at an IVF attempt but lost the pregnancy at a very early stage, I would most definitely see that as a baby loss, not a cluster-of-cells loss. I can reconcile this newer outlook with my Pro Choice belief because this is my experience, my body, and my choice. Just because I am struggling to get pregnant myself does not mean that I begrudge other women in difficult circumstances their right to terminate their unwanted or dangerous pregnancies. (I also don't begrudge myself the right to wonder how it is that people who don't want babies can get pregnant and I can't when I desperately want one, but that's besides the point.)

Selective Reduction
Moving on to a somewhat related note, "selective reduction" is a term that haunts infertility and adds fodder to people who think that infertility treatments take the sanctity of life lightly. If you become pregnant with high-order multiples, it can be dangerous to carry them all to term--dangerous to the mother, dangerous to the fetuses. Or, you can be pregnant with triplets and have an "incompetent cervix" and risk losing all of the babies. You are urged to consider selective reduction, where the doctors determine which fetus(es) are least likely to survive and "reduce" them (abort them) in the best interest of the strongest fetus(es). Sound harsh and Darwin-esque to the extreme? Let me assure you, NO ONE wants to be put in the position of having to undergo selective reduction. It is traumatic. You risk losing all of your potential babies. It is horrific emotionally and physically. The good thing is that most clinics have guidelines in place for treatment to prevent the need for selective reduction in the first place. Most of the time this happens in IUI and not IVF, since with IUI (intrauterine insemination) your ovaries are stimulated to make multiple eggs but how many fertilize is not controlled beyond how many follicles you are permitted to have at the time you undergo insemination. The result is totally dependent on how many sperm reach how many eggs in the body. With IVF, many eggs are fertilized outside the body but usually only 1-3 embryos are put back in depending on age. It is possible for embryos to split once implanted and for you to end up pregnant with triplets or more with IVF, but it is very rare (at most conservative clinics). Jon & Kate Plus Eight and the Octomom are not the norm. (In fact, the Octomom's doctor lost his license because it is totally irresponsible and dangerous to implant that many embryos on purpose!) So, selective reduction is unlikely to be a choice that I have to make at this point. But I have thought about it and the repercussions of being in that situation.

What Happens to Those Embryos?
Before you can even start an IVF cycle, you need to sign all sorts of paperwork. Paperwork that necessitates having a conversation with your husband that you never in a million years imagined earlier. What happens to your embryos in the event of a divorce, the death of one parent, or the death of both of you? Even though these embryos are a cluster of cells, they are still worthy of a pre-nup of sorts. You need to think about what happens to them. If you divorce, who gets them? Or do they get destroyed so no one gets them? Same thing if one or both of you die. Do you say "Ok, you can have the embryos if I die so that you can implant them in your new wife and have a piece of me live on in a somewhat creepy way?" Or do you say "If I can't be there, they go bye-bye!" It's a very serious conversation. You also have to think about what you will do if you have surplus embryos and you are done building your family. Do you save them just in case? (Storage is not free.) Do you destroy them? My clinic does not have the option to donate them, which is unfortunate. They used to up until 2005, but I'm not sure why that option went away. I am personally hoping that once you store them on your own (in another storage facility, not amongst the ice cream) you can find a way to do that if you would like. Although it's really odd to think of a child with both my and Bryce's genetic makeup walking around in someone else's house somewhere else in the world, I can't imagine what a gift it would be to give that option to another couple not as lucky. Of course, this is all hypothetical--you sign away your embryos before you've even taken a single shot of follicle-stimulating hormones. It turned out on IVF #1 that we didn't even have any embryos that met the quality specifications for freezing, so at this point we do not have to worry about that. I will tell you that not having embryos to freeze was a devastating part of my last cycle. I didn't want a zillion, I just wanted enough so that I could do a (much, much cheaper) frozen cycle if it didn't work out, or if it did work out and we wanted to try again for a sibling later on the cheap. We may have to worry more about these decisions with this next cycle, as they want to increase the number of follicles I produce dramatically in hopes that I will produce more better-quality embryos. In a way, we will be lucky to have to seriously consider what to do with physical, existing embryos.

When Is Enough...Enough?
Hopefully we don't have to come to this point, but we have to discuss it at length anyway to make sure we are on the same page with when to stop treatment. Financial considerations definitely play a part, but a bigger concern is... what am I really doing to my body with all of this? I am pumping my body full of drugs that stretch my reproductive organs to their limits. It takes weeks to have your ovaries recover back to their normal size and stop being tender after egg retrieval. All of the literature explaining the risks points to the fact that pushing so many hormones through your body does carry a higher-than-average risk of ovarian cancer. Taking the follicle stimulating hormones increases your estrogen levels to astronomical heights--you are monitored throughout the process to prevent hyperstimulation, but it does happen. OHSS, Ovarian HyperStimulation Syndrome occurs when your estrogen levels spike and the fluid that fills the follicles starts filling your abdominal cavity as well. In extreme (and very very rare) cases, you can end up in the hospital to drain the fluid because it can surround your lungs and your heart and other organs and be fatal. It is scary shit. IVF puts you at the highest risk of OHSS, because they can pump you up to produce as many follicles as possible since fertilization occurs outside the body. My estrogen on my last cycle hit 2425 at last monitoring. (To put it in perspective, on my last medicated IUI cycle it was 490 at the highest, and on my last non-responsive clomid ridiculousness cycle it was 49.) Close to 5,000 and you are entering serious OHSS danger zone material. If you go too high, the clinic will cancel you in the interest of your well-being. But again, you have decisions to make--how high are you, personally, willing to risk? What is the price to your body for the baby you want so badly? When do you cry Uncle and decide that a biological child is no longer a safe option for your health? (I'll tell you--I am DEFINITELY not there yet.)

So there you go--IVF is a very serious and complicated procedure on a physical level, but it is absolutely just as complicated on an ethical level. We have made our choices and we stand by them, because we believe that we have the right to try for a child that is ours biologically. A child that has my vocabulary and spelling acuity and Bryce's scientific mathematician mind; our musical sensibilities and creative bent; Bryce's green eyes and my curly dark hair. Or maybe a total anomaly child who is super sporty and looks like neither of us, but we will love to the point of embarrassment. We are not yet ready to wade through the ethical dilemmas and sticky situations inherent in adoption (and there are a LOT of considerations on that avenue to parenthood as well). We'll explore those when and if we decide to go that route. But, for the time being, we will continue to wrassle with the viscous mass of IVF issues we're mired in and make the best choices we can for our family-to-be.