In the United States, some 10% of people who wish to have children struggle with infertility. It’s especially common in the African American community, and fertility preservation can be difficult for transgender individuals as well. But why is this? And what can be done about it? NOVA explores barriers to fertility, from the social to the biological, and the state of assisted reproductive technologies. Follow the journeys of people navigating challenges from structural inequalities and racism to falling sperm counts, egg freezing, and IVF. (Premiered May 12, 2021)
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Fighting For Fertility
PBS Airdate: May 12, 2021
CASSIE JOSEPH (I.V.F. Patient): This is what I.V.F. looks like. Wow. This is what my life is going to be consumed of. All these meds in 20 days, thousands of dollars. This is I.V.F.
ERIN LEVIN (I.V.F. Patient): Infertility just feels like a special little corner of hell that just goes on and on and on.
TIFFANY HARPER (I.V.F. Patient): Every community has that taboo subject, that thing they just don’t talk about at the dinner table, and fertility is ours.
REVEREND STACEY EDWARDS-DUNN, M. DIV., D.MIN. (Trinity United Church of Christ): Black women are struggling with infertility at almost two times the rate as our Caucasian brothers and sisters.
DR. AIMEE EYVAZZADEH, M.D., M.P. H. (Reproductive Endocrinologist): I think there’s an infertility pandemic, and I think it’s getting worse. Infertility rates are quoted as one in eight, but I think it’s much higher.
DR. SHANNA SWAN, PH.D. (Environmental Medicine, Icahn School of Medicine at Mount Sinai): Men from the general population, we found that their sperm counts had dropped 50 percent in 40 years.
DR. JAMES A. GRIFO, M.D., PH.D. (New York University, Langone Prelude Fertility Center): There’s no embryo that has all normal cells. Mother Nature’s all about spectrum.
TRYSTAN REESE: If you want to see the belly, I am trying to wear, wearing a whole belt under my shirt.
One thing that people would always say is, like, “Two men can’t make a baby.” And so, I’m sort of, like, “Watch us.”
DR. CINDY DUKE, M.D., PH.D. (Nevada Fertility Institute): No one likes hearing that you take black women from America, put them in other countries that are supposedly lower resourced, and they do better. That is shocking.
ERIN LEVIN: I don’t like to say that it’s a miracle, ’cause that doesn’t have the smack of truth to it; she is the spoils of war.
CASSIE JOSEPH: I met Zack, and he was a guy that I just found myself falling in love with. And he brought out the best of me.
ZACK JOSEPH (I.V.F. Patient): You just get excited about the prospect of having a family, and you meet the girl of your dreams, and then you decide, you know, to get married. And, you hope that kids are the next step.
CASSIE JOSEPH: In my family, my sisters got pregnant right away, my mom got pregnant right away. So, I never thought that infertility would be a word that I would have to use in my own personal life.
ZACK JOSEPH: We tried for years. Everybody gave us advice: “Well, you just need to relax.” And you know, “It’ll happen. Just…you guys are just too stressed.” And we kept trying, and, eventually, we both reached a point where we said something’s wrong.
CASSIE JOSEPH: After a year, I went in to the doctor. They took my labs. A few days later they called me back and said, you know, “You ovulate regularly, you…all your labs, hormonal-wise, are in check.” And so, the next step would have Zack go in. Of course, my husband did not want to go in to the doctor. So, he waited for about six more months.
ZACK JOSEPH: I thought, “There’s nothing wrong. There can’t be anything wrong. That would be crazy that something was wrong.”
CASSIE JOSEPH: The doctor called me and he told me the news that Zack had zero sperm in his semen analysis. And that was the first time we heard it.
DR. AARON MILBANK, M.D. (Minnesota Urology): Having no sperm in the ejaculate is not very uncommon, but most of the time there’s an obvious cause, a man has had a vasectomy, men who are taking testosterone. So, in Zack’s case, unexplained no sperm in the ejaculate with no blockage is relatively uncommon.
Sometimes, we find genetic reasons. That’s not the case in Zack’s case.
ZACK JOSEPH: When you’re told you don’t have sperm, you feel like you are less of a man. You feel like, “Well, why am I different than all the other guys that are out there? And, how am I less qualified?”
CASSIE JOSEPH: You’re in good hands.
ZACK JOSEPH: I know. Just have to have faith everything is going to work out.
I was diagnosed with “non-obstructive azoospermia,” which, by definition, means that there are zero sperm. The doctor proposed that we go in surgically and look in the testicle, and see if there is sperm there.
DR. KARINE CHUNG, M.D., M.S.C.E. (California Fertility Partners): In a patient who has non-obstructive azoospermia, what that means is that the sperm production is likely very compromised. And so, in order to get sperm, the urologist is making an incision in the testes and pulling out some of the little tubules that will contain small amounts of sperm.
NARRATOR: Contrary to popular belief, male infertility is as common as female infertility, and has many causes, including abnormal sperm production, chronic illness, injury or lifestyle choices.
AARON MILBANK: All right, Jeff, find something good.
TECH AT MICROSCOPE: So, we want sperm that has normal shape to it. The sperm that has the most normal shape is usually going to have a better chance for fertilization than sperm that has abnormal shapes.
AARON MILBANK: Found one?
TECH AT MICROSCOPE: Yeah, there’s a few sperm here.
AARON MILBANK: Nice!
TECH AT MICROSCOPE: This is a sperm that has a nice head, mid-piece and tail. You can see it, right here at the center.
AARON MILBANK: So, if you think in terms of what Zack’s chances are of having a child without intervention, it is zero. We have moved him from zero percent success to, at this point, with sperm in the lab, probably about a 50 percent chance of having a child that is genetically his.
ZACK JOSEPH: I’m, of course, happy that they did find sperm. But you still have all those questions about what is next.
SHANNA SWAN: If we take an average man today and look at his sperm, his father’s sperm, his grandfather’s sperm, we see that he has, on average, about half the number of sperm as his grandfather.
So, what we found, when we looked in western countries, that is men from the general population, who didn’t know whether or not they were fertile, we found that their sperm counts had dropped 50 percent in 40 years.
Because it’s not likely to be genetic. Why? Because it’s too fast. It’s too fast a decline for a genetic change. So then, it’s environmental.
Lifestyle factors, like smoking too much, binge drinking, stress, a man’s body weight…his obesity is directly related to his semen quality.
Another is the chemicals in our daily life that have the ability to interfere with the production, distribution and utilization of testosterone. And they are part of a category called “endocrine disruptors.” “Endocrine” means hormone. Testosterone is a hormone. So, chemicals in plastic, soft plastic in particular, have the ability to decrease testosterone.
We know that the chemicals in personal care products include many endocrine disruptors. The chemicals come into the mother’s body, they get to the fetus there’s no question that they get to the fetus, so this is a really, really critical link to the picture.
NARRATOR: These chemicals can reduce testosterone in the developing fetus, and that can affect males’ sperm production and health later in life.
SHANNA SWAN: The consequences, one of which is lower sperm count, and we see a lot of that in, all over the United States.
It’s not just the number of sperm that we care about. We also care about the shape of the sperm, which has gone downhill, as well. It’s got to swim straight, circles won’t do. It’s got to get to the target. So, what we’re seeing is that the sperm are failing the test in lots of ways.
NARRATOR: But healthy sperm are just one piece of the fertility puzzle when it comes to making a baby.
KARINE CHUNG: In order for natural conception to occur, there are actually a lot of things that need to go right.
So, the very first thing that needs to happen is there needs to be ovulation, which means that one mature egg is released from the ovary. That egg then needs to be picked up by the fallopian tube, and it lives there for about 24 hours. If there is sperm around, the sperm needs to find the egg in the fallopian tube and then they join together, which we call fertilization. The egg now transforms and becomes an embryo.
CINDY DUKE: Reproduction is really exciting, because it’s the best example of multiplication you’ll ever see.
So, the embryo goes from one cell to two to four, and it just keeps doubling. So that, by the time the embryo gets into the womb, it’s hundreds of cells. Once it’s in the uterus, that blastocyst needs to send signals to the uterus, and the uterus needs to send signals back, until there’s a connection, which we call implantation.
KARINE CHUNG: Even when a couple has no fertility issues whatsoever, the chances that all of that will go right in a given month is only about 25 to 30 percent.
Approximately one in eight couples suffer from infertility in the United States. I think it’s a private issue, where a lot of people who are struggling with fertility issues don’t really talk about it, but I think it’s important that we all acknowledge one in eight is a lot of people.
NARRATOR: Each year, about 160,000 women in the U.S. turn to in-vitro fertilization, or I.V.F.
In the coming weeks, Cassie will take drugs to stimulate the development of multiple eggs, in hopes that they can be fertilized with Zack’s sperm in the lab.
CASSIE JOSEPH: This is what I.V.F. looks like. These are all the meds, and they come in a package, a big box. And you open it up and you’re like, “Wow! This is what the next 20 days of my life is going to be consumed of.” All of these meds, in 20 days; thousands of dollars; this is I.V.F.
STACEY EDWARDS-DUNN: It hurts to give yourself shots. It hurts when your spouse has male factor infertility. It hurts when you and your spouse don’t see eye to eye. It hurts because no one knows the silent tears that you cry at night. It hurts because you don’t have insurance or money to cover treatment or adoption services. It hurts, because it seems like God is silent. It hurts because of the crazy comments people say to you like, “Just relax.” It hurts, because the baby you’ve always dreamed of seems like a distant reality that may not ever happen.
In the African-American community, what I would hear is that we were fertile, that we were hyper-fertile. Much of this is steeped in breeding myths, particularly during slavery. Black women, in particular, we didn’t struggle with infertility. That’s what we were told. And for those women that were experiencing fertility challenges, it was a secret, you know? No one was talking about it.
NARRATOR: Reverend Stacey Edwards-Dunn was 37 years old when she married her husband, Earl. They planned to have a child right away but were unable to, and turned to I.V.F.
EARL DUNN: I think one of the more…the key issues, with a lot of couples, especially minority couples, is financial. It’s financial. It’s expensive.
DR. WANDA BARFIELD, M.D., M.P.H. (Centers for Disease Control, Division of Reproductive Health): Assisted Reproductive Technologies, or ART, does relate to socioeconomic status, because fertility treatments are relatively expensive.
CINDY DUKE: I.V.F. could cost anywhere from $10,000 and as high as $25,000, if using your own eggs. In terms of who gets to have a baby, it’s whether you can afford it, whether you have access to it. We know that, unfortunately, just simply looking at geographics, in terms of locations of fertility clinics, they tend to be located in more affluent neighborhoods.
For many people, it’s cost prohibitive.
DR. HANK GREELY (Stanford Center for Law and the Biosciences): I.V.F. is usually not covered by either private insurance or by the state health care program for the poor, the state/federal program, Medicaid. We’re one of the few rich countries that doesn’t think of it as part of basic health coverage.
CINDY DUKE: The good news is that more and more states in the United States now provide what we call mandated coverage, which is a strong requirement or recommendation that employers or other insurers provide fertility coverage.
NARRATOR: For six years, Stacey and Earl poured their life savings into multiple I.V.F. treatments. Finally, a doctor alerted Stacey that she had a rare condition that no one had ever told her about.
STACEY EDWARDS-DUNN: I went to go see the doctor. She said, “Had anyone ever told you that you had one fallopian tube?” I said, “Absolutely not.” “Has anyone ever told you that you have a unicornuate uterus? That your uterus is much smaller than the average uterus?” I said, “Absolutely not.”
Now, although I had been diagnosed with unexplained infertility, they still never told me that I had one fallopian tube or had a unicornuate uterus, which could have been a, you know, a major game-, play-changer for every doctor that had seen me.
WANDA BARFIELD: For African-American women, there has been a long-standing history of reproductive coercion, of sterilization that we know that’s gone on in the history of the United States. And there is a concern about trust.
KARINE CHUNG: Across the board, there are disparities. Clearly, disparities in the medical system for the treatment of African-American men and women. And I think that’s true in the world of infertility as well.
STACEY EDWARDS-DUNN: In our community, I hear it all the time. When we go to doctors, many doctors do not take us seriously. Many of them provide…many doctors have provided a diagnosis, oftentimes, that’s incorrect.
NARRATOR: Reverend Stacey came to see the first six years of her private fight for fertility as her “season of delay.”
STACEY EDWARDS-DUNN: A lot of people struggle with this idea of delay, and you wonder when your time is coming. And so I had to get to the point that, you know, each time I got a negative pregnancy test or that the I.V.F. wasn’t successful, I had to eventually arrive to the point that delay didn’t mean denial.
NARRATOR: Believing she would become a mother, Reverend Stacey decided to break her silence.
STACEY EDWARDS-DUNN: The moment that I was willing to open up and publicly share about my story, what happened is that women and couples began to come out of the woodworks, because they were like, “My God, she gets it. She, she’s going through what I, what I’m going through.” Or “She’s now been through, you know, what I’m going through.”
Black women are struggling with infertility at almost two times the rate as our Caucasian brothers and sisters.
TIFFANY HARPER: I knew when I was about 25 years old that I had a…what they kept telling me, “You have a uterus full of fibroids.” And so, I didn’t know if that was going to impact my fertility. I had just graduated from law school. I wasn’t interested in having a baby at that point. And so, I kind of, I didn’t have symptoms. I kind’ve let it go on and go on and go on.
NARRATOR: Fibroids are benign tumors of muscular and fibrous tissue that typically develop in the walls of the uterus.
AIMEE EYVAZZADEH: Fibroids cause a disruption inside the uterus such that it becomes not only hard to get pregnant, it also becomes harder to stay pregnant. Black women experience miscarriages at a much higher rate, and I think it’s almost always due to fibroids.
NARRATOR: When Tiffany married and was ready to start a family, she struggled to get pregnant, but did not know where to turn for help.
TIFFANY HARPER: I think every community has that taboo subject, that thing they just don’t talk about at the dinner table, and fertility is ours. I didn’t have a voice. I was just struggling. I’m a lawyer by trade, and so I’m used to advocating for people. But in this, I couldn’t advocate for myself. I didn’t know how. And I had, I had too much pain, too much shame. And that’s when I came across Fertility for Colored Girls.
WOMEN #1 (Fertility for Colored Girls Video): It’s so difficult, and it’s very difficult to be told, basically, this lie your whole life, that, just, everything’s going to work out. And it really isn’t.
STACEY EDWARDS-DUNN: I do believe that God called me to start Fertility for Colored Girls, to create this safe space for women, particularly African-American women, who were struggling at insurmountable rates, because there was no place for them to go.
TIFFANY HARPER: I went to the meeting, and I was shocked, because there were so many Black and brown women there like me, who were struggling. And it was the first time that I didn’t feel alone.
STACEY EDWARDS-DUNN: (In Fertility for Colored Girls) We’re believing, and we’re cheering you on until the end.
Black women, in particular, we have experienced generations of oppression. We carry generations of stress, as someone says, that this stress and trauma is cellular, and it particularly impacts us on this infertility journey.
WANDA BARFIELD: Women, particularly African-American women, have experienced long-standing social, economic and environmental stress, that has really placed a burden on their bodies in a way that translates into more adverse reproductive health outcomes, and— that term is called “weathering”—that this weathering, in a way, prematurely ages Black women.
CINDY DUKE: Your stress hormones, cortisol, your “flight or fight” hormones, known as catecholamines or epinephrine, norepinephrine, those hormones actually should only be present in low doses, overall, in your general day-to-day, and only spike when you truly have a new, short-term scare or anxiety.
For people who find themselves in societies where there’s maybe institutional racism, structural racism, their catecholamines and their cortisol levels are way higher than they should be. And so, if someone is constantly under stress, where their body is weathering, that has a lot of long-term impact on all your organ systems. And over time, we see that manifesting in earlier ages of diagnosis with disease, earlier ages of diagnosis in terms of high blood pressure, diabetes, stress-related tension, and even birth outcomes in women.
TIFFANY HARPER: The black community is often described as the most religious community in America. And there’s a big push to just pray about it. Rev. Stacey, because she’s a reverend, really kind of demystified that and said, “God made the science, too.” I had gone through one round of I.V.F., and when they went in to retrieve the eggs, they could not really get to my ovaries, because they’ve got these fibroids all over the place.
And upwards of 80 percent of black women suffer from fibroids. And we don’t do anything about it unless it’s life-threatening. And Rev. Stacey just really gave me the push I needed and, and the permission to, to remove the fibroids and move forward on my path to, to motherhood.
NARRATOR: After surgery to remove her fibroids, Tiffany embarked on more rounds of I.V.F.
HANK GREELY: I.V.F. doesn’t seem to be any more efficient than nature.
Still, most I.V.F. embryos do not become babies, just as most embryos that are produced the old-fashioned way don’t become babies. But if you’ve got blocked fallopian tubes, or if your sperm, for some reason, won’t fertilize an egg, or for a variety of other reasons, there are a lot of people out there for whom the old-fashioned way just won’t work, and for them, I.V.F., amazingly, outperforms nature.
NARRATOR: This is the second time Cassie and Zack have tried to conceive a child through I.V.F. using sperm extracted from Zack. Their first attempt did not produce viable embryos. Within 24 hours of Zack’s procedure, Dr. April Batcheller will attempt to collect eggs from both of Cassie’s ovaries.
DR. APRIL BATCHELLER, M.D. (CCRM Fertility): We give women like Cassie extra follicle-stimulating hormone, so that, instead of just growing one egg, maybe we can get 15 or 20 eggs from the ovary.
The goal is going to be to place a needle in each of these follicles, here, and aspirate all of these beautiful eggs that Cassie spent the past two weeks growing.
NARRATOR: Follicles are the tiny sacs inside the ovaries that nurture and release a woman’s eggs.
AIMEE EYVAZZADEH: During an egg retrieval, a doctor will place a probe inside the vagina, and through a needle-guided procedure, follicles are drained of follicular fluid.
NARRATOR: In the room next door, the embryologist will isolate Cassie’s eggs and try to fertilize them with Zack’s sperm.
APRIL BATCHELLER: Fertilization is probably our biggest hurdle that we have here, because of Zack’s sperm challenge.
In this case, because Zack’s sperm were surgically extracted, they lack the ability to swim. And so, we have to give them a bit of a boost by injecting the non-swimming sperm into the egg with a needle called an I.C.S.I. needle, “intracytoplasmic sperm injection.”
NARRATOR: This revolutionary technology was developed to assist fertilization for men with weak or few sperm. Today, it is widely used in I.V.F. laboratories.
Within eighteen hours, Zack’s sperm and Cassie’s eggs create three embryos.
APRIL BATCHELLER: From there, then, is an anxiety-provoking five or six days, while we wait for the embryos to grow and divide.
CASSIE JOSEPH: I think being faced with infertility is extremely hard. It’s emotional. You have the steps of grieving. You’re trying to accept and you’re trying to, you know, predict what’s going to happen.
Everybody has such a unique story. And when you have a child of your own and you say, “why not adopt?” that’s their opinion, you know? They decided to be parents themselves, they have biological children. And it’s, it’s really hard to hear that. You look into your future. What does that look like for us?
Who’s going to be with us for our family Christmases? Like, who’s going to be with us? Like, when we’re saying our last words, I think, like, we want to have the joys of children.
CINDY DUKE: There are a lot of causes for infertility. So, big items are male factor, where there’s something going on with the sperm; tubal factor, where there’s something going on with the fallopian tube; and anovulation, where there’s an issue relating to ability to release an egg from the ovary.
NARRATOR: One condition that affects a woman’s ability to ovulate regularly is polycystic ovary syndrome or P.C.O.S., a hormonal disorder that, if left untreated, can have long-term consequences.
CINDY DUKE: We know that people with P.C.O.S. because of insulin resistance also struggle with their weight. And so, in the United States, where we’re facing an obesity epidemic, and thus a diabetes crisis, as well, it’s really important to diagnose P.C.O.S., even in teenagers.
NARRATOR: An even more common illness affecting a woman’s fertility is endometriosis, an inflammatory disease of the reproductive system that can begin in puberty. It afflicts at least 10 percent of women and takes an average of six to eight years to diagnose.
CINDY DUKE: One of the biggest downsides to endometriosis progressing without diagnosis or treatment is that it can cause really bad scarring of the fallopian tubes. But it also can cause the eggs to die. Some women may stop ovulating regularly, and some may even go into menopause, prematurely, as a result.
NARRATOR: But one of the major challenges for women who are struggling to conceive is the age of their eggs.
JAMES GRIFO: We, as a society, all need to know that there are issues with having babies when we’re older, and we need to be thoughtful about planning our fertility. It’s not a popular message, and it does create anxiety, which no one wants to do. But, on the other hand, you know, I can’t tell you the number of women who have said, “No one told me this stuff. I can’t believe I’m 44 and thinking it’s easy to get pregnant. And now you’re telling me I almost have no chance.”
NARRATOR: As a woman ages, not only does the quantity of her eggs decline, but so does the health of her eggs. There’s a crucial moment during fertilization, when the egg needs to eject exactly half of its chromosomes with perfect precision.
JAMES GRIFO: Eggs are aging as you get older. And they don’t release the chromosomes ’til they’re ovulated and fertilized. And that’s this graphic here, which shows a sperm and an egg.
This is the egg kicking out half the chromosomes. When this egg is 25, it’s moving the chromosomes around with 25-year-old machinery, versus 40-year-old machinery. You’re going to see more mistakes, where a chromosome goes where it shouldn’t. And, for instance, with chromosome 21, there should be one copy here and one copy there.
NARRATOR: But sometimes, an egg, especially an older egg, fails to eject its extra copy.
JAMES GRIFO: Now, all of a sudden, you’ve got an embryo that has three copies of chromosome 21, trisomy 21, that’s Down syndrome.
NARRATOR: In the last decade, egg freezing has become increasingly popular for women interested in delaying childbirth or who are going to undergo chemotherapy.
KARINE CHUNG: I’m asked all the time, “What is the ideal age to freeze eggs?” And I think that somewhere between 28 and 34 would be the ideal age. That’s because, in that window, the quality of the eggs and the quantity of the eggs is still optimal. After 35, it is possible to freeze eggs, but the outcomes are not quite as successful.
AIMEE EYVAZZADEH: Egg freezing is one of the greatest discoveries in modern times. It is a huge game-changer. It allows women to donate eggs to themselves at a time when they may not have as many options. It allows women to choose partners based on things that are not related to their biological clock.
TRYSTAN REESE: When I first saw him in the hospital and everyone’s screaming at me to push, and they’re screaming at me to slow down. And then everything goes completely silent. And then I hear him come out and then they lift him up in the light, and I get to see him for the first time. And he opens his mouth, and he just starts to cry, which was the most amazing sound I’ve ever heard.
NARRATOR: Creating a baby was the last thing on Trystan’s mind as he searched for his identity.
TRYSTAN REESE: I, like many people, always did feel there was something different about me. And I think, tragically, I actually felt that there was something wrong with me, that I was broken. For me, it was just excruciating, and it came to the point where I didn’t believe that I could continue to live a kind of life that I was living.
And it really wasn’t until I was 18 or 19, and when I realized, “Oh, my god, I’m not broken at all, I’m just transgender. When I finally did tell my mom, specifically, you know, “I’m transgender. I’m going to be transitioning,” I just watched her face fall. And it’s not that she’s transphobic, she just truly believed that it meant choosing an unhappy life for myself.
KARINE CHUNG: For people who have gender dysphoria, what that means is that they have a really distressing discomfort, because there’s a discrepancy in their gender identity and how they appear on the outside or the sex they were assigned at birth. So, by matching their physical appearance to their gender identity, that allows the world to perceive them as they already perceive themselves.
NARRATOR: Trying to match his appearance to his identity, Trystan turned to testosterone.
TRYSTAN REESE: Looking back on it now, I’m like, oh, I took testosterone from the black market. And that is a really, really, really dumb idea, because your whole endocrine system is a very delicate constellation. It’s like a spider web, you know? You pull on one piece and everything else goes.
KARINE CHUNG: There’s a complex signaling that occurs naturally in men and women, where there’s hormone signals that come from your brain that speak to the ovaries and speak to the testes. When you take testosterone or you take estrogen, those hormones then take over the signaling that would normally be driven by the brain. And that can have implications for reproductive health.
For example, testosterone therapy can lead to increased risks of stroke, heart attacks, blood clots.
TRYSTAN REESE: You should really be under doctor supervision, or if not a doctor, but a nurse or a naturopathic doctor, but someone who has advanced training in hormone management. But a lot of L.G.B.T.Q. people take risks with their health, because they’re scared.
NARRATOR: Discrimination towards the L.G.B.T.Q.+ community has hindered access to healthcare and led to misperceptions.
BIFF CHAPLOW: The message has always been that, like, gay people are dangerous to children, that gay people shouldn’t raise children, that, like, we are the opposite of family: we destroy family.
When it became clear that, that Lucas and Haley, my biological niece and nephew, were going to need a home, it was pretty clear that we were going to be the only people that could take them, or they would need to go into foster care. And so, you know we had a discussion and Trystan was like very supportive, was, like, “Yes, let’s do this. Let’s take them.”
TRYSTAN REESE: It never occurred to me, until I met Biff, I started thinking, you know, I would love to have a family with him. And seeing him with kids, I was just like, that door could open for us. We could have a physical manifestation of this, you know, profound and true experience of love we have for each other.
BIFF CHAPLOW: Many people like me don’t ever have the opportunity to have a kid that is biologically connected to them. Either because they, the, the reproductive systems don’t match up, or they don’t have the resources.
TRYSTAN REESE: I mean, in many cases, I think people don’t even imagine. That was one thing that people would always say is like, “Two men can’t make a baby.” And so, I’m, sort of, like, “Watch us.”
NARRATOR: How do two men make a baby?
KARINE CHUNG: Hormone treatment can suppress the reproductive system. So, for example, a transgender man who is taking testosterone will experience a cessation of menses. So, periods will stop coming. And that’s actually an intended consequence of the treatment. But in addition, it will suppress the ovaries, so that he is no longer ovulating. When they come off of testosterone, there are reports that the menses will return.
TRYSTAN REESE: Testosterone really acts to the ovulatory system the same way that any hormonal birth control that stops ovulation and menstruation impacts the system. It just hits pause on the, sort of, egg-maturing factory. And when you go off testosterone, as I did, it takes a few months and then the egg-maturing factory kicks back into gear, and you ovulate and menstruate just as you had before.
KARINE CHUNG: There have been reports of pregnancies. But what we don’t know is if a person has been on testosterone for a long period of time, is that return of ovarian function going to actually occur.
TRYSTAN REESE: If you want to see the belly, I am trying to wear, wearing a whole belt under my shirt to try to support things, so it’s less pressure on my skin here. As you can see, it’s gigantic, giant.
NARRATOR: Trystan had been taking testosterone for 12 years before trying to get pregnant. After experiencing a miscarriage, he soon became pregnant with Leo.
TRYSTAN REESE: Leo looks so much like you that people just assume that I wasn’t involved at all.
BIFF CHAPLOW: They do assume that we had a surrogate and just used my sperm for that. We did have a surrogate and we did use my sperm.
TRYSTAN REESE: It was me. I was my own surrogate.
BIFF CHAPLOW: It was just, Trystan was the surrogate.
TRYSTAN REESE: How do you navigate pregnancy as a transgender man? Maybe you feel conflicted about or even negative about having breasts, but now that is being used to nourish a human. Maybe you felt conflicted about having a uterus to begin with, but now it’s being used to create a person. You are building a family.
NARRATOR: Trystan felt grateful that he was able to become pregnant and give birth. But for patients about to transition, there are steps they can take to preserve their fertility.
KARINE CHUNG: In patients who are undergoing gender-affirming therapy, I think it’s important that they are presented with the option to either freeze eggs or freeze sperm before they start those treatments.
TRYSTAN REESE: Fertility preservation is invasive. It is very expensive, and it takes a long time. It can take weeks or even months, depending on how successful the first retrie…, retrieval is. And a majority of trans adults who say they wish they’d preserved their fertility, they said that they were not counseled. They didn’t think about it.
KARINE CHUNG: Counseling the younger group about fertility preservation before gender-affirming therapy is particularly challenging, because these are teenagers. And many times, they’re so distraught by their gender dysphoria that they’re really eager to start their gender-affirming treatments.
TRYSTAN REESE: Honestly, if you had told me at age 22, you know, you have to choose between transitioning and ever having a biological child, it would not have taken me one second to make that decision. I would have chosen transition. I thought I was choosing transition over ever having a family, ever falling in love, ever having community support, ever getting married.
KARINE CHUNG: What the research has shown is that at least 50 percent of transgender men and women do wish to have children or have a family in the future.
TRYSTAN REESE: Change comes from moving into the place that is hard and looking for the light. Often, when you say, like, “Well, why don’t you just adopt?” It’s rooted in this belief that we shouldn’t have access to the same things as everyone else.
I don’t want to be like men who are not transgender. I feel like what I am is unique. It’s powerful. It’s a gift. If I had been assigned male at birth, I never would have had Leo. So, when I look at me pregnant, you know, I’m just one of the many men who happen to be unique in that we can create life. And I think that’s pretty cool.
APRIL BATCHELLER: Hi Cassie, it’s Dr. Batcheller calling. I was just calling you with some excellent news this morning. I wanted to call and let you know that we have your C.C.S. results back and that both of these embryos are normal and available for transfer, which is pretty exciting.
CASSIE JOSEPH: We got that call, and it was two embryos, and they’re both normal, and they’re both baby girls. So, we’re super excited, at least I am, about the girl part.
NARRATOR: Both of Cassie and Zack’s embryos were frozen and one has been thawed out to be transferred today.
CASSIE JOSEPH: Our embryo today is a 5BB, that’s the grade of it, and frozen embryo transfer and it’s a baby girl. And just Baby Joseph, January, 2020. So, today is the day. We waited four years for this, so we are over the moon excited.
APRIL BATCHELLER: Are you guys ready? All right, I am ready too.
So, we are here today doing Cassie and Zack’s transfer, after a long road of going through several I.V.F. cycles to get here. So, we warmed up their embryo a few hours ago and then transferred it successfully. Everything went very smoothly today, so now we are just in the nine-day waiting period.
ERIN LEVIN: It’s been five years, four embryos, three transfers, zero pregnancies, for me. And then, one mosaic embryo, one surrogate, and our baby.
Infertility just feels like a special little corner of hell that just goes on and on and on. And you can keep throwing money into it and time and sadness and blood and sweat and tears, and you may end up with nothing.
I don’t like to say that it’s a miracle, ’cause that doesn’t have the smack of truth to it; she is the spoils of war. She is the result of many years of battle, and she is our victory.
NARRATOR: After four years and three failed cycles of I.V.F., Erin was diagnosed with recurrent implantation failure, meaning her embryos were unable to embed themselves into the wall of her uterus.
AIMEE EYVAZZADEH: Erin came to me. She was frustrated, she wanted answers, she didn’t have a diagnosis.
NARRATOR: Testing pointed to an issue with Erin’s immune system: it was identifying her embryos as foreign.
AIMEE EYVAZZADEH: And that’s why we decided, as a team, to consider using a gestational carrier.
NARRATOR: Before transferring any of Erin’s embryos to the gestational carrier, or “surrogate,” Dr. Aimee Evyazzadeh used pre-implantation genetic testing or P.G.T., to make sure they had the correct number of chromosomes.
Offered at most I.V.F. clinics, the test is used by about 35 percent of patients and can cost between $1,500 and $5,500. This test is typically done when an embryo is about five days old and has divided to roughly 300 cells.
The inner cell mass is what could develop into a fetus. The outer layer of cells, called the “trophectoderm” is what could develop into the placenta. An embryologist plucks just a few cells from this outer layer, and a lab performs a genetic test on them to count how many chromosomes each cell contains. Based on this test, the embryos are generally classified as abnormal or normal.
But if the sample contains a mixture of genetically normal and abnormal cells, then the embryo is considered “mosaic.”
ERIN LEVIN: We had four embryos left. One of them was abnormal, two of them were normal, and one of them was mosaic. And so, you think, I want to get my best chance. And so, I want to use the embryo that looks the best, that has the highest grade, and that has really good genetic testing results. And I don’t want to use these garbage embryos that have tested abnormal or partially abnormal like a mosaic.
NARRATOR: One of the normal embryos did not survive the thaw, so Erin and her husband Gary considered transferring the mosaic embryo with the remaining normal one.
GARY LEVIN (I.V.F. Patient): We knew we would transfer this one healthy one that we had left, but then the question was, “What do we do with the mosaic embryo that’s left?” We also didn’t want to discard it.
ERIN LEVIN: Right.
GARY LEVIN: ’Cause there was a, a certain percentage chance that it could result in a healthy pregnancy.
NARRATOR: In the end, one “normal” embryo and one mosaic embryo were transferred into the surrogate. Soon after, Erin and Gary got good news.
ERIN LEVY: Fortunately, we got positive pregnancy results.
GARY LEVIN: So, we knew our surrogate was pregnant. The two embryos were different sexes. So, the healthy one was a male embryo, and the mosaic embryo was a female. When we were told there was just one that had implanted, we assumed we were having a boy.
NARRATOR: A blood test revealed a girl. The mosaic embryo had implanted.
KARINE CHUNG: In discussing the risks associated with transferring a potentially abnormal embryo, we talk about three possible scenarios: one is that the embryo just wouldn’t implant; the second scenario is that that embryo would implant, and it would result in a miscarriag; the third possible scenario, though, is that if the embryo truly is abnormal and implants, it could result in a baby with genetic abnormalities, due to abnormal cells being present. Before we will transfer a mosaic embryo in any patient, they need to have genetic counseling.
ERIN LEVIN: That throws you into a whole other world that you have to get expertise in to decide if that’s going to be a viable pregnancy, and how do you find out if it is, and will we need to look at early termination? Or what are the odds that this is a miscarriage, and if it’s not, what are the odds that this is a baby who will be born with special needs.
KARINE CHUNG: There have been several case reports of patients who have had pregnancies from transfer of mosaic embryos. And I think it’s too early to say whether any of these embryos actually translate into birth defects for the baby. Maybe later in life as we follow these babies as they grow older, there might be something that’s identified that’s related to the mosaicism.
GARY LEVIN: We’re in this world of testing everything and going through I.V.F. We’re getting all this information that most couples that have natural pregnancies never even have to face, right?
KARINE CHUNG: What we really care about is whether the baby is going to have the proper amount of genetic material. But what we’re testing is a small portion of the trophectoderm, which we know is the portion of the embryo that is destined to become the placenta. So, there is some controversy over how accurate this test is and whether we are at the point where we should be doing it for all of our patients.
JAMES GRIFO: Mother Nature’s all about spectrum, all about continuum. So, there’s no embryo that has all normal cells. If 70 percent of the cells are abnormal, those are called high-level mosaic. If only, you know, 30 percent of the cells are abnormal, those are low-level mosaics.
NARRATOR: When fewer abnormal cells are present, miscarriage rates are predicted to go down and the chances for a live birth increase.
JAMES GRIFO: And there seems to be a better outcome with the lower level mosaics over the high-level mosaics, but we’re still learning that.
KARINE CHUNG: There is actually a lot of research that suggests that the embryo may be capable of correcting itself once it’s inside.
NARRATOR: But how? Researchers, including Dr. Shawn Chavez, have found evidence that suggests that on day four, the embryo performs a self-inspection.
DR. SHAWN CHAVEZ, PH.D. (Oregon Health & Science University): I like to liken it to a card game. So, that you can actually share information with your neighbor. And so, you can start to decide, based on your card game, who looks good to become a placental cell, part of the placenta, and who looks good to become part of the inner cell mass which is going to become an embryo.
NARRATOR: At this developmental stage, Dr. Chavez has noticed embryos discarding cells or fragments of cells that are chromosomally damaged.
SHAWN CHAVEZ: They have a significant amount of D.N.A. damage. And we think that the embryo actually knows that it’s there and, basically, has a signal to it that says, “You are not going to divide, because you’re chromosomally abnormal, and your D.N.A. is highly damaged.”
I really like to point out for your attention is this large, excluded cell. So, you can see, based on its size, it probably came from very, very early in development. Besides being excluded, it is never allowed to divide again.
NARRATOR: More needs to be understood about mosaic embryos but some couples, especially those who are running out of options, are deciding that the prospect of having a healthy child is worth the risks.
SHAWN CHAVEZ: If a woman only produces mosaic embryos, most clinics don’t want that liability, but I think the tide is turning. I think they’re finally starting to realize, if that’s the only thing a woman has is a mosaic embryo, that they should give it a shot. And so, I’m hoping that more clinics are going to accept that responsibility.
AIMEE EYVAZZADEH: Finally, in August of 2020, the American Society for Reproduction Medicine came out with a committee opinion saying that every single clinic needs to have a policy in place for mosaic embryos and patients need to be told about it, as well.
ERIN LEVIN: Don’t let a clinic or testing lab tell you you shouldn’t use these embryos. Keep them, and maybe, if you are more comfortable, use them as a lower priority. But they really could be a real baby.
CASSIE JOSEPH: We transferred Baby Girl a few weeks ago. We got a positive pregnancy test, which we were over the moon about. And a few days later, my H.C.G. level, which is the indicator of your pregnancy, went down. And then it was confirmed that I, we had a miscarriage.
CINDY DUKE: One in four women of reproductive age will experience a pregnancy loss at some point in her reproductive lifetime; that means twenty-five percent of women. It is quite natural and very common for women to blame themselves. And the first way to help someone understand it’s not their fault is to let them know how common this is.
ZACK JOSEPH: Through this journey we’ve come closer and closer and closer to being able to actually have a child, and it feels like it’s within reach. It’s just, just barely out of reach.
NARRATOR: Cassie and Zack have one remaining embryo to transfer.
CASSIE JOSEPH: For the next frozen embryo transfer, I’m nervous. I have one more embryo left.
ZACK JOSEPH: This needs to work, and if this doesn’t work, what’s next? We haven’t talked about what’s next, if this doesn’t work, because we’re just praying that it does.
NARRATOR: I.V.F. succeeds only about half the time, for couples. Cassie and Zack’s last embryo resulted in another miscarriage. They plan to try again with I.V.F., starting with another surgery for Zack.
STACEY EDWARDS-DUNN: To hold onto hope means to look beyond what might be negative or what might not be working out in a way that you desire to happen, in that time, and know that something better is going to come.
TIFFANY HARPER: I went through my third round of I.V.F. in May of 2018. They retrieved two eggs they fertilized. My doctor came into the room, and I’ll never forget, she said, “Tiffany, they look great!” And I remember thinking, you know, no one’s ever said that to me. No one’s ever said they look great. Like this is…I have a shot. And so, we put them both back in, and the rest is history.
I gave birth to my son nine months later, and he is everything that I prayed for, everything that I’ve been waiting for, everything that, like, I didn’t know I needed.
NARRATOR: Reverend Stacey Edwards-Dunn and her husband Earl decided to try one last time.
EARL DUNN: After seven years, I just told her, “Let’s try one more time,” ’cause I think I had a good feeling, our bonding together, our faith together, that whole collectiveness.
STACEY EDWARDS-DUNN: On January 2nd, we received the call from the doctor, around 2:30. Everything like, the world seemed to stop. The doctor, the nurses, everybody was on the phone, saying, “We call with good news. We want you to know that you are pregnant.”
Our daughter that…Shiloh, that was born on September 11th, she is, she’s a gift to so many. Whether your path is becoming pregnant naturally or becoming a parent through I.V.F., donor eggs, donor sperm, surrogacy, embryo adoption or adoption, there is a plan or a path for you. That’s what you hold onto, and know, at the end of the path, there is a miracle waiting for you. And whatever path that is, the path isn’t deficient, it’s just different.
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Image credit: (sperm injection into egg)
© 2021 WGBH Educational Foundation
- Wanda Barfield, April Batcheller, Biff Chaplow, Shawn Chavez, Karine Chung, Cindy Duke, Earl Dunn, Stacey Edwards-Dunn, Aimee Eyvazzadeh, Hank Greely, James Grifo, Tiffany Harper, Cassie Joseph, Zack Joseph, Erin Levin, Gary Levin, Aaron Milbank, Trystan Reese, Shanna Swan