Friday, October 8th 2010
This is the third post of four on my experience with IVF and pregnancy, and my thinking on its broader meaning to the public and to anthropology. Find the first post here and the second here.
“Why are you just standing there?”
Last time, I ended with my water breaking all over my bedroom floor. Thankfully, it was a hardwood floor and was easy to mop up. But I’m getting ahead of myself.
I slept terribly for my entire third trimester. My doula serenely said it was my body’s way of preparing me for sleepless nights with a newborn. You will be happy to know I didn’t strangle her. I ended up having to take a nap every afternoon to even approach five hours of sleep for every twenty four, because I was uncomfortable and restless at night. Unfortunately, I often even struggled to read or work at night, because the discomfort that kept me from sleeping also kept me from concentrating.
So when I got a decent night’s rest on the evening after my due date, and found myself roused once groggily in the night, felt a little wetness that made me worry I had peed myself, and decided to drift back to sleep, I hope you won’t think too ill of me.
Chances are good my amniotic sac started to tear sometime in the night, and the movement of standing up blew open that tiny rip.
I looked down at the floor. Brendan looked down at the floor. We looked at each other. I started to laugh. “Why are you just standing there?” he asked incredulously.
“What should I be doing?” The more I laugh, the more I leak.
“I don’t know, get in the tub or something!”
So I do. Brendan hands me the phone while I’m standing in our bathtub, and I call the birth center. The midwife is pleased to hear my water has broken, is unconcerned, and says to keep her updated in terms of if and when labor starts. She wants me to come in in twelve hours to do a non-stress test, but otherwise recommends I go about my day.
This one of many major differences I experienced with a midwife versus a doctor. Hospital protocol is to bring a pregnant woman in if her water breaks, even if labor hasn’t started, and they are a lot more aggressive about inducing labor if it doesn’t start on its own.
I convince Brendan to go into work for a few hours so he can do some things that really needed to happen that day, and I lounge around a bit. By mid-morning I am having very mild contractions that are seven minutes apart or so.
Brendan and I spend the day grocery shopping, baking cookies, and going for walks along the Charles River. I was feeling triumphant and strong. I was kicking ass at this whole labor thing. It must be my athletic background, I told Brendan, and my high pain threshold, that is making me have such an easy time of things. I was buoyant, even as I started to need to pause and concentrate on the contractions when they happened.
Around six in the evening we went to the Birth Center, where I completely believed they would check my dilation and say I was at four centimeters. I had been laboring all day, after all. My midwife checks me. “Maybe one centimeter,” she says.
Are you kidding me? I begin to feel nervous, like maybe my vision of hanging out in the birthing tub while playing cards with my sister and husband was not going to happen. Maybe I had underestimated labor a little bit.
My non-stress test comes out fine. I’m starting to really feel contractions, and my body keeps trying to move away from them. I have back labor, which isn’t so great.
At this point, time starts to feel different. I know we went home for a while, where my sister joined us and she and my husband got some good. I know I lay down on the floor, then the bed, that I tried to take a hot shower, and that nothing really worked. I was starting to feel miserable, and a little panicked. I am a perfectionist, and I had had this idea that somehow labor would be different for me, than, you know, the millions upon millions of women who have come before me.
Time to go
I asked to go back to the birth center, probably around eleven at night. We get there and I’m maybe three centimeters dilated, and I can’t be admitted until I’m in active labor, which is at least four centimeters. We hang out in the lobby with my two midwives (one is in training). They inject little subcutaneous sacs of water into my lower back that burn horribly, but reduce my back labor pain by half. I am starting to moan with each contraction, and while I want to be holding someone’s hand, I don’t really want to talk. I really start to wonder what I was thinking with this whole natural labor thing.
By one thirty or so in the morning, I am considered in active labor so we can go upstairs to one of the birthing suites. No one else is there that night so I get the best one (though all three are great). I get into the tub as soon as the water is ready. Nothing feels right, the water temperature feels wrong, it doesn’t seem deep enough, I can’t position myself to get comfortable, I hate everything. Over the next few hours the pain gets worse. Yes, contractions are like menstrual cramps. They are like menstrual cramps that cover several orders of magnitude more surface area, are several orders of magnitude more painful, and they come in waves of pain that crest, only for you to know that in another minute and a half you’ll have another one. I am a natural birth advocate, but I am not going to tell you labor is fun.
There were some highlights, of course, like the times Brendan carefully smoothed the hair from my face and got me to sip some water, like the way he and my sister watched out for each other over that long night. The moment I opened my eyes between contractions to see every midwife and doula sitting on the floor of the bathroom, reading their own copy of my birth plan while they waited for my next contraction.
After a while, the midwives smartly decided I needed to move from the tub, since a change of pace might help move my labor along. I labor on all fours on the giant king-size bed for a while, but am starting to panic about the pain and how long everything seems to be taking (again, it’s actually all taking a normal amount of time). The midwives suggest a gentle intervention – how about an injection of Benadryl? It won’t harm the fetus and will make me a little sleepy, which will help me rest between contractions. Amazingly, it works: I am alternately screaming and sleeping for a few more hours, giving me the strength I need to ride out my dry back labor.
Those of you who know anything about birth know how women act during transition. This is the point at which a lot of women tell everyone, in no uncertain terms, that they have decided not to have the baby and are going home. They start packing their things or otherwise give up on the process. For me, I started apologizing. I thought, though no one had indicated it in any way, that I was about to be transferred to the hospital for an epidural, that that was my fate. “I’m so sorry, Brendan. I can’t do it. I’m sorry.”
“You are doing it, though,” he said. “You are doing it.”
I thought I saw a hint of a smirk in the face of my doula and midwives, who have seen hundreds more births than we have. They got me to move to another position, and told me maybe I might feel like pushing soon, and if so that I could. They also said, gently, maybe we should go over to the bathroom again. You can pee, and maybe we can set up the tub for you again.
So I pee, and then when I get up I get the URGE TO PUSH. The URGE TO PUSH, to me, was the most delightful, empowering, wonderful part of childbirth. Labor is all about getting out of the way of your body so it can do its job of dilating your cervix. Pushing is something you get to do. Of course it hurt. But it was also one of the most awesome (not as in awesome, dude, but awesome, full of awe) things I have ever done.
It turns out I am good at pushing. So when I felt the URGE TO PUSH I started to push my baby out. I felt the well-named ring of fire as the baby’s head crowned. “Wait, wait!” my midwives yelled. “We aren’t ready!” They sprinted to get everything together so they could catch the baby.
And that is how I ended up giving birth to my amazing daughter standing up, at 9:45am on a drizzly day in March 2008, holding on to my husband’s shoulders, standing by a toilet.
Bonding to our baby
This gorgeous baby troll (let’s just be honest, all newborns are a little troll-like) was passed to me from between my legs where my midwife had caught her. I looked at the baby. I looked at the baby again. “It’s Joan!” I shouted. “It’s Joan!” It was a baby girl, a rather purply-blue baby girl, but a girl nonetheless.
We had wanted to let the cord pulse a bit more and not cut it while I held her, but the midwives were understandably concerned about the color of our daughter, so they encouraged us to cut the cord now so they could warm her up and make sure she was breathing well. Brendan cut the cord, then followed the midwife to the bedroom where they put Joan on a little warming table and ran some oxygen near her face. I am guessing that the reason Joan came out looking a little blue was due to my rather overzealous pushing, rather than there being anything inherently wrong with her. They slowly walked me away from the bloody massacre of the bathroom over to the bed, where I could push out the afterbirth and hold my baby.
Because I had lost so much blood (they estimated I lost 500cc, which is the technical definition of postpartum hemorrhage), the midwives decided to give me an injection of pitocin to speed up the afterbirth so they could be sure I wasn’t hemorrhaging. I pushed out the placenta and thankfully I was fine, but it was a smart intervention anyway.
There are so many other pieces of this story I could tell, from the sound of my sister crying with joy as she videotaped the birth, to the doula who held my hand as I was sewn up (I had a second degree tear). All the grandparents got their moment to hold Joan. Brendan went to Christina’s to buy us milkshakes (this was a very important part of our birth plan). And I sat in a darkened room, staring and staring with a mix of fear, delight, and unadulterated love at the bright pink, eight pound three ounce baby in my arms. We were home by five o clock that same night, where the grandparents greeted us again and we celebrated our wondrous, gorgeous, perfect child.
* * *
In the final installment next week, I’ll reflect on the experience and broader issues around sexism and overpathologization regarding both IVF and reproductive choice.
Wednesday, October 6th 2010
This is the second post of four on my experience with IVF and pregnancy, and my thinking on its broader meaning to the public and to anthropology. Find the first post here.
A few weeks after the positive blood test, I had my ultrasound where we saw a tiny little bean and a beating heart. During this time I was having what felt like bad menstrual cramps. The nurse told me this was quite normal, but I still spent a lot of mental energy fretting over it. The rest of the first trimester was pretty uncomfortable. In addition to being exhausted, I was nauseous. I didn’t want to eat vegetables. In fact, all I really wanted was toast (gluten free, of course). I concocted a pretty awesome smoothie that I would drink once or twice a day, made of chocolate almond milk, peanut butter and ice cubes. It settled my stomach, and it’s probably because of those smoothies that I only lost four pounds.
At this point we also transitioned from medical doctor care to a midwife. At first we were just given to the next available midwife in our practice. But when it became clear that in order to stay in that practice we’d have to have a hospital birth, we transferred to the Cambridge Birth Center in Cambridge, MA and the midwives there.
Where to give birth and why
The Cambridge Birth Center is a stand-alone birth center associated with (and across the street from) the Cambridge Hospital. There are no doctors, but you can get into the OR in four minutes for an emergency C-section if you need to (yes, they practice and time these things). So I was completely confident that, if I had a straightforward, low-risk pregnancy and labor, I would be best suited to the birth center, and if anything went wrong I was minutes from a doctor.
We were a bit nervous about this decision, because of the stigma attached to IVF children. Do IVF pregnancies lead to more difficult pregnancies or labors? Are we going to have a child with greater or fewer limbs than the average? The reality is that, while the egg was fertilized in a rather special manner, a fertilized egg, then blastocyst, trophoblast, and so on that makes it to become a fetus, and then makes it trouble-free through the first trimester? That fetus is very, very likely to be healthy and normal.
The other reason we were firm in our decision is that a number of interventions that are automatic upon entering a hospital are not physiologically necessary, and even increase the risk of later interventions. Pubic hair shaving is still a common practice in some hospitals, which is just plain dehumanizing. More common are continuous fetal monitoring and putting in an IV immediately. Continuous fetal monitoring is more likely to find false positives, which means it’s more likely to find pathology in a fetal heartbeat that goes up or down but resolves on its own naturally. IVs restrict movement and lower the barrier for a doctor to suggest, and a woman to agree to, pharmaceutical interventions. This is in addition to the many other criticisms I could launch but won’t because I find it all so exhausting.
The biggest issue, for me, is that if you walk into a hospital you have at least a 33% chance of having a Cesarean section, and the reasons behind that are largely related to the ratcheting up of interventions as one intervention necessitates the next one. A C-section is major abdominal surgery. It takes a long time to recover. It is hard to breastfeed, it is hard to pick up your child, and you spend more days in the hospital. These are days when your sleep is more disrupted than when you’re home, and you increase your and your child’s chances of infection by being in a hospital, and extra days when you as a family could be figuring out a routine at home to make sure the mother isn’t the only one bonding to the new baby.
Then there are indications that C-sections create health concerns for the baby as she gets older. Babies of C-sections have higher rates of allergy (i.e., Roduit et al 2009), asthma (i.e., Davidson et al 2010) and Celiac (gluten intolerance) (Decker et al 2010). I am a C-section baby myself and I have severe allergies, allergy-induced asthma, and gluten intolerance (a trifecta of awesomeness!). Given that I’ll be passing on some of the genetic proclivities for these things, I wasn’t too keen on giving my child the environmental components that would also increase her risk if I could avoid it.
So we started seeing a midwife, and I got to know a different part of Cambridge better than I’d known before. I really fell in love with Inman Square.
Throughout my pregnancy, I devoured popular books on pregnancy (good: anything by Sheila Kitzinger, bad: What to Expect When You’re Expecting) but also searched for a lot of information on PubMed and kept an Endnote library devoted to my results. I read about the craptastic relationship between symphysis-fundal height measurements (this is when they use measuring tape to measure the size of your belly) and birth weight (i.e., Johnstone et al 1996) – even in those studies that found a statistical correlation, SFH often explained very little of the variance in birth weight. I read about exercise during pregnancy (de Groot et al 1994) – and I played soccer through my first trimester, jogged through my second, and worked out five days a week through the whole pregnancy, up to the day before my due date. I read about meconium, I read about fetal monitoring, I read about maternal stress. When I wasn’t working I was reading, and when I wasn’t reading I was exercising. All the other time I was in prenatal appointments or sleeping.
Of course, as excruciatingly long as the pregnancy felt, as boring and normal and yet delightful as it was, it did eventually come to a close. Family flew in from out of town to be around for my due date, and there was a lot of pressure – joking, but pressure nonetheless – to produce offspring before everyone left. When my due date brought with it the occasional half-hearted contraction, nothing I hadn’t felt before, I went to bed disappointed.
The next morning I woke up, got out of bed, and my water broke all over the bedroom floor.
* * *
Next time, I’ll talk about the joys of drug-free labor.
Davidson, R., Roberts, S., Wotton, C., & Goldacre, M. (2010). Influence of maternal and perinatal factors on subsequent hospitalisation for asthma in children: evidence from the Oxford record linkage study BMC Pulmonary Medicine, 10 (1) DOI: 10.1186/1471-2466-10-14
Decker, E., Engelmann, G., Findeisen, A., Gerner, P., Laass, M., Ney, D., Posovszky, C., Hoy, L., & Hornef, M. (2010). Cesarean Delivery Is Associated With Celiac Disease but Not Inflammatory Bowel Disease in Children PEDIATRICS, 125 (6) DOI: 10.1542/peds.2009-2260
de Groot LC, Boekholt HA, Spaaij CK, van Raaij JM, Drijvers JJ, van der Heijden LJ, van der Heide D, & Hautvast JG (1994). Energy balances of healthy Dutch women before and during pregnancy: limited scope for metabolic adaptations in pregnancy. The American journal of clinical nutrition, 59 (4), 827-32 PMID: 8147326
Johnstone, F., Prescott, R., Steel, J., Mao, J., Chambers, S., & Muir, N. (1996). Clinical and ultrasound prediction of macrosomia in diabetic pregnancy BJOG: An International Journal of Obstetrics and Gynaecology, 103 (8), 747-754 DOI: 10.1111/j.1471-0528.1996.tb09868.x
Roduit, C., Scholtens, S., de Jongste, J., Wijga, A., Gerritsen, J., Postma, D., Brunekreef, B., Hoekstra, M., Aalberse, R., & Smit, H. (2009). Asthma at 8 years of age in children born by caesarean section Thorax, 64 (2), 107-113 DOI: 10.1136/thx.2008.100875
Tuesday, October 5th 2010
A few things have made me decide to tell my conception, pregnancy and birth stories, and provide some broader context, on my blog. Of course one thing is the CNN.com story that came out on Monday. Then I was struck by how the criticisms being launched by opponents of IVF – to me personally on the CNN.com story’s comments, and broadly in the media coming off of Edwards’ Nobel Prize win – are so overtly sexist and are so related to the way I frame my research. And, earlier this semester I also had a student leave me a note in my Question Box. (The Question Box is a box I leave out for students to submit anonymous questions. Sometimes serious, sometimes ranting, often clever, it’s an interesting part of Anth 143.) This student asked whether my understanding of reproduction, as someone who studies it, affected how I viewed pregnancy and childbirth when I went through it myself.
So this post chronicles how I got to be pregnant. Later posts will discuss my pregnancy, my childbirth, and how sexism and the pathologization of women’s bodies are damaging and incorrect.
The beginning of my family
Brendan and I met in college, at Nerd School. I knew Brendan had had leukemia just a few years before, and I remember thinking that it made him calmer, more mature. I valued his thinking above the other young men I knew. Thankfully, he felt the same way about me. It took us six or seven months to start dating, and a few months after that for me to discover he was infertile. I just asked him one night, he told me he was, and that was that.
I remember feeling as though the chance to have children was slipping away, because of who I had fallen in love with. I remember seeing how Brendan turned inward a bit, in that moment, I think expecting rejection from me. He talked about how much he wanted to be a dad one day, and I thought, I fucking hate cancer. And then I figured, science will take care of this by the time we actually want kids. Either that or we’ll adopt. So I tried not to think about it. And of course, over several years, we fell more in love, and we got engaged, and we got married.
Over this period, we were both going to graduate school. I was doing dissertation fieldwork in Poland until two weeks before we got married. After a year of lab work (undiluted spit and piss stink more than you might expect) and I was in the writing stage, I moved back up to Cambridge and, for the first time since we started dating, we lived together.
Brendan, being a year ahead, finished his doctorate before me and went on to an amazing post-doc position at Children’s Hospital. I was a lecturer at Yale, and then preceptor faculty in the Harvard Expository Writing Program while finishing my dissertation. But while writing in coffee shops and libraries, I found myself intensely, painfully jealous of pregnant women. I wanted to hold little babies and smell their hair. So I started talking to Brendan about it, and it was something he wanted too. He looked into his healthcare, and it was amazing. In vitro fertilization would be totally covered. Totally covered. As in, cough up the occasional co-pay and you can try to have a baby. It made me feel almost like a normal person.
Going for it
We made an appointment with a fertility specialist. We figured it made sense to try while I was young and not a limiting factor, seeing as we already had one in Brendan. Poor Brendan had to submit to a number of tests, because it was decided that there was a very, very small chance that maybe there were some sperm in there somewhere. There weren’t, but let’s say he found out the hard way. Then there was a chance that Brendan had a single vial stored somewhere that was taken between chemo treatments. Chances were nothing was alive inside it, but our doctor was excited by this news and recommended we try IVF to see if we could use this sample.
Then it was time to figure out a backup plan. Neither of us wanted to use a stranger’s sperm. So then it was a matter of deciding who to ask.
Of course, privately, years ago, we had already discussed Brendan’s youngest brother. You see, his middle brother was his bone marrow donor when he had leukemia. We always felt it would be fitting to have his other brother be our sperm donor. But how the heck do you ask someone to be your sperm donor, especially a twenty two year old someone who, understandably, doesn’t exactly have babymaking on his mind?
We needn’t have worried. We called, we chatted, we nervously explained, and Brendan’s brother was beside himself with delight. I suspect he had always been disappointed to be the brother who wasn’t a bone marrow match. As a fifth grader with his oldest brother battling cancer and his middle brother getting holes punctured in his hip to donate bone marrow, he got his class to sit down and make paper cranes. They didn’t quite get to one thousand, but they got close.
With Plans A and B all set in terms of the sperm, it was time to figure out the eggs (I’ll spare you what turned out to be insane details scheduling and timing Brendan’s brother’s trip to coincide with my treatment). I had to undergo a battery of tests including a hysterosalpingogram and vials and vials of blood to make sure I was fertile and wasn’t harboring any nasty diseases or genetic proclivities to nasty diseases. Brendan and I also had to go to a therapy session. I felt like all my spare time went to phone calls and doctors’ waiting rooms. I understood why I had to go through it all, but resented what I had to go through when other people could just have sex and get pregnant. Once we were cleared, we couldn’t even get started with the stimulation protocol, because we had to be fit into the embryologist’s schedule: they don’t want too many embryos to watch at one time. As rational as all this was, it was hard to feel rational when I wanted to move forward.
IVF in accord with our lifestyle and environment
Our doctor was exceptional. She was hopeful in a measured way, she listened well, she was not condescending, and she appreciated the fact that I was a scholar in women’s reproduction and had a few opinions of my own. We discussed going for a very mild protocol to avoid hyperstimulation, because a higher dose would be unnecessary for someone like me: healthy, young, athletic, fecund. I said I would rather have this all not work then feel like I was so desperate to have a baby that I would risk my or my child’s health.
So we went for a lower dose. Birth control pills, then little needles in my leg, more appointments to count follicles and measure my endometrial thickness, a perfectly timed hCG shot to mature my eggs.
Fourteen eggs were aspirated in an outpatient procedure. Brendan’s sample was thawed. The sample was essentially empty. Brendan’s brother’s sample was used. My heart broke just a tiny bit when I was told that part. But then I remember thinking to myself, rather fiercely, of the incredibly strong baby that will come out of all this, and call Brendan Daddy, and how the bonds of our family would knit even closer in the wonderful blend of genes and environment that would be our child.
We risked a five day protocol before blastocyst transfer. In IVF, the most typical protocols are to transfer a three day embryo, or a five day blastocyst, back into the mother. The three day was more common in the past, but you risk the mother’s endometrium not really being receptive yet. The five day transfer would mean a few more risky days of being cultured in vitro, but a greater chance of there being an alignment with the receptivity of the endometrium. The other decision we had to make was whether to transfer more than one blastocyst. Continuing with our decision to not take risks with my or potentially a baby’s health, we wanted to reduce the chance for having multiples, so we opted for a single embryo transfer.
These were a panicked few days, waiting for the embryos to culture, hoping some would actually be left by the time we got to the fifth day. I had trouble maintaining a rational perspective, that the way we were doing this was best. But we got there. We went in for our outpatient procedure to have the embryo transferred to my body. I had to take a Valium and drink an enormous glass of water: the Valium was actually more to keep my muscles, including the muscle of my uterus, from contracting, and the water was to get my bladder as full as possible to make it easier to image my uterus using abdominal ultrasound while they implanted the embryo.
|Our “textbook” blastocyst.
The ultrasound and embryo transfer were excruciating, not because it was painful, but because I needed to pee so badly that I wanted to scream. You try drinking an enormous glass of water and then have someone pressing an abdominal transducer down on your bladder while someone else is making you stay still while they put an embryo in you. Then, continue to lie still there for a while before you can get up and pee.
The second the doctors left the room, I turned to Brendan and burst into tears. At least for that moment, I was pregnant. There was a blastocyst inside me, and I was so absolutely happy and terrified that I could barely contain myself. We grinned at each other like fools, clutching our picture of our “textbook perfect blastocyst” and when I finally got to go to the bathroom I hoped that I wasn’t flushing anything else down the toilet.
A new beginning
A week later while on a family vacation in Maine, I was exhausted all the time, wanting to go to sleep early, and writing it off as wishful thinking or aftereffects of the stimulation protocol. We still had another week before our official pregnancy test. So of course on the drive home from vacation Brendan and I went to the store and bought three.
The first one came up immediately and unequivocally positive.
We had our official test soon after, and it told us what we already knew. I fell to the floor of our apartment as the nurse on the phone, accustomed to such a reaction, waited for me to stop crying.
I was pregnant.
* * *
Tomorrow, I go all meta on my pregnancy.