We Wanted a Test Tube Baby

The doctors warned us that it wouldn’t be easy. We didn’t know how right they were.

November 1985By Comments

On March 10, 1984, my wife hemorrhaged from an ectopic pregnancy. We rushed to the hospital emergency room and met with Sarah’s doctor. After a brief examination Sarah was taken to the operating theater on the third floor, where the doctor performed abdominal surgery that evening.

Two hours later the doctor came out to the waiting room an told me about the surgery. He explained that in most cases the egg is met by the sperm in the fallopian tube, where it is fertilized and then travels down to implant itself in the uterus. In Sarah’s case, however, the fertilized egg didn’t make it to the uterus. For some reason the embryo implanted in her right fallopian tube, where it stayed and grew. Within a week it had ruptured the walls of the pencil-size tube, and in less than an hour Sarah lost more than a quart of blood.

The doctor tried to save the tube. He worked to stop the bleeding three times—applying pressure to the tube, milking the blood free, and compressing the tube. Each time blood seeped in, filling the tube. It just wouldn’t stop. Finally, he took the tube out.

The doctor’s voice became a whisper. We were alone, but we sat hunched toward each other, inches apart, under the cool fluorescent light in the center of an empty waiting room. He had known Sarah and me for four years, for almost as long as we had been trying to have children. He had done everything within his medical powers to help us have those children. He had run numerous tests on us. When endometriosis blocked both of Sarah’s fallopian tubes, he had opened them up, hoping that they would remain open long enough for us to conceive. He had been with us when she first miscarried. Now, when Sarah had become pregnant again at 32, the embryo had burst through her fallopian tube and almost killed her.

It was late. Darkened hallways ran from the elevators to lighted outposts where nurses worked quietly. The waiting room, an open area lined with settees and sprinkled with religious pamphlets, was cold. The darkness seemed to close in around us. My throat was tight, my hands trembled. I asked about the left tube. His eyes answered before he spoke. It was a mass of adhesions, twisted like an old garden hose. Scar tissue covered the left ovary; he hadn’t been able to see it. He paused. I could say nothing; what was there to say? The doctor knew how badly we wanted children. He really wanted us to succeed. That was when he first mentioned in vitro fertilization and embryo transfer (IVF). He said there was a program starting here in Austin that might offer us another chance to have children. He said we should think about it, that the IVF procedure was our only remaining hope—that, or a miracle.

Sarah and I had heard of the in vitro fertilization and embryo transfer technique. Infertility was newsworthy in the eighties. Couples usually had their children while they were in their twenties and early thirties. However, as our population aged, couples had been postponing their childbearing years. That gave women more time to develop endometriosis, pelvic infections, or ovulation problems. Younger women, those between the ages of 20 and 24 who were having children, were experiencing increased infertility because of smoking, drinking, drugs, promiscuity, contraceptives, and overexercise. In men, a decreased sperm count was noted. America’s fertility rate was on the wane.

Infertility, however, had stimulated research and new techniques. In vitro fertilization and embryo transfer is one of the latest methods to combat this epidemic. It was for couples who because of damaged fallopian tubes, a low sperm count, endometriosis, or some unexplained infertility, couldn’t have children any other way.

What sounded so simple—the fertilization of an egg outside of the womb and its transfer back into the uterus—had resulted from years of research continually besieged by ethical questions, technical difficulty, and risk. It was only marginally successful. But Sarah and I knew none of that when we considered in vitro fertilization. We wanted a baby; IVF gave us a chance.

IVF grew out of ten years of collaboration between a physician and a research scientist, Dr. Patrick Steptoe and Robert Edwards, in London. The world’s first “test tube” baby was born in 1978; since then, more than a thousand children worldwide have been the result of IVF.

There are 125 registered American Fertility Society IVF programs in the United States. Two years ago Houston and Dallas offered IVF programs at six hospitals. Houston had the better-established programs, with Baylor, the University of Texas Health Science Center, and Woman’s Hospital of Texas successfully performing IVF treatments. But if we were going to leave town to enter a program, we could as easily look into out-of-state programs, searching for the best. That meant enrolling in the Eastern Virginia Medical School’s IVF program in Norfolk, Virginia. It was the first American program. It had nearly 130 IVF-conceived babies to its credit. Repeating the procedure so many times had helped make the Norfolk program the best; simple practice goes a long way toward perfecting technique.

In 1984 some infertility specialists teamed up at St. David’s Hospital in Austin to start an IVF program. Although its success rate was unknown, the program in Austin meant that Sarah and I wouldn’t have to leave home and spend weeks in a motel near a medical complex in an unfamiliar city. We decided to see what St. David’s had to offer.

Our real introduction to IVF was a Nova documentary about couples going through the first American IVF program, in 1981. As Sarah and I sat in an empty hospital classroom watching two televisions mounted on poles, the information we were getting floated past as if in a dream. Though the technical aspects of fertilization and transfer captivated Sarah, she sensed that the film wasn’t giving her the whole picture of the process. I couldn’t keep my mind on technicalities. I drifted past the low success rate and the number of ifs that built up as couples went through the program. All I saw was medical science to the rescue.

I was struck by one part, in which five or six couples were together in a motel room waiting for a doctor to call about some tests. They were expecting to see who would be selected, who would be the lucky one to win the baby. There was a subtle desperation in their waiting. Desperate for hope, desperate from the finality of their infertility, desperate from wanting a miracle. Their desperation made me wonder why we had to suffer through this at all.

“Lo, children are an heritage of the Lord and the fruit of the womb is his reward.”

I kept wondering whether I was being punished by God. Isn’t there a reason for everything? I had been married once before. Had a daughter. Gotten divorced. Failed as a father. Sarah’s and my misfortune happened because I didn’t deserve to have any more children. In a church sermon, I had heard that God didn’t work that way. He didn’t seek out and punish. Did He therefore not reward? Was life merely an accumulation of catenated events or a dadaist’s collage?

Sarah’s views on life were more accepting. Though she questioned, sometimes tearfully, “Why me?” she knew there was no answer. IVF was her only chance to have a child biologically; wondering why it had come to that was useless.

The tape ended. Afterward, we met briefly with Ruby Fischer, the program coordinator. Sarah told her that if we were accepted into IVF, we would like to start in the summer of 1985, since she would be on summer vacation from her job as a teacher. We made an appointment with Dr. Thomas Vaughn, the program director, to review our case.

The first meeting didn’t go well for me. I hate waiting. In a doctor’s office, you wait. After nearly an hour we met Dr. Vaughn. Thomas Vaughn, in his late thirties, had a boyish face that seemed at odds with the air of somber concern and general weariness that accompanies good doctors. And Vaughn was supposed to be one of the best.

He flipped through Sarah’s medical history and asked a few questions. Had we done the pertinent fertility tests, sperm counts, endometrial biopsies or temperature readings? Any previous surgery, IUDs, pelvic infections? What was Sarah’s menstrual and ovulation history, her general health? Did we smoke or drink, do drugs? Sarah, aware that the answers were already in medical files, answered patiently. She began to wonder if anything in her medical history would keep her from being accepted.

Dr. Vaughn asked us about our families. Any history of Down’s syndrome, multiple sclerosis, birth defects? Then he asked whether we had any questions. I had one, though I couldn’t state it very well: did the IVF process circumvent natural selection when the sperm and the eggs were mixed? Of course, I didn’t ask it like that. I took about five minutes and used my hands a lot, but Vaughn figured out where I was headed. He said that he didn’t know. We paid fifty bucks and left.

As we walked down the hallway of the medical building, Sarah told me she was irritated by my barking at Dr. Vaughn’s receptionist when we paid the bill. I had been too impatient. She was used to waiting in doctor’s offices; she had been in so many. That only added to my inchoate feelings about in vitro fertilization. I knew things weren’t going to get any clearer. Looking back now, I can see that the visit was a great introduction to the expense, the waiting, and the unknowns of IVF.

A couple of months later Vaughn examined Sarah, and the following month we took in $100 to apply to the program formally. Then it was my turn to be scrutinized. Though I had a twelve-year-old child and had been through tests two year earlier, when Sarah and I started trying to have children, St. David’s wanted fresh information. In other words, semen analysis.

I had an appointment to meet St. David’s IVF gamete physiologist, John Repp, the “egg man.” He would check my sperm count. He would be the one who would eventually take my sperm, Sarah’s eggs, and commingle them, which I likened to a game of red rover in a petri dish.

It’s all numbers with spermatozoa. The more you have, the better your chances are of getting what you want. To fertilize an egg, a range of 20 million to 150 million sperm per cubic centimeter is considered acceptable, thought some IVF programs can work with less. But numbers aren’t enough. The sperm also have to be forward-swimming (motile) and at least 60 per cent must look normal.

I arrived at the hospital apprehensive. It was hard to believe that everyone didn’t know why I was there. I went to Repp’s office. Behind a crowded desk in a pinched room was John Repp’s sympathetic face. Too sympathetic. Like he was doing his damnedest not to laugh at my embarrassment. We shook hands. He, like Vaughn, was quiet-spoken. I asked my question about natural selection again, explaining my dismay at sperm being dumped on the egg like pepper on a sunny-side-up, with no differentiation between the bad sperm and the good sperm—sort of like a microscopic equal-opportunity plan. Repp said that the sperm would have some competition in reaching the egg but we didn’t have time to philosophize.

He took me next door and unlocked the masturbatorium. It was a closet jammed with a hospital recliner, a wall rack spilling Playboys and one dog-eared, loathsome-looking Penthouse. On top of the magazine rack was a portable radio. Wasting no time, Repp pointed out a specimen cup, the sink, a mashed tube of K-Y jelly, and the lock on the door. I got the point. He left and shut the door.

As I fiddled with the lock, I heard him reenter his office. Our rooms shared a wall. A wafer-thin wall. His chair squeaked as he sat down. I could hear him scratching notes with a pencil. The radio’s purpose became clear. Suffice it to say that the Mormon Tabernacle Choir’s exaltations were ludicrously received.

My sperm count checked out okay—low average but high motile. I took that to mean what they lacked in number they made up for in spirit.

In April the IVF team reviewed our application. Though the files had already been screened and had been tacitly accepted before the meeting, the review gave all the doctors another opportunity to recommend other treatment. Most of the time, the one to five files per meeting are given five-minute summaries and then accepted. Our file was no exception.

Sarah decided to start IVF toward the end of May, to coincide with her summer vacation as planned. What a vacation! At least she wouldn’t be surrounded by first graders every day; we would be surrounded only by our friends, all pregnant and dropping kids like crazy.

It was the baby boom’s baby boom, and we were right smack-dab in the middle of it. The great issues of the day? Diaper service versus disposable diapers, not the federal deficit. Strollers and battery-operated swings. Each baby shower or visit with friends emphasized our social uniqueness. We were the ones without kids. Our friends knew our situation and weren’t so foolish as to tiptoe around us. We didn’t want that. There was just a hint of something, a subtle inadequacy, an inability to share. It wasn’t dominant, but it was pervasive.

In May Sarah and I met Ruby in her office. She gave us a booklet about in vitro fertilization and embryo transfer and a general treatment calendar. As we looked over the schedule, St. David’s program started to look like boot camp.

The intensity of it slapped me hard. There was a month of injections. Sarah abhors shots. One of the syringes was on the table. The needle was one and a half inches long. Sarah shuddered. One option was that I could give Sarah the progesterone injections. Were they kidding? A shot a day for as long as four weeks?

Besides the actual injections, there were all the hormones that would be administered. Chemicals, lots of them: progesterone, Pergonal, and clomiphene. What were the side effects? One was an increase in emotional highs and lows. Just our expectations of the program yielded enough depression, joy, and anxiety without any chemical assistance. Would depression become melancholia? Would apprehension twist into paranoia?

There were also rare physical side effects. Hyperstimulation syndrome: dangerous swelling of the ovaries and fluid draining into the abdomen. Shock. Blurred or double vision. One death had been recorded when Pergonal was first used, before the drug was monitored. The probability of severe side effects was minimal, but not minimal enough for us to overlook it blithely. As for the more possible side effects, Sarah could expect headaches, tenderness, bloating, cramping. And, of course, pain.

Then there was surgery. Somebody would be cutting into my wife. I remembered her first operation. I waited outside and envisioned Sarah’s lying on a black-padded stainless steel table, and nurses lifting her limp body, positioning her. The utter helplessness of it all. The image overwhelmed me. I could never forget it.

And then there was the waiting, waiting to see if you got past one stage, if you could go on to the next. Eight out of ten couples failed IVF—the 20 per cent success rate is based only on the number of pregnancies. If you made it past the injections, the side effects, the surgery, the waiting, you would have spent a little under $5000, you would both be emotionally pulverized, your wife’s arms and hips would be bruised, and she would be either pregnant or not. That, in a nutshell, was in vitro fertilization.

I looked at Sarah. Though she had been listening and taking notes, she seemed astonished. She was thinking about the manipulation from the chemicals being injected every day into her 115-pound body. Everything had to be ready at the right time for that to work. Half seriously, she said she was wondering whether she would survive it all. She laughed apprehensively, then quieted, her lips pursed tight in determination.

Then we saw under item number four in the risks and hazards section of the IVF consent form: “In addition, there is the possibility that the early embryo(s) may implant in a fallopian tube causing an ectopic (tubal) pregnancy that would require surgery for treatment.”

I came unglued. Overprotection, lack of trust, insecurity, ignorance, fear, and anger—it all boiled out. I saw my wife being used as a guinea pig in an experimental program. It was barbaric, medieval, and fly-by-the-seat butchery. Why didn’t they perfect this on animals before they did it on humans? Why did they feel that 20 per cent was an acceptable success level to offer us? I didn’t consider 20 per cent to be a solid record of achievement. They might as well wave a smoking stick in the air and mutter incantations to Niobe. The program amounted to about as much. Did they really expect us to judge something like IVF rationally? Infertile couples who want children don’t make rational decisions; they don’t use logic. Put reason up against emotions in such a situation, and nine times out of ten reason gets decapitated.

Sarah let me spew. She was used to my narrow-minded, cynical tirades. She didn’t say much, just laughed nervously. Though she was becoming acutely aware of the physical and mental sacrifice, she saw the possibilities. I only saw the pain she would suffer.

My philippic exhausted me. I had assailed Ruby, but she had heard it before. There was another reason my frustration churned into anger. I didn’t like being put in the position of having to make a decision to resort to IVF. Ruby and Dr. Vaughn sympathized with our frustration, but no one really could understand until they shared our anguish, until they went through something like this.

The next night I told Sarah that I didn’t want to go through with it. Too many chemicals were required to make her body do something it couldn’t do. I wasn’t comfortable about the side effects, even though statistics indicated the low odds for the severe effects. But my wife wasn’t a statistic. And there were the shots that she would have to have, some that I would have to give her. I would be hurting her, and both of us knew it. Would she hate me just for that moment during the shot? IVF was too new and its standards were too broad to cover all of the gray area where decisions were made. Let St. David’s get some treatments under way first. The more research that was done, the more chance there would be for a medical breakthrough. We had time, at least a couple of years.

I held Sarah by the shoulders. We wanted children, of course, but not at her expense. The risks were too great for the slim chance of success. That was my argument. I had only one other thing to say: the final decision had to be hers. It was her body that would be mortified; her sacrifice would be far greater than mine. She had the right to decide whether we would go through it. I asked her not to tell me right away.

I had to leave town on business for a few days, and by the time I got back, Sarah had decided. It bothered her that I had changed my mind two weeks before we were to begin the program, because she never considered not doing IVF. Her logic was simple. If she tried it and by chance it succeeded, we’d have a child; if she didn’t try IVF, we wouldn’t have even that slight chance. Therefore she wanted to go through with it. She believed that it would be worth it; she would just have to get used to the shots. I had known that that was going to be her decision. Ruby had said that women who went through IVF were heroes. She was right. Husbands were supernumeraries in the IVF drama; the wives made the real sacrifice. Injections, chemicals, surgery, waiting, waiting, waiting—all for a 20 per cent chance of success. I would never understand maternal zeal. Before we knew it, the ordeal had begun.

On May 26 Sarah received her first injection of Pergonal, a preparation of natural hormones given to stimulate the ovarian follicles—blisterlike sacs on the ovary. Theoretically, each sac contains an egg. As the follicle grows, the egg within matures. In IVF, when you stimulate the follicles, you hope to stimulate the eggs. A nurse gave Sarah the shot at St. David’s emergency room. Though a quick injection of two cc’s of Pergonal, about a quarter of the length of a number two pencil, it was painful, and Sarah’s hip hurt the rest of the day. When she got home, I made a map with two spheres signifying Sarah’s buttocks. I put an X where each injection went. That way, we wouldn’t forget where each one was. It was our butt map. It was worthless. After the first few injections I gave up on the map. The injection had to be given in about the same stamp-size area on either hip away from the spine, away from the hipbone, and into the muscle high on the buttock. If the injection was too close to the spine there was a danger of infection if it hit the bone, or if it hit the sciatic nerve, paralyzation; too close to the hipbone, and there was more pain. Hitting the right spot was no consolation—it hurt anyway.

Three days into the program Sarah began taking a synthetic fertility drug, clomiphene. Its chemical makeup looks like estrogen, and it works indirectly on the ovary by masking the amount of estrogen present, fooling the brain into increasing the stimulation of the ovaries. During her lunch hour, she had to leave school and drive to the hospital for her daily Pergonal injection. Ruby gave Sarah the second injection of Pergonal. This time it took a minute and a half to inject; the emergency room nurse had done it too fast. Ruby explained that the shot should be administered slowly for Sarah because of her body type. Sarah called me to tell me how it went. It had been very painful; she had almost fainted. I wanted to know if she was having any reaction to the drug yet. That was most in my thoughts. She was worried about headaches. Though so far there were none, we were waiting for the side effects. It was like standing out in a field during a thunderstorm.

Several more days of shots went by. School was finally over, but there would be no break for Sarah. With more injections and fertility drugs, the pain and discomfort increased. The heating pad was now part of Sarah. She stayed on it day and night. I was concerned that it would raise her temperature and affect other more delicate things, like a BB-size follicle. Approaching medicine with a layman’s logic, I called Ruby to see if that was true. “Would heat hurt anything?” Nah, it didn’t matter.

Remember when we were told to brush our teeth in a circular motion? Well, some years back, that was changed to a downward motion. A circular motion was wrong. Medicine is like that too. It gets amended. Remember thalidomide? Remember when DDT didn’t cause cancer? Remember when you used that heating pad? Remember when we injected your wife with progesterone? That’s why I always asked questions based on a logic that most doctors laugh at. That’s why I usually got an answer sounding like, “You stick to your business, and we’ll stick to ours.” Or, “Nah, it doesn’t matter, and when it does we’ll let you know.” My wife’s body was at the mercy of medical science. Advanced, yes; deductive, certainly; unpredictable, always. It was part of the ferment of my cynicism.

The second week was rough. Dr. Vaughn was watching Sarah’s estrogen level and the growth of the follicles in the right ovary to determine how many eggs he might get and when he could perform the surgery. He looked for an estrogen level of 800 to 1600 picograms per milliliter in the blood and a follicle size of 18mm, about the size of a grape.

Monitoring was done by checking the estrogen level in the blood and examining the follicles on a sonogram, a picture produced by sound waves bounced off the pelvic area and picked up on a computer screen, a sort of body radar. Sarah reported to St. David’s lab at seven-thirty every morning for a blood draw. Afterward, we would go across town for the sonogram. She would get her Pergonal injection around midday depending upon the results of the sonogram and her estrogen level.

That was a two-heating-pad week, one for her butt and one for her arm, where the blood was drawn. Sarah asked for a phlebotomist who was experienced with squeamish victims. Every bit of empathy helped her with the needles.

Fortunately the ultrasound was painless, though uncomfortable. Sarah had to drink a quart of water before the sonogram, so that her bladder would fill, making the abdominal area more pronounced. Chris Kellogg, one of the ultrasound technicians, was very kind and helpful, pointing out on the screen the follicles on the ovaries and other internal minutiae. Ultrasound technology still needs refining. The low resolution and definition is reminiscent of TV in the fifties. Sort of like trying to pick out a white dog in a snowstorm. But things like the small, pea-size follicles were visible enough to tell the doctors what they wanted to know. In our case, Sarah had one 9mm follicle visible on the left ovary and two on the right ovary, of 9mm and 10mm.

We called Ruby every morning to get Sarah’s estrogen level. One morning’s blood sample showed a level of 550 picograms per milliliter. Sarah was encouraged, because her body was responding to the stimulation. But the follicles and the estrogen level needed to double in size within four days if we were to go on to surgery. At that time Ruby wouldn’t list your name on the board in her office unless surgery was certain. To be listed on the board was an indication of partial success. We weren’t there yet, and the image of the board lingered in Sarah’s mind.

On the ninth morning, a phlebotomist drew two more tubes of blood. Then we drove over for the ultrasound. It was eight-thirty on Sunday. Chris seemed to snap out of his early-morning fog as he slid the ultrasound scanner over Sarah’s lower abdomen. Three follicles were visible on the right. They were 9mm, 11mm, and 12mm. The left still had only one follicle, but it had grown to 12mm. Dr. Vaughn wanted to see at least two 18mm follicles before he would operate. We still had a way to go.

Sarah’s estrogen level, on the other hand, was 1154. It had doubled overnight. Dr. Vaughn didn’t want her to have an injection that day, because the level was high enough. So she got a much-needed reprieve from the Pergonal. Her hips were swollen and bruised; lying on either side was painful. We heard that some women had no problem with the shots even with twice the dosage Sarah was getting. Of course it helped to have a layer of fat on one’s posterior to buffer a one-and-a-half-inch needle. Sarah was not so fortunate. She was paying the price for a taut body.

The next morning’s sonogram showed most of the follicles had stopped growing. One more was visible, but others had gotten smaller. And Sarah’s estrogen level had dropped to 662. She resumed the injection schedule because the estrogen had not increased on its own.

She was disappointed that her body couldn’t produce enough hormone. It seemed to continually need external catalysts to make things work, as if it were unnatural. She started thinking about getting canceled and not making the board. She began to consider when she could repeat the program.

But by Tuesday morning the follicles had started to grow again. They were at 15mm, 12mm, 7mm, and 7mm on the right ovary and 13mm and 11mm on the left. We were encouraged, but the sizes and the 780 estrogen level might not reach the accepted threshold in time. We were still afraid that we would get canceled.

There was some relief at the prospect of failure, of reaching the goal we had drilled into our heads. Going through the apprehension, anxiety, and pain a second time did not seem unreasonable, though. We weren’t alone in this strange dialectic, this charge of the Light Brigade mentality forged of parental desire. Of the program’s 33 couples, four returned to try again. Two of those would have their babies in October. If we were eliminated, Sarah wanted to try again in July. I heard myself agree with her.

The next day, a Wednesday, was a bad one—four blood draws. Dr. Vaughn was looking at the estrogen level and for a surge in luteinizing hormone, which signaled egg maturation. When the LH level surged, ovulation, or the follicles’ release of the eggs, was near. If it surged, Sarah would go into surgery a day earlier. If it didn’t surge, a human chorionic gonadotropin injection, which boosted LH, would trigger ovulation anyway in 36 hours. The HCG would be injected today if her follicles and estrogen showed enough cooperation to warrant continuation of treatment.

They did. Kellogg found one follicle on the right at 18mm and one on the left at 17.5mm. Three others were visible, two at 14mm and one at 11mm. The radiologist couldn’t believe that the follicles on the left had grown so much. Dr. Vaughn was pleased. He planned to go ahead with surgery in two days, even though the large one on the left might not be accessible. He said he would try to remove three eggs from the right ovary and any he could get from the left. The only barrier to surgery would be the estrogen level, which needed to be at least 800.

At eleven-thirty Sarah went to Ruby’s office to await the estrogen results. Her level was 1350. Ruby and Sarah dashed across the courtyard to the lab for the LH blood draw. The technician drew three extra tubes of blood for Repp to process for the embryo culture medium in which her eggs and my sperm would fertilize.

Because of the high estrogen level, Sarah won another reprieve from her Pergonal injection. All that remained were the blood draws at three-thirty and seven-fifteen.

We had an early dinner before the last blood draw. If the tests showed an LH surge, Sarah would be scheduled for surgery the next day. To cover that contingency she was to begin fasting at midnight. I figured Sarah’s last meal might as well be a good one. We went to Ruth’s Chris Steak House and ordered a banquet. I kept the scotches coming, but Sarah wasn’t up to it. The emotional and physical demands of the day had exhausted her. We still weren’t sure whether she would make it to surgery or what Vaughn would be able to find or get. And if she did make it to surgery, there was still a month and a half left before we would find out whether any of this had been worth a damn.

We were awakened the next day by a call from Ruby, who told us that the LH hadn’t surged. If it had, that would have meant that Sarah was about to ovulate and we would have gone to surgery early. That was if we were lucky. For some IVF patients the LH surged either too late at night or too early in the morning for surgery to be scheduled. They would be canceled at the last minute. But Sarah’s didn’t surge, which meant the HCG, the LH surrogate, would kick in and cause her to ovulate on time. Ruby set Sarah’s surgery for Friday morning.

At three-thirty Ruby called. We were to report to St. David’s Day Surgery Center at five-thirty in the morning. Sarah could eat light foods, but she would have to start fasting at midnight before surgery. Also, Ruby was going on vacation for a week the day of our surgery. I joked that she had abandoned us to the capricious whims of strangers; Sarah wasn’t so lighthearted about it. She had come to rely on Ruby for more than shots. Ruby was the conduit for the immediate good or bad news.

When we got up at four-thirty, Sarah’s sides were sore from the swelling of the ovaries in preparation for ovulation. As we drove to St. David’s, Sarah said she was concerned that there wouldn’t be any eggs. We had no guarantee that each follicle contained an egg; the ultrasound couldn’t show what was inside a follicle.

At day surgery, a nurse gave Sarah a drab gown while I made coffee for myself and others just arriving. John Repp showed up. He would take the eggs that Dr. Vaughn hoped to remove. I went to the room where Sarah was filling out surgery releases. The anesthesiologist, Dr. Gary Mihm, came in. He ran down a list of “have you had this or that?” questions. Spotting cough medicine on the nightstand, he asked about it. Sarah had had sinus congestion all week. Mihm listened to her chest. Vaughn then entered and asked about her health and also listened to her chest. The doctors discussed Sarah’s congestion, then Mihm left. Vaughn explained that because Sarah was not in perfect health, the anesthesia presented a greater risk. He suggested that we might wait for the next cycle, in July.

I asked Vaughn whether Sarah’s condition warranted grave concern about the surgery and recovery. No, not grave, just enough to mention the risks. Sarah and I looked at each other. She was sitting on the bed in her surgical gown and leaning forward, her feet in paper slippers tapping at the floor. There was no hesitation in either of our expressions. I knew damn well that she wanted to go ahead. She knew I did too. We hadn’t gone through thirteen days of shots and pain and chemicals for nothing. There was no need for us to talk it over. I told Vaughn we both wanted to proceed. He left. It was only six-fifteen and still too dark to see anything outside. Sarah chuckled at the drama, but she was concerned that there was still a chance of being canceled at the last minute.

Vaughn came back in. “Let’s go,” he said. I wished him luck. A nurse entered and gave Sarah a blanket. It was cold in day surgery. The nurse told me to kiss Sarah good-bye and then led her away.

I did my best to read Leon Hale’s Easy Going while Sarah was in surgery. I wandered, made some phone calls, bought a pack of cigarettes, smoked one. During my listless peregrinations, the IVF team worked.

Mihm put an IV into Sarah’s arm and injected the anesthesia while a nurse put life monitors on her chest. As Sarah was getting drowsy, Vaughn asked her if she was ready. She said yes, wished him luck, then fell asleep. Vaughn got to work.

He made four small incisions, about half an inch each. One, in the navel, was for the laparoscope, an internal telescope about the thickness of a golf club shaft. Below that incision, one was made for the hypodermic needle that would collect the follicles on the right ovary. Another incision was made for a grasping instrument to hold the ovary in place. The last incision was needed for a grasping instrument to push the colon out of the way. This was delicate surgery, and it took place in an area the size of a soup bowl.

Dr. Vaughn slipped the laparoscope into the abdominal cavity. The light attached to it enabled him to see the lemon-shaped ovaries. He searched the right one for the blisterlike follicles on its surface. When he saw a follicle he wanted, he stuck the long large-gauge hypodermic needle inside the blister and drew fluid through the needle and into a test tube. In the fluid, he hoped, was an egg—smaller than the dot over an i.

John Repp took the tube to the lab to look for the egg under the microscope. Meanwhile, Vaughn was seeking out another follicle. Each time he opened one, a tube was taken to the lab for Repp to examine. That kept the nurses busy—assisting the doctor, delivering tubes to the lab, taking notes on where the follicles were so if Repp didn’t’ see an egg, Vaughn could go back to the notes to help him find the follicle in question and maybe retrieve the egg. As it turned out, Vaughn entered twelve follicles and found three eggs. Within an hour Sarah’s incisions were stitched up and she was in recovery.

I was on the bed reading when he came to tell me about the three eggs. They were from the right ovary and were very mature. The left ovary, though, was badly damaged. It bled every time he touched it. I asked if he had had a chance to look at the left fallopian tube. Maybe it was no longer damaged, and we would have another chance of natural conception. He said there was little hope of the tube’s ever working, but he was pleased with the surgery. Repp then came to the door with a look of expectation on his face. It was time for me to perform the one duty expected of husbands in the IVF program. I had come prepared.

The Playboys placed in the masturbatorium to gratify someone’s conception of what every male wants were much too lame for a real man like me. So I had borrowed a dirty magazine from my friend Kevin—another real man not intimidated by prurient exploitative trash. I sneaked Party Pieces #1 into the room in a manila folder beneath a United Way agency’s board report and Stephens’ Incidents of Travel in Central America, Chiapas, and Yucatan. No one suspected a thing.

After I dropped the sperm off at Repp’s office I called our folks and friends to let them know about the three eggs. Everyone was excited. Sarah came out of the anesthesia clearheaded. I told her about the eggs and that Vaughn was pleased. She was happy—she had done a good job.

The eggs still needed to be fertilized and divide, transfer and adhere to the uterus. Sarah’s body would still be manipulated with hormones. But Sarah felt good, we were happy, and John Repp had three very mature eggs to work with.

What followed was, to me, the most fascinating aspect of IVF. Repp would take my living sperm and Sarah’s living egg and allow them to conjugate to produce a new life. He would be there at the incipient stages of human life, at the initial formation of human beings, Sarah’s and my human beings.

Perhaps for many, the primordial embryonic stew was not of real consequence. Perhaps to them a matter of choice was more important than a matter of life. For us, however, fate decreed that viscous, spittle-size blob a matter of the utmost importance. St. David’s agreed. A normal, healthy fertilized egg was sacrosanct. It was not that it could be transferred, it was that it had to be. It was life.

Certainly Repp’s job took on a moral and ethical burden, but it was mainly one of technical, not philosophical, expertise. He took my sperm and washed it to separate the gametes (the reproductive cells) from the fluid, which he didn’t need. While washing, he concentrated the sperm into a small amount of fluid by centrifuging it so that he could draw the sperm into an eyedropperlike pipette. He introduced the pipette into a test tube about half filled with a solution of salts, vitamins, minerals, sodium bicarbonate, and 10 per cent serum from Sarah’s blood. This procedure was a sperm “rise” or “swim up,” so called because the sperm moves in one direction, working its way to the top. That eliminated all the non-motile sperm. It also reduced any abnormal sperm by 90 per cent.

From those that remained, he drew about 200,000 sperm for each egg. Sarah’s three eggs, one to a petri dish, were suspended in the solution. Repp labeled each dish with Sarah’s name, the kind of medium in the dish, and a number for the egg. He then injected the sperm into each dish. The sperm, at that point about six hours old, dispersed and began a task dictated by eons of evolution. Repp placed the petri dishes in a small refrigerator-size incubator, where the sperm moved through the solution to the egg in the 98.6-degree temperature of the incubator’s profound and dark stainless steel womb. In about sixteen hours, the eggs would either be fertilized or not. Any one of them could be our future child.

They fertilized. All three. John Repp called the next morning to tell us the good news. We were all excited. He always got excited even though it was old hat to him. Repp knew his eggs. He was getting 86 per cent of the program’s eggs fertilized. But fertilization wasn’t the only step toward transfer; the eggs had to divide. To help them along Repp placed the fertilized eggs into a growth solution, which had more of Sarah’s blood serum. Then they went back into the incubator. Twenty-four hours later, Repp would look at them again.

When he checked the eggs the next day, they had begun to divide. Two were four cells and one was at five cells. Repp called them embryos when he gave us his report. We were to be at day surgery at six-fifteen the next morning so that the embryos could be returned to Sarah.

We arrived full of anticipation. This was the climax of the treatment, what all the stimulation was for—to get Sarah’s eggs, let them fertilize with my sperm, and return them to where they belonged.

I had heard that I could be in the operating room for the transfer, but I wasn’t so all fired up to be there. I didn’t know what Sarah would be put through. When Repp told me that two of the embryos were eight cells and one seven, though, I knew I would be there. I wanted to see them, our embryonic children. Hell, it might be the only time I would see any offspring that we’d ever have. Repp said it wasn’t possible. He had taken pictures, and we could have copies. Our first baby pictures. Sarah and I would be armed with something to pull out and coo over at friends’ homes. Vaughn came in and cut short my daydream by motioning us into the operating room.

Surgery was a room crowded with machines and trays arranged around an operating table. Lights and flexible tubes hung from the ceiling, and green-suited nurses crisply readied an altarlike table. Someone had tried to add human touches to the room by taping posters of hot air balloons and mountains to the glazed-brick walls. It didn’t work.

And so it was all business to the nurses when we entered. One rolled a stool to the head of the table and commanded me to sit. Another helped Sarah onto the table as the rigid polished arms that clasped the calf brace and stirrups were installed. The nurses positioned Sarah’s legs in them, and a green sheet was placed across her stomach. I was beginning to feel nauseated. Vaughn came in, gloved, and sat on a stool at the foot of the table. He had the table tilted up slightly and the lamps adjusted for maximum light. Repp entered, waiting for a signal from Vaughn to bring in our embryos. A nurse handed Vaughn as alien a piece of stainless steel as I had ever seen, a speculum. Vaughn’s head disappeared below the draped sheet that mercifully blocked my view. He nodded to Repp, who went across the hall to his lab and carefully picked up a wandlike catheter with a syringe attached. Before we entered surgery he had grouped the embryos together into one dish. He then placed the catheter into the giant drop of liquid. When he pulled back on the plunger, the catheter filled with Sarah’s maternal serum and the fertilized eggs.

Repp returned, cradling the catheter as he walked over to Vaughn. Like two brothers passing an infant, Vaughn received the catheter gently and removed it from a sterile protective sheath. He then leaned toward Sarah and asked her to remain very still. He eased the catheter past her cervix and into the uterus. He pushed on the plunger of the syringe and released the embryos into the natural void. The transfer took all of one minute and fifteen seconds.

As a precaution, Vaughn gave the catheter back to Repp, who went back to the lab. There, he would check the tube under a microscope to make sure that all the embryos were out. If by chance one remained, Repp would return the catheter to Vaughn to redo the transfer. But no eggs were left. They were somewhere inside Sarah’s uterus and to accommodate them, she was instructed to stay perfectly still. We did, Sarah inclined and me at her head, for about five minutes.

It was an unpleasant passage of time. I was confused by an emotion that had raced through me during the transfer. I couldn’t pin it down. It lasted only about five seconds, but my throat thickened and my eyes teared when the transfer took place. It wasn’t joy or sadness. And it wasn’t hope.

I tried to mentally joke about this clinical sex, to overpower the wave that swept over me. I envisioned the nurses kicking back, lighting up cigarettes. We would all talk about how it was after the transfer. “Was it okay? Did you like it?” But my protective humor was thin. I couldn’t laugh. I couldn’t move. I looked over the sheet covering Sarah’s legs, toward the brick wall in the unfriendly blue-accented room. The shine of stainless steel was everywhere. I was very cold. The emotion again moved from my chest to my throat; my eyes misted. And then I recognized the feeling. It was shame.

Some nurses entered pushing a gurney. They slid it next to the table and tilted it. Sarah wasn’t to move a muscle. Vaughn and Repp adroitly slid her onto the gurney and rolled her to her room. She would be there for five hours, remaining still.

What happened when a fertilized egg was naturally released into the womb from a fallopian tube? What communicated between the folded uterine walls and the embryo’s gelatinous covering? What caused the two linings to intermarry, join, and develop? No one knew. Vital embryos could be transferred, but only a small percentage developed to join the living world as an infant. What happened to the embryo after the transfer was the enigma in IVF that sustained the low success rate. Medical science had done what it could. It was up to Sarah now.

She had talked to her sister, Mallory, in California before the transfer. She told Sarah to think good thoughts, relax, to imagine her womb as the best of all possible worlds, and other Californiana. For once I thought the advice was good. Sarah’s positive thoughts flowed while she lay tilted on her back: find a place, burrow deep. I accept you every one and hope you become my children. She tried to doze but couldn’t sleep.

Dr. Vaughn had prescribed progesterone to begin after the transfer. That might help reduce the chances of miscarriage. There would be an injection a day for at least two weeks, and I had agreed to give them to Sarah. I told myself that if I really loved her, I could do this. Some reasoning. Now my fortitude was deserting me. I had to get out of there. I drove around. Sometimes that helped; that time it didn’t. I went over to Kevin’s and smoked a couple of his cigarettes. I got nervous from being gone too long from the hospital so I went back.

Sarah was awake and still tilted when I returned. She said she wouldn’t mind if all three took, she couldn’t single out one to make it. Twins would be fine, especially since she wanted to have more than one child but didn’t want to go through IVF again. She was sure about one thing: if she got pregnant, she would stay pregnant. There weren’t any excuses of bad tubes to use now. I agreed, but I wasn’t going to get my hopes up. I just wanted Sarah to relax and was relieved that most of it was over, no matter what.

Sarah reminded me to go to the pharmacy in the hospital annex to pick up the progesterone. There I got a paper bag that contained a vial of progesterone and a two-week supply of syringes and needles. I took out the box with the vial of progesterone. Stuck inside was a yellow strip on which was emblazoned in bold type “Warning for Women.”

While reading the warning, I took a wrong turn back to St. David’s. There was much new construction going on, and I wasn’t paying much attention to my path because of the first paragraph on the flimsy yellow flag.

“There may be an increased risk of birth defects in children of women who take this drug during the first four months of pregnancy.” I walked up and down the same flight of stairs twice while I was reading. “These drugs have also been used to prevent miscarriage during the first few months of pregnancy. No adequate evidence is available to show that they are effective for this purpose.”

I raced across the courtyard to day surgery. I ran to the desk and read the warning to the nurse. “…one study fond that babies born to women who had taken sex hormones (such as progesteronelike drugs) during the first three months of pregnancy were four or five times more likely to have abnormalities of the arms and legs than if their mothers had not taken such drugs. Some of these women had taken the drugs for only a few days.” She discounted such foolishness with a shake of her head, “Don’t worry about it.” Dr. Vaughn had prescribed it, Ruby had approved it, the nurse said it was okay, and Sarah consented, at least tacitly. We had come this far without bucking the system, and we hadn’t been canceled. I followed the nurse into Sarah’s room.

She showed me how to prepare the injection, how to switch the needles, and how to fill the syringe. I exuded confidence. I didn’t want to show Sarah how shaky I really was. The nurse would do one hip, then I would do the other. She popped the needle in like a dart, drew back on the syringe to make sure there was no blood, then pushed in the hormone. Sarah said it hurt like hell. My confidence began to dissipate.

Sarah slowly turned to her other side, her eyes drilling a warning into mine. Though afraid that I would hit a nerve or a vein, I took a breath and committed myself, plunging the needle in. After checking for blood and injecting the progesterone, I pulled the needle out swiftly and massaged Sarah’s hip. It was a job I never got used to even after giving Sarah 28 injections. I hated doing it. My hands shook and my heart pounded after every one. But I was the best—she told me so.

Very little, however, could dampen Sarah’s mood that day. An orderly rolled her out to the curb, and she slid from the gurney into the car for the drive home. None of that “it won’t work” attitude now. We had to be positive. It wasn’t forced. Sarah perhaps was utilizing some of that maternal feeling, enveloping the three eggs within her in a safe and welcoming home. Dr. Vaughn had prescribed bed rest for the remainder of the day and limited in-home activity for two more days. We had to wait two weeks for our first pregnancy test. Though it was unspoken between us, I knew Sarah planned to spend most of that time as inactive as possible.

For the next week, we lazed around the house. I injected Sarah every day around noon. Her body began making changes, subtle changes. Any tenderness or swelling, each cramp or stitch we would interpret. It could have been the hormones, we supposed, but it also could mean that Sarah was either pregnant or miscarrying, a cruel similarity. Since she had miscarried before, we were that much more apprehensive, that much more susceptible to the uncertainty that the waiting fostered.

A week passed. We were at Day 24. Sarah had a blood test to assess her progesterone level. Pregnant women are supposed to have high levels of the hormone. The blood was sent to Dallas, and we got the results in two days: her progesterone level was high—a good sign. Sarah couldn’t get comfortable. During the next week, she seemed to be doing well emotionally, though her dreams told otherwise. They were filled with mansions and rooms and hallways and walking. I remembered fewer dreams; I slept less.

One night Sarah spoke from her sleep. “The roof’s on fire, get up and check.” I looked out the window into the unilluminated night. “It’s on fire?” I asked. “The roof’s on fire from the cinders of my dream,” she murmured, tossing her head. I thought she had been listening to some bad sixties folk music and caught some kind of mental ptomaine. But I wasn’t doing so hot myself. I dreamed that we were driving up a drawbridge. The bridge lifted as I drove. It raised higher and higher, and I was afraid, afraid we would crash backward into cars or plunge off the bridge. I woke up before we tumbled from the ramp. There was something funny in the dream. In the back of the car, strapped in properly, was an empty infant seat. I shook my head clear.

Neither one of us slept the night before we would learn the final results of the pregnancy test. As the night wore on, the anxiety and lack of sleep made us both sick to our stomachs. Three years of anticipation and grief massed thickly with the last 31 days into one night of joy, fear, anger, and guilt. How could we sleep?

Sarah got up early; I stayed in bed, awake. We kept saying to each other that we’d be all right if it didn’t work out. We hoped we would believe that.

Sarah called Ruby at seven-forty-five. I was still in bed, and Sarah stood next to me with the phone. The moment was glacial. Ruby answered the phone. Sarah’s facial expressions indicated that the IVF hadn’t worked.

Actually, what Sarah’s face indicated was that Ruby had tried to call us but couldn’t find our number. It was unlisted, and she had called the wrong one.

Then Sarah said, “I am?” She beamed, her eyes glazed. She was pregnant. I turned my face into my pillow as Ruby gave Sarah a list of dos and don’ts to follow. Sarah hung up. I looked at her; we both had a look of dumb joy on our faces. We couldn’t believe it had actually worked. We were part of the lucky few. We quickly dialed our friends and relatives. They too rejoiced with us.

In three weeks Sarah would have a sonogram. That would be the real test for me. I wanted to see the embryo. By then we would see the heart beat. That flicker of life was the proof I wanted, the proof to dissolve my doubt.

Dr. Vaughn wanted to continue the progesterone injections. Sarah switched to having them injected in her arms; her hips had worn out. The arms were more painful than the hips. But she was keeping this baby, and if that meant getting shots that might prevent miscarriage, so be it. We still analyzed the slightest cramp or physical change as a symptom of pregnancy or the precursor to miscarriage, but we were more relaxed about everything. Sarah had shots for ten more days. She calculated that she would have had a total of 53 injections or blood draws in a little more than a month. She was ready for them to end. With the shots over, there was nothing to do but wait for the sonogram. All the results to date were good, and I treated Sarah as if she were pregnant, meaning that I was overprotective.

When it came time to do the sonogram, we were sent to Dr. Byron G. Darby. We held our breath as he dragged the scanner across Sarah’s abdomen. The image on the screen transformed from blobs to defined shapes and back to blobs. Darby focused on one shape while adjusting the machine’s contrast. It looked like a black bean. It was the gestational sac. Darby looked for the heartbeat or a nub or an embryo. Neither was there. He said it was still too early to tell. As for Sarah’s pregnancy? He called it an “unequivocal maybe.” He wasn’t negative, though. It was just too soon to tell. He mentioned that another one of Vaughn’s IVF patients had had the same thing; the embryo was visible a week later.

I asked if the sac’s position was good. Darby said it was in an excellent place in the uterus. I asked what would happen if the sac were empty. Sarah would probably start to miscarry. He would see us again in a week and would let Vaughn know what was going on. He joked that Vaughn was trying to get his patients in earlier and earlier. It was simply too soon to know anything.

Dr. Vaughn called that afternoon. He said that the sonogram was good or bad news. Either it was too early to see anything or the pregnancy was bad. We would just have to wait another week, hoping that Sarah was pregnant, and if she were, that she wouldn’t miscarry.

That was a long week. As it progressed, so did our confidence. Sarah didn’t miscarry. We both were sure she was pregnant. Our appointment with Darby was on Monday, July 22. The fifty-ninth day since we began in vitro.

Monday came. After leaving Dr. Darby’s office, Sarah made it to the elevator before she started crying. I remember reading something about Hiroshima after the bomb was dropped. The people walked around but they seemed dead. Their expressions were glazed, they were shocked from the enormity of the blast. That’s how I felt when Darby quietly turned to us and said that the sac was empty. There was no embryo, no baby. It was a blighted ovum. In about one out of eight of all pregnancies, the embryo doesn’t develop. They don’t know why; it just happens. He said he was sorry. That was it.

On the drive home Sarah began to blame herself through the tears. She felt somehow responsible, that something was innately wrong with her body. My guilt was reborn; I was responsible. We succumbed to such punishments in a search for blame. But we knew we couldn’t really blame ourselves. Looking for purpose only did one thing; it unearthed my faith. That trickled back after I quit asking why.

Our cherished intention simply was denied, turned awry for reasons we would never understand.

We couldn’t blame Dr. Vaughn. No matter what happened, we wholeheartedly believed he had done the best he could with the skills and knowledge at hand. Were his intentions any less than ours?

I still had my doubts about the program, but the science of in vitro fertilization and embryo transfer came down to one hard reality. A 13 per cent chance was better than nothing. Ask those four couples who had ongoing pregnancies.

They had made it; we had failed. Our desire was like that fragile gestation sac, never filling, a potential deliquescing into emptiness. The emptiness hurt. But like that sac, it was absorbed back into our system, and time began its slow dissolve of joy and grief.

So that was that. We had some IVF syndrome, I guess you’d call it. Despondency, a few dreams wracked with frustration and anguish, tears out of nowhere. For 28 other couples like us, IVF had become a cruel joke or an unfulfilled hope. We wouldn’t be the last.

There are two sides to a coin. Our friends Jeff and Claire had a ten-pound boy; Kevin and Mary a nine-pounder. Whoppers, both of them. We couldn’t help but smile, and though we might feel a pang for a second, our friends didn’t begrudge us that. In fact, their babies germinated hope in us.

We want to try IVF again, while we have the chance, before our age prevents us from trying. IVF gives us hope. It’s a qualified hope, sure, but that’s what God’s for, right? And what’s not under his purview, statistics get.

We’ll accept those statistics, IVF’s meager offering. We have made our choice. We want to have children. It is, after all, the only choice we have.

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