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The Art of Waiting

On Fertility, Medicine, and Motherhood

Graywolf Press

The Art of Waiting

It's spring when I realize that I may never have children, and around that time the thirteen-year cicadas return, tunneling out of neat, round holes in the ground to shed their larval shells, sprout wings, and fly to the treetops, filling the air with the sound of their singular purpose: reproduction. In the woods where I live, an area mostly protected from habitat destruction, the males' mating song, a vibrating, whooshing, endless hum, a sound at once faraway and up close, makes me feel as though I am living inside a seashell.

Near the river, where the cicadas' song is louder, their discarded larval shells — translucent amber bodies, weightless and eerie — crunch underfoot on my daily walks. Across the river, in a nest constructed near the top of a tall, spindly pine, bald eagles take turns caring for two new eaglets. Turtle hatchlings, snakelets, and ducklings appear on the water. Under my parents' porch, three feral cats give birth in quick succession. And on the news, a miracle pregnancy: Jamani, an eleven-year-old female gorilla, is expecting, the first gorilla pregnancy at the North Carolina Zoo in twenty-two years.

I visit my reproductive endocrinologist's office in May and notice, in the air surrounding the concrete-and-steel hospital complex, a strange absence of sound. There are no tall trees to catch the wind or harbor the cicadas, and on the pedestrian bridge from the parking deck, everyone walks quickly, head down, intent on making their appointments. In the waiting room, I test the leaf surface of a potted ficus with my fingernail and am reassured to find that it is real: green, living.

The waiting room's magazine selection is scanty: a couple of years-old New Yorkers, the address labels torn off, and a thick volume of the alarmingly titled Fertility and Sterility. On the journal's cover is a small, square photograph of an infant rhesus monkey clasped by an unseen human's hands in a white terry-cloth towel. The monkey wears a startled expression, its dark eyes wide, its mouth forming a tiny pink oval of surprise. A baby monkey hardly seems the thing to put in front of women struggling through the confusion and uncertainties of fertility treatment — What are those mysterious, grayish blobs on the ultrasound, anyway? — but, unsure how long I'll wait before my name is called, I reach for the journal. Flipping through, I find another photograph of the monkey and its monkey siblings, and the corresponding article about fertility preservation in human and nonhuman primates exposed to radiation. This monkey's mother, along with twenty other monkeys, was given an experimental drug and exposed to the same kind of radiation administered to women undergoing cancer treatment. On other pages, I find research about mouse testicular cells, peritoneal adhesions in rats, and in vitro fertilization of baboons.

Of course, this research was designed to study human, not animal, infertility. Nonhuman animals don't expose themselves to fertility-compromising radiation therapy; nor do they postpone reproduction, as I have, with years of birth control. Reproducing and ensuring the sexual maturity of offspring is a biological imperative for animals — their success depends on it, and in species after species we see that both males and females will sacrifice everything, their lives, even, to achieve it. But in species with more complex reproductive systems — the animals genetically closest to humans — scientists have documented examples of infertility, hormonal imbalances, endometriosis, and reproductive suppression. How do they cope? I wonder, staring at the photo of the baby rhesus monkey, its round, wide-set eyes designed to provoke a maternal response. Do they deal with infertility or the inability to become parents any better — or any differently — than we do?

My name is called, and a doctor I've never met performs a scan of my ovaries. I take notes in a blank book I've filled with four-leaf clovers found on my river walks: Two follicles? Three? Chance of success 15 to 18 percent.

On the way out, I steal the journal with the monkey on the cover. Back home, under the canopy of oak and hickory trees, I open the car door, and sound rushes in, louder after its absence. Cicadasong — thousands and thousands of males contracting their internal membranes so that each might find his mate. In Tennessee it gets so bad that a man calls 911 to complain because he thinks it's someone operating machinery.

A few days later, I visit the North Carolina Zoo, where Jamani, the pregnant gorilla, seems unaware of the dozens of extra visitors who have come to see her each day since the announcement of her condition. She shares an enclosure with Acacia, a socially dominant but relatively petite sixteen-year-old female, and Nkosi, a twenty-year-old, 410-pound male. The breeding of captive lowland gorillas is managed by a Species Survival Plan that aims to ensure genetic diversity among captive members of a species. That means adult female gorillas are given birth control pills — the same kind humans take — until genetic testing recommends them for breeding with a male of the same species. Even after clearance, it can take months or years for captive gorillas to conceive. Some never do.

Humans have a long history of imposing various forms of birth control and reproductive technologies on animals, breeding some and sterilizing others. In recent years, we've administered advanced fertility treatments to endangered captive animals such as giant pandas and lowland gorillas. These measures, both high- and low-tech, have come to seem as routine as the management of our own reproduction. We feel responsible when we spay and neuter our cats and dogs, proud when our local zoos release photos of baby animals born of luck and science.

Jamani and Acacia were both brought to the North Carolina Zoo in 2010, after Jamani was recommended for breeding with Nkosi, which was accomplished simply by housing the animals in the same enclosure. The zoo staff confirmed Jamani's pregnancy through an e.p.t. pregnancy test, the kind you can buy at a drugstore.

I ask Aaron Jesue, one of her keepers, if either Jamani or Acacia seems to have registered Jamani's pregnancy, if he or the other keepers have noticed any changes in behavior, but so far the only differences in routine are the increase in zoo visitors to the gorilla exhibit and the many consultations with scientists and zookeepers to help prepare for the birth. "Jamani is still the submissive female," Jesue says. "We'll see if that stays the same."

Many infertile women say that the worst part of the experience is the jealousy they feel toward pregnant women, who seem to be everywhere when you are trying (and failing) to conceive. At the infertility support group I attend, in the basement of another hospital an hour from home, the topic of jealousy and petty hurts frequently begins our conversations.

"I don't mind babies and children, but I hate pregnant women," says one woman, trim and pretty, with a sensible brown bob. "I hate them, and I don't care how that sounds."

So we talk about that for a while: deleting Facebook friends whose frequent status updates document their gestational cycle, steering clear of baby showers and children's birthday parties. We talk about our fears that we will be left out, left behind, while our friends and relatives go about the business of raising their ever-growing families.

The family as a socially isolating unit is an idea not limited to humans. In the wild, infants represent competition for resources, and it is not uncommon for a mother's job to be primarily about hiding and protecting her infants from members of her own species. Jane Goodall observed chimpanzee mothers completely protecting their infants from contact with other, non-sibling chimpanzees for the first five months of life, pulling their infants' hands away when they reached for nearby chimps.

In a marmoset community, the presence of a pregnant female can actually cause infertility in others, though the result is not isolation but rather increased cooperation. Marmosets are tiny South American monkeys that participate in reproductive suppression; typically only one dominant female in a breeding group reproduces, often giving birth to litter after litter before any of the others has a chance. This is accomplished through behavior — some females simply do not mate — and also through a specialized neuroendocrine response to the perception of subordination, which, like the pill, inhibits ovarian follicular development and ovulation. Some never get their chance but remain in the submissive, non-breeding category all their lives.

Marmosets make their nests in rain-forest canopies and live in groups of three to fifteen, feeding on spiders, insects, and small vertebrates. Peaceful cooperation is remarkable among marmosets, particularly in regard to infant care. All group members over five months of age — male, female, dominant, subordinate — participate, and a dominant female will allow her offspring to be carried by other group members from the first day of life. Scientists have speculated that this dependence on helpers — marmosets usually give birth to twins — is the reason for behavioral and hormonal reproductive suppression. The phenomenon of suppression occurs both in the wild and in captivity.

Occasionally a subordinate female will reproduce, although her infant has a diminished chance of survival. One reason is the practice of infanticide, which researchers have observed multiple times in the wild (more frequently, the tiny infants just disappear). Infanticide most commonly occurs when a subordinate female gives birth during the pregnancy of the dominant female, who is often the attacker. Despite the apparent brutality of such a system, it does not seem to diminish social relationships or cooperation among the marmosets.

Sometimes cooperation is so extensive that it becomes difficult for researchers to establish which female is the biological mother. In one instance, recorded by Leslie Digby in Brazil in 1991, two adult females gave birth to twins in the same week. Less than a month later, two of the infants had disappeared, but because both mothers continued to nurse both surviving infants, it was impossible to tell which female was the biological mother or "even whether those that disappeared were members of a single litter," according to Digby's report.

Like ours, the animal world is full of paradoxical examples of gentleness, brutality, and suffering, often performed in the service of reproduction. Female black widow spiders devour their partners after a complex and delicate mating dance. Bald eagle parents, who mate for life and share the responsibility of rearing young, will sometimes look on impassively as the stronger eaglet kills its sibling. At the end of their life cycle, after swimming thousands of miles in salt water, Pacific salmon swim up their natal, freshwater streams to spawn while the fresh water decays their flesh. Animals will do whatever it takes to ensure reproductive success.

For humans, whatever it takes has come to mean in vitro fertilization (IVF), a procedure developed in the 1970s that involves the hormonal manipulation of a woman's cycle followed by the harvest and fertilization of her eggs, which are transferred as embryos to her uterus. More than 5 million babies worldwide have been born through IVF, which has become a multibillion-dollar industry.

"Test-tube baby," says another woman at the infertility support group, a young ER doctor who has given herself five at-home inseminations and is thinking of moving on to IVF. "I really hate that term. It's a baby. That's all it is." She has driven seventy miles to talk to seven other women about the stress and isolation of infertility.

In the clinics, they call what the doctors and lab technicians do ART — assisted reproductive technology — softening the idea of the test-tube baby, the lab-created human. Art is something human, social, non-threatening. Art does not clone or copy, but creates. It is often described as priceless, timeless, healing. It is far from uncommon to spend large amounts of money on art. It's an investment.

All of these ideas are soothing, whether we think them through or not, just as the experience of treating infertility, while often painful and undignified, soothes as well. For the woman, treating infertility is about nurturing her body, which will hopefully produce eggs and a rich uterine lining where a fertilized egg could implant. All of the actions she might take in a given month — abstaining from caffeine and alcohol, taking Clomid or Femara, injecting herself with Gonal-f or human chorionic gonadotropin, charting her temperature and cervical mucus on a specialized calendar — are essentially maternal, repetitive, and self-sacrificing. In online message boards where women gather to talk about their Clomid cycles and inseminations and IVF cycles, a form of baby talk is used to discuss the organs and cells of the reproductive process. Ovarian follicles are "follies," embryos are "embies," and frozen embryos — the embryos not used in an IVF cycle that are frozen for future tries — are "snowbabies." The frequent ultrasounds given to women in a treatment cycle, which monitor the growth of follicles and the endometrial lining, are not unlike the ultrasounds of pregnant women in the early stages of pregnancy. There is a wand, a screen, and something growing.

And always: something more to do, something else to try. It doesn't take long, in an ART clinic, to spend tens of thousands of dollars on tests, medicine, and procedures. When I began to wonder why I could not conceive, I said the most I would do was read a book and chart my temperature. My next limit was pills: I would take them, but no more than that. Next was intrauterine insemination, a less-expensive, low-tech procedure that requires no sedation. Compared with the women in my support group, women who leave the room to give themselves injections in the hospital bathroom, I'm a lightweight. Often during their discussions of medications and procedures, I have no idea what they're talking about, and part of the reason I attend each month is to listen to their horror stories. I'm hoping to detach from the process, to see what I could spare myself if I gave up.

But after three years of trying, it's hard to give up. I know that it would be better for the planet if I did (if infinitesimally so), better for me, in some ways, as a writer. Certainly giving up makes financial sense. In my early twenties, when I saw such decisions as black or white, right or wrong, I would have felt it was selfish and wasteful to spend thousands of dollars on unnecessary medical procedures. Better, the younger me would have argued, to donate the money to an orphanage or a children's hospital. Better to adopt.

The thirty-four-year-old me has careful but limited savings, knows how difficult adoption is, and desperately wants her body to work the way it is supposed to.

A large part of the pressure and frustration of infertility is the idea that fertility is normal, natural, and healthy, while infertility is rare and unnatural and means something is wrong with you. It's not usually a problem you anticipate; from the time we are very young, we are warned and promised that pregnancy will one day happen. At my support group, someone always says how surprised she is to be there.

My parents married in their early twenties and moved to the country to live on a farm and raise a family. It took them thirteen months to conceive me, and my mother says that during those months of waiting she thought she had been ruined by her previous years of birth control. That's how she put it — ruined — as if the rest of her working body, her strong back, her artist's hands, her quick wit, did not matter.

Although I married almost as young as my mother — I was twenty-six — it never occurred to me to have children right away. In my first year of marriage, I was teaching writing workshops to kindergarteners in Brooklyn, and at the beginning of the year I remember drawing and labeling a diagram of my bedroom on a big pad of paper while my students worked in their own notebooks. Daniel, a bright and charming five-year-old, pointed at the drawing of my bed. "Why are there two pillows?" he asked. "One for me, and one for my husband," I said. He gasped. "You're going to have a baby!" I laughed and shook my head. "I'm too young to have a baby," I said. On parent-teacher night I realized that Daniel's own parents were younger than I was.

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Excerpted from The Art of Waiting by Belle Boggs. Copyright © 2016 Belle Boggs. Excerpted by permission of Graywolf Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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