Infertility in Arlington

Local couples in Arlington, McLean and Falls Church weigh the pros and cons of fertility treatments.

Last year, my husband, Ron, and I got together with a group of friends and told them we were thinking about having a baby. We asked for their prayers. Ron and I had already been down this road once before. It all started in 2005, when, still living in Southern California, we had flipped open our calendars, counted off nine months, and thought: Great! January sounds like a wonderful time to welcome a child! I was 31.

Six years, one miscarriage, two reproductive surgeries and a major cross-country move later, our fertility journey came to end—without a baby. Or so we thought. But when a friend offered to be our surrogate, the dizzying world of fertility clinics, invasive medical procedures, insurance policies and mind-bending ethical questions flew back at us, like a boomerang.

Some 11 percent of women between the ages of 15 and 44 in the U.S. have difficulty getting pregnant or carrying a pregnancy to term, according to the Centers for Disease Control and Prevention (CDC). But, of course, infertility isn’t just a female problem. Almost 8 percent of men under 45 have seen a fertility doctor, another CDC study shows.

It’s relatively easy to determine whether male infertility is a factor. There’s one test: a semen analysis. (Ron passed his with flying colors.)

Females, on the other hand, are more complex and diagnosis can require a battery of tests and years to figure out. Some women never get a clear answer. Instead they are left with the mysterious edict of unexplained infertility.

My diagnosis came in 2007, a few months after my miscarriage. Morning sickness had turned to mourning sickness, and I wandered around our townhouse teary-eyed, unable to shake the blues. It had taken me well over a year to conceive, but once it happened, I thought our fertility troubles were over. They weren’t. The day my doctor told me our baby no longer had a heartbeat, he also discovered a growth on my ovary.

A subsequent surgery revealed that I had endometriosis, a condition in which tissue similar to the lining of the uterus implants in places it’s not supposed to. This condition affects more than 8.5 million women in North America, according to the Endometriosis Foundation of America, making it one of the top three causes of female infertility. Nevertheless, many women with endometriosis are able to have children in spite of it.

Determined to be an exception, Ron and I continued to try to conceive the old-fashioned way. To double our efforts, we also went to Dominion Fertility on South Glebe Road in Arlington and tried a few less-invasive treatments, including a small dose of fertility drugs and artificial insemination. After those attempts failed, I had to decide whether to undergo in vitro fertilization (IVF), a procedure in which the sperm and egg are fertilized in a lab and the embryo is then transferred to the woman’s uterus.

When it comes to IVF with a woman’s own eggs, the most important variable for success is age. “Men make new sperm every 72 days, but women are born with all their eggs and they don’t get anymore,” explains Michael DiMattina, one of four reproductive endocrinologists at Dominion Fertility. “As women age, their eggs age, too. Even though you may have someone who is 40 who looks 25, her eggs are still 40. It’s not fair in a sense,” he says.

And in the highly educated suburbs of Northern Virginia, the phenomenon of would-be parents who are just getting started in their late 30s and 40s is not unusual. Some postpone parenthood so they can focus first on graduate school or their careers. Some are in second marriages.

Though science indicates that a woman’s ability to conceive naturally begins to drop after 35, CDC statistics show that the birth rate for first-time mothers between the ages of 35 and 39 in Virginia rose by nearly 40 percent from 2000 to 2012. How is that possible? The number of women using fertility treatments, particularly IVF, is higher than ever.

In 2012, more than 165,000 IVF cycles were performed using fresh embryos from a woman’s own eggs, compared with roughly 119,500 similar cycles in 2004, according to the Society for Assisted Reproductive Technology, an organization that reports data on success rates of fertility clinics nationwide. Of those performed in 2012, 31 percent resulted in a live birth for women between 35 and 37, while 22 percent resulted in a live birth for women between 38 and 40.

 

Those odds may not sound great, but they’re pretty good when you consider that the average fertile woman has about a 20 to 25 percent chance of conceiving naturally each month. With the advent of better technology, DiMattina says he has observed more women getting pregnant with fewer treatments.

“Does everyone get pregnant? No. But in the old days, a significant number of couples were not successful. Nowadays, most people who receive fertility care can be successful,” he says. “Persistence is key.”

PERSISTENCE WAS key for Alison and Dan Barkan, who moved from New York City to Crystal City in 2013 after Dan took a teaching job at Yorktown High School.

Alison’s biological clock was already ticking when she got married at age 36. (When she was single, she had even considered egg freezing, a practice many fertility specialists recommend for women who hope to have kids one day.) The Barkans started trying to have a baby shortly after their wedding in 2011.

After three months without success, Alison learned that she had a benign cyst on her ovary, although it wasn’t endometriosis. Her fertility doctor decided to leave the cyst alone, and Alison underwent three rounds of a type of artificial insemination known as intrauterine insemination (IUI)—the so-called “turkey baster” method. None were successful.

So the Barkans took it to the next level and tried IVF. “The first time you do an IUI, you’re like, I can’t believe I have to do this,” says Alison (who later had the cyst surgically removed from her ovary, along with polyps in her uterus). “Then you’re like, Okay, I’m going to add drugs, but this is as far as I’m going. Now, I’m going to do IVF. This is as far [as I’m going]. You keep setting this bar, and then you don’t get the results you want, so you lower the bar.”  

Once they moved to Crystal City, Alison made an appointment with Eric Levens, a physician at Shady Grove Fertility Center, which has 21 offices throughout Maryland, Pennsylvania, Washington, D.C., and Virginia.

In November of 2013, she dropped Dan off at work and drove to Shady Grove’s Annandale office for monitoring. At night, Dan administered all her shots. He was with her when she underwent surgery to retrieve her eggs.

“I remember sitting with Alison as she was waking up from the anesthesia,” Dan recalls. As a guy, he says, there were times he wished he had someone else to talk to, but he never found the right audience. “I think there is a particular loneliness that men have to fight through during IVF.”

This time, the procedure worked, and the couple soon discovered that Alison was pregnant with twins. They held their breath. Then an ultrasound at 8 weeks revealed one twin was a blighted ovum (a pregnancy where the embryo never develops).

The second twin had a heartbeat, but a follow-up ultrasound two weeks later showed that the heartbeat had stopped.

They were devastated. “I remember howling,” Alison says. “I remember feeling it’s my job as a mother to protect my child, and I couldn’t protect her. It was a hard day.”

After further tests, Alison was told that she had a gene mutation linked to recurrent miscarriage. Levens offered to put her on steroids to improve her odds for a third round of IVF. She agreed.

“We transferred two embryos and one took,” she says, recalling the elation she felt upon seeing the heartbeat at 6 weeks, followed by the agony of yet another miscarriage. “I became depressed. I couldn’t get out of bed.”

By that point, Dan was also spent. “It’s constantly awful, and you are constantly obligated to be optimistic, and it could not be more draining,” he says, “especially as one round leads into the next and it seems more and more hopeless that doing this to yourselves is going to be worthwhile.”

TODAY, THE OPTIONS in fertility treatments are legion. In addition to fertility drugs, artificial insemination and IVF, would-be parents can try donor eggs, donor sperm, donor embryos or surrogacy—and doctors can deploy a plethora of supplemental techniques and tweaks to increase the odds that any one of these approaches will work.

But there’s also a downside to all the advanced science. The choices can make infertility treatments overwhelming, difficult to navigate and expensive. (Costs will vary, depending on the medications, insurance and other factors, but a round of IVF, with medication, can range from $12,000 to $20,000.) And the more vested one becomes in the process, the harder it is to step away.

“All these options didn’t exist 25 years ago,” says Barbara Collura, president and CEO of RESOLVE: The National Infertility Association, which is headquartered in McLean. “Success rates were really low, doctors were more likely to say ‘Stop,’ and you weren’t conversing with people all over the world [on social media] who were telling you the eleventh time they tried IVF, that did the trick.”

The roller coaster of uncertainty and grief that so often defines such treatments can also put a heavy strain on couples who are trying to conceive.

 

“Fertility treatments can impact every facet of a couple’s relationship,” says Benta Sims, a Falls Church therapist who counsels people through infertility, pregnancy loss and postpartum depression. “Hopes and dreams are tested. Physical intimacy is negatively impacted. Finances are stressed. Jobs are impacted due to the time commitment of medical appointments.”

Tensions can be further compounded when one spouse or partner wants to take a different course of action or end treatment before the other is ready. I still remember the night that Ron and I had a heated argument about what we would do in the event that we ended up with extra embryos from IVF. The trials of infertility had brought us to a point where we were fighting about offspring who didn’t exist from a procedure we had yet to try.

But there are ways to manage the strain. Sims encourages couples to schedule a daily time to discuss fertility issues. “Set aside 15 to 20 minutes each night,” she suggests, adding that it can be helpful to carry a notebook and write down questions or thoughts that arise during the day, saving them for later discussion. “It helps if both members of the couple become educated about the infertility journey,” she says. Understand the medical tests, treatment plans and options.

Support groups can also be beneficial, in that they alleviate the pressure on each spouse or partner to be the sole source of comfort for the other.

The first time I attended a RESOLVE support group (which, at the time, was meeting in Tysons Corner), I approached it with trepidation. I wasn’t sure I wanted to listen to other people’s sob stories of infertility. But I immediately felt a connection to the other women, especially when I saw bits and pieces of my story in theirs.

I realized I had finally found a community of others who understood exactly what I was going through. And it was nice to make new friendships, given that most of my other girlfriends were, appropriately, devoting their time to their expanding families. I also found that many of the women in the support group were experimenting with Eastern medicine therapies, such as acupuncture, in addition to Western fertility treatments. I had gone down the holistic road, too. I had even taken a trip to an Ayurveda health clinic in India—my rationale being that, if nothing else, diet, yoga and mind-body therapies would put me in a better state to deal with the major life decisions that loomed ahead.

SARAH (who asked to be identified by her first name only) had a similar thought. She was 37 when she and her husband began trying for a baby. But by then, her egg quality had declined. She underwent multiple fertility treatments over the course of three years.

During that time, she also began acupuncture treatments with Kathleen Fraser, owner of White Lotus Acupuncture & Holistic Services in Arlington. Fraser works closely with clients of Dominion, Shady Grove and Columbia Fertility Associates (another fertility clinic with offices in Arlington). She estimates that about a quarter of her practice is dedicated to fertility patients.

“Tension and tightness tends to build up in our bodies, and if it builds up enough, we tend to get symptomatic,” Fraser says. “Signs like clotting, pain, irregular cycles, migraines, digestive problems, things like that around your period are signs that something isn’t moving well.”

With acupuncture, tiny needles stimulate certain points of the body to relieve the tension, improve blood flow and regulate hormones. Some studies, including one published in 2002 in the medical journal Fertility and Sterility, suggest that acupuncture may increase the success rates of IVF, although many doctors are skeptical of this claim.

“The most recent reviews fail to show a benefit in terms of pregnancy rates,” says Preston Sacks, a physician at Columbia Fertility. Given those findings, he recommends weighing the side benefits of acupuncture, such as stress reduction, against the time and expense.

If nothing else, Sarah says, acupuncture helped her relax in the midst of all the emotional and physical stress of undergoing fertility treatments—not to mention financial worries, which had taken a toll. Even though Sarah’s insurance partially covered both the IVF and the acupuncture (an initial consultation at White Lotus is $150; subsequent sessions are $85, though the practice does accept some insurance), she estimates that she and her husband still paid about $9,000 out of pocket.

After her first IVF cycle ended, she went to Shady Grove for a special pregnancy test—often called a beta test—which measures the amount of human chorionic gonadotropin (HCG), or pregnancy hormone, in the body. A “good” initial beta number might be around 100. Sarah’s number came back at 6.

Technically, it was a positive result (she had traces of HCG in her blood), but it was too low to register as a pregnancy by Shady Grove’s definition. Sarah was having a maybe. Soon, she began to miscarry.

For her second IVF cycle, Sarah’s doctor recommended an increase in medications that would stimulate her ovaries and control ovulation, but explained that this could bump her out-of-pocket expenses as high as $14,000. She paid. Then she miscarried again.

Emotionally, “it was horrible,” Sarah says. That, in combination with the financial burden, put an end to treatment with her own eggs.

Sarah and her husband decided to try the donor egg option under Shady Grove’s “shared risk” plan. In the donor egg approach, the eggs of a younger, fertile woman would be used instead of Sarah’s eggs, though Sarah’s husband would use his sperm and Sarah would carry the baby. Payment would only be required if the procedure worked. If it didn’t, they’d get a refund.

“My husband really, really wanted a genetic tie to the baby,” Sarah says. She felt okay letting her biological connection go—something she credits to her job as a social worker, where she provides therapy to foster kids. “The genetic tie wasn’t an end-all be-all for me. I was well-versed in blended families. In my mind, the more personal thing was I wanted to have children.”

But after two unsuccessful tries with donor eggs, her husband was ready to call it quits. “I don’t think we should do this anymore,” he told Sarah one day. The couple no longer traveled for fun, and they had delayed some practical purchases to reserve the money they needed for treatment.

“We’d put our lives on hold for so long,” Sarah says, realizing how much the obsession with conceiving had left them chronically unhappy.

They decided to try the donor egg option one last time, and took a trip to Rhode Island during the two-week wait. When they returned, they found it had worked. Sarah’s baby is due in January.

RON AND I NEVER felt the donor egg option was right for us. It didn’t make sense anyway. My eggs weren’t the problem—my uterus was. And my endometriosis had spiraled out of control. In addition to incredible pain, I experienced abnormal bleeding, a common symptom of the disease that makes it difficult for a fertilized egg to implant.

 

My symptoms were so debilitating that I had a hysterectomy in 2011. I never did try IVF. I didn’t feel comfortable being injected with high doses of hormones. (To date, there is no strong evidence that fertility drugs cause severe long-term side effects, DiMattina says, and a study recently published in Cancer Epidemiology Biomarkers and Prevention showed that, with the exception of a small subset of women, fertility drugs didn’t increase breast cancer risk. But I decided to stick with my gut over science.) I also had my doubts that IVF would work in my case, no matter how persistent we were.

Still, I opted for a subtotal hysterectomy instead of a radical one. In other words, I saved my ovaries. Just in case.

Hope can be irrepressible, in spite of the odds. Which is why, after three rounds of IVF with heartbreaking results, Alison and Dan Barkan steeled themselves for a fourth round last fall at Shady Grove Fertility.

This time, Dr. Levens adjusted Alison’s treatment by putting her on an anticoagulant to help offset her tendency to miscarry. He also prescribed a couple of pharmaceutical supplements that are reputed to improve egg quality. Tweaking the protocol is important, Levens explains, as fertility treatments are never one-size-fits-all. “We learn things as we go forward with regard to how an individual responds,” he says. “Subtle changes can make a big difference.”

They did for Alison. In fact, the fourth time was a charm. “I was a wreck until I hit 20 weeks,” she recalls. But her anxiety eased when she felt the baby kick. In June, she and Dan welcomed a daughter. They now live in the Mosaic District in Merrifield.

“I heard the baby cry. I couldn’t stop smiling,” Alison says. “She was here. She was healthy. She was screaming her head off. It was the most beautiful sound.”

AROUND THAT TIME, Ron and I were still contemplating the option of surrogacy. If we decided to proceed, the doctor would surgically remove my eggs and mix them with Ron’s sperm. An embryo—if one formed—would be transferred to my friend’s healthy uterus, which would serve as our baby’s incubator.

Given that possibility, I thought I could muster the faith to try one round of IVF. But then the friend who had offered to be our surrogate moved to China. It would have been a nightmare to work out the logistics and legal complications. And we learned our insurance wouldn’t cover the procedure—not a penny.

In short, surrogacy would take a huge chunk of our energy, time, money, thoughts and devotion. And it might not even work. We realized we could apply all of that energy to adoption instead. Or we could direct it elsewhere, to productive endeavors that bear fruit in other ways. Ultimately, that’s what we decided to do.

There are days when Ron and I still cannot believe that we’re not parents. We always thought we’d create and raise a child together. Didn’t we want to be parents enough? Will we have regrets? These are questions we will likely wrestle with for years to come. But for the most part, we’re at peace.

I don’t miss being poked and prodded in medical exams. More importantly, we’ve both discovered other ways to give and nurture, whether by helping others through their fertility struggles, spending time on meaningful work, hiking in nature or discovering ways to deepen our faith.

If there is one thing our journey has taught me, it’s this: Even though I can’t have a baby, I can still live a fertile life.

Jenny Rough hosts the RESOLVE Alexandria Decision Crossroads support group.

 

Fertility, insurance and the law

When it comes to assisted reproductive technologies (ART), medicine isn’t the only field that is booming. Courthouses are filling up, too.

As the treatment options become more complicated, so does the law. “This is probably one of the fastest-growing areas in family law,” says Peter Wiernicki, an attorney with the Rockville-based firm Joseph, Reiner & Wiernicki. “The issue is whether general assemblies and state governments will address it.”

The Virginia Code has a section titled “Status of Children of Assisted Conception,” one of the older reproduction statutes in the country that addresses issues of parentage in situations involving sperm donation, egg donation or surrogacy. “It’s a dinosaur, but it’s effective,” Wiernicki says, although it’s not entirely up to date, in that the law does not address singles, same-sex couples or unmarried couples who have a child using ART.

In January 2012, Virginia lawmakers proposed another piece of legislation known as the “Virginia Personhood Bill” (HB-1), which, had it passed, would have defined an embryo as a human being. Though the bill included a clause that would have permitted lawful assisted conception, advocacy groups such as RESOLVE: The National Infertility Association opposed it. Why? They feared that it would endanger or put an end to IVF fertility treatments.

“When you get into the practical effects of granting personhood status to unborn children, it could impose on doctors how many embryos may be created and how [those embryos] would be stored,” explains Joseph DiPietro, a family law attorney in McLean. “Taken to the extreme, it could mean exposure to criminal liability for mishandling them,” he says, given that certain fertility treatments put embryos at risk. When a procedure results in a surplus of embryos, for example, the extra embryos are often destroyed. And pregnancies are sometimes terminated if the health of the embryo or mother-to-be is endangered. The bill was defeated in February 2012.

Insurance is another gray area for those who hope to conceive with ART. At present, 13 states have a law that requires insurance companies to cover infertility treatment, according to the National Conference of State Legislatures. Virginia is not one of them.

There is no legislation on the horizon to change that, although most insurance companies do cover treatment anyway—or at least portions of it. RESOLVE is nevertheless pushing for a change in Virginia’s laws to require an insurance mandate and to make fertility laws easier for would-be-parents to navigate.

RESOLVE President Barbara Collura encourages Virginia residents who are struggling with infertility to meet with their state senator, state delegate or assembly member. “Tell them your story, and let them know why the issue is important to you,” she says. “It’s important they know you are a constituent and that you care about family value options.”

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