After a year of trying to get pregnant in the time-tested manner (intercourse with mate, slow jams and cocktails optional), Beth Kohl discovered that, like 6.1 million of her fellow Americans, she was clinically infertile. So she and her husband, Gary, then 29 and 32 years old, respectively, embarked on a different, but increasingly common, baby-making journey -- one using assisted reproductive technology (ART) to conceive.
But along with prenatal vitamins and baby-name books, Kohl found a mess of ethical questions. Why spend so much time and money conceiving bio-kids when many already-born babies could benefit from the same resources? How many embryos is it OK to transfer, given that later a mother might be faced with the decision to selectively reduce (read: abort) one or more of her fetuses? Are IVF kids the same -- healthwise, soulwise -- as naturally conceived children? What about the risk of pregnancy complications, premature birth, and the host of long-term problems that come along with them? Can "man-made" babies ever be reconciled with religious faith? And the biggie: What should would-be parents do with their leftover embryos?
Kohl, who grew up in a conservative Jewish household in suburban Milwaukee, tackled her ethical and reproductive journey with a typically Midwestern work ethic, digging for answers in sources ranging from the Bible to congressional testimonies about forced abortion in China. Now she chronicles her struggle, both with fertility and morality, in a new book, "Embryo Culture: Making Babies in the Twenty-First Century." The bones of "Embryo Culture" is Kohl's own story of two IVF-assisted pregnancies, but she beefs it up with an impressive amount of research on the technical matters and moral questions facing would-be parents, clinicians and the government.
While the subject is serious, her touch is light. Trying to find a metaphor for their infertility, her husband suggests "botanists in the Arctic Circle" -- and Kohl replies: "That is better. Not only does it suggest that my uterus is inhospitable to life, it also manages to hint of my frigidity." She's compassionate, but unsentimental (especially when you compare "Embryo Culture's" language to the banter in infertility chat rooms and blogs. Kohl reports that some women refer to their frozen embryos as "embies" and nickname the eight-cell clusters "Frosty" and "Snow White"). And she never claims to have all the answers.
In late July, while her three daughters were at summer camp, Kohl spoke to Salon from her home in Chicago about reproductive rights, "test tube babies" and the unexpected impact IVF has had on her.
When you began IVF treatment 10 years ago, were there any books about infertility treatment available?
I think there was a "Fertility for Dummies" book. I didn't buy it for myself because of the title, but somebody who was also going through IVF gave it to me. It was very nuts and bolts -- basically it explained the procedures and the bazillion acronyms.
When I poked around on the Internet, I found that there were some clinics that were starting to advertise, but back in those days there weren't any overriding organizations. You could just see the little seedlings of what have now become the American Society for Reproductive Medicine and support organizations like Resolve starting to spring up.
Without a network, was it difficult to find a doctor you trusted?
I think that, as with any kind of doctor, you click with certain people and not with others. Some doctors are interested in manipulating tiny cells and all of the research that's going on (certainly not federally funded). There are some that want to help otherwise infertile people have children.
But you also have people -- like my second doctor, actually -- who feel like a lot of the problem is that woman have been so go-getting that they have changed their cellular structures and have what they see as hysterical infertility. So on one hand, it's nice to have a place where you're not just this number, but on the other hand, you want to feel like you have someone...
...who isn't going to blame you.
Exactly! Polycystic ovarian disorder is genetic. You cannot blame women for their infertility.
Now, IVF is at the point where certain clinics are rising to the top. A lot of insurance doesn't pay for fertility treatments in this country, and people think, "I don't want to mess around." They just want to be somewhere where they think doctors are making good choices, that doctors give them all of the information they need, that they're not going to end up in a position where a doctor lowballs their chances of conceiving and convinces them to put three, four, five embryos in and they end up severely pregnant.
In trying to figure out what choices you could live with, you consulted a lot of clergy -- some of them pretty hard-line. What was your religious background?
I grew up in a conservative Jewish house in a town where we were the only Jewish people. We kept a kosher house and we were observant. So I had this weird, sheltered upbringing in many ways -- I didn't know how different religions viewed any of this stuff. And I think if you're raised ultra-conservative, you really do have a reckoning. It requires a more flexible way of thinking. I don't think you can call yourself a Catholic and just make up a bunch of rules, or a conservative Jew and then make up a bunch of rules. So you either have to redefine yourself or quit defining yourself.
When I started looking at the IVF issue, I started with my old rabbi, who is very conservative. He pulled out some books that definitely predated 1978 and pointed to this rabbi and that rabbi who had so clearly spoken about these issues -- and I thought, "What are you talking about? IVF wasn't even around then!" He said, "Well, don't underestimate what people envision." And I just thought, Well, that's it for me. If this is the person I'm going to have to talk to when I'm faced with having to reduce a quadruplet pregnancy, he's not my guy. Later, to research the book and for my own edification, I called the Archdiocese of Chicago and spoke to a woman in their Respect Life office who made it very clear that it was sinful, very sinful.
A lot of people have been disappointed in their spiritual leaders' response to their questions, but luckily, recently there's been a surge in the other direction. Most religions, if they're not orthodox or not fundamental in the way that Orthodox Judaism is or Catholicism can be, are willing to admit that this is all fairly new and open to debate. They're holding conferences and trying to come up with a thoughtful approach.
Did you find any camaraderie from women or couples who were also going through fertility treatment?
My husband and I were on our own a lot largely because a lot of support groups were just starting to form and solidify. But we were fortunate in that two of my very best friends were also going through IVF at different clinics -- though I think it was a good thing that my friends were at different clinics. You can't help but look around at your clinic, and knowing your statistics, start doing the math. If it's the woman to my right and the woman to the left who are going to get pregnant, then maybe it's not going to be me. As much as you smile at everyone and think good thoughts, you're aware of that.
What effect did IVF have on your marriage?
There's no gauging how hard this is going to be on any individual or couple. Gary's a really reasonable guy and he talked me down quite a few times -- I was really lucky that he was my partner in all of this.
But I do know several people who did not survive IVF as a couple; often it's the thing that ends up being the couple's death. Some women want to be really aggressive, some men don't; some men like a certain doctor for his own reasons and a woman doesn't. I know other couples who decided to give up on IVF after one round, two rounds, five rounds because they realized it was not worth sacrificing their marriage to have a biological child.
What was the hardest decision you had to make?
I had the hardest time deciding what to do with the embryos. We didn't want to transfer them all, even if our doctor would have let us. But we were never at the place where we thought, "OK, let's just get rid of them." We chose to freeze our embryos because we still wanted to have a choice. So here we are, all these years later. We have seven embryos and I go back and forth every day. I'm not sure what the right thing to do is, if there is a right thing.
I have a gay cousin who's trying desperately to have a child. There's a part of me that thinks, maybe he'd like some of our embryos! I love him and at least we'd know the kid that way. Then I come to my senses and I think that it'd be terrible -- what would happen if I regretted it and I wanted the kid back, or I disagreed with how he was parenting?
I also think it would be a fine and wonderful and blessed thing to donate them to science, but I can't help but picture them disassembling these embryos and pulling apart the cells, and saying, "Aw, know what? This one wasn't really what we were looking for!" and tossing them all.
Did that change your stance on abortion?
Until I discovered that I was infertile, my belief that abortion was a purely political matter went unexamined. I looked at abortion as men trying to control what women do with their bodies. I was an activist and I supported every reproductive rights group there was. I marched and I wrote letters and all of that.
Then I started trying to get pregnant and found out that it was much harder for me (and a lot of people) to get pregnant than I had once believed, and I started thinking that I could no longer take for granted -- I don't want to call it the "switching on of life," but that life was miraculous. And believe me, to talk in those terms makes me really uncomfortable, because it sounds like I'm "pro-life" and I'm not. I'm pro-"the right for a woman to choose just what she does with her body," including whether or not she gets pregnant. In fact, I'm probably one of the few people who wouldn't criticize the 60-year-old woman who ended up going to South Africa and having IVF and having twins recently.
My husband and I very consciously chose to create embryos, and for me, those seven embryos were a struggle to achieve. I really didn't want to face selective reduction, particularly because it's quite arbitrary; the fetus that they reduce just happens to be one that's easier for the doctor to reach.
So I can't help but see those embryos in that same universe of choice. I know that none of them is implanted, and there's no proof that any one of them will ever develop into a baby, but having said that, there is the potential there.
Do you think it is possible to reconcile reproductive technology with faith?
That's a hard question. Gary's convinced that people just believe different things and there's no way of knowing what's right and what's wrong. For me, it was a struggle between what I had really absorbed as a kid as the truth -- that life is God-given and spontaneous, provided one "engages in the marital act," right? So it was a big shock, seeing the other ways to make it happen. IVF was something that was developed when I was growing up. I was 10 when Louise Brown, the first IVF baby, was born, so I had an awareness of it. Do you remember that?
Yes! The "test-tube baby"!
I used to picture a big, chubby baby, smushed into a test tube.
Maybe because I grew up conservative, I did want to come up with some way to explain it all. If you believe that God is the source of everything, then you may believe that man's intellect and man's scientific ability stem from the God-given, and it's then blessed and holy and all that. Or, you could believe that it's all evolutionary and that maybe the very beginning is God-given, but it's up to us to evolve and develop and progress.
I have personally drifted further away from the God-given model and more toward the science model, but I don't feel like it's one or the other. I'm not sure. I think if you're comfortable with that state of not knowing, it's OK to say I'm not sure what the source is, but I'm thankful that it exists.
What do you think will be the next big debate about assisted reproduction?
Who knows what the next thing will be? Now we're at the point where the technology is fairly refined and the doctors are better able to control outcomes to some extent -- although there's still a huge amount of mystery. They're not sure why some embryos end up thriving and others don't, but they're better at evaluating things in the dish.
We're also at the point where there are tens of thousands of leftover embryos and people are faced with what they're going to do with them. Nobody can stand the idea that they're going to be the one who decides to get rid of embryos. They're afraid of being sued or that someday parents are going to resurface.
We're also getting into areas that are kind of scary for prognosticators and bioethicists. For example, we can grow embryos in an artificial womb. Researchers say, "We got this far and we're not ready to go any further." We know how to do it; the question is: Do we do it?