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The Medical Issue: Mysteries Within

The conception challenge

Even for the toughest infertility cases, options exist.

Illustration by ANDY MARTIN

ON A RECENT SUNDAY, my wife, Jill, woke with a start at 3 a.m. Propped up on one elbow and looking grim, she said, “I want another child.” And that made me nervous.

I’m not opposed to more children. It’s just that getting pregnant, for us, has always been about a lot more than a perfectly timed romp in the hay. See, about 10 percent of American couples are hampered by infertility. The US Department of Health and Human Services Office on Women’s Health defines the condition as “not being able to get pregnant after one year of trying (or six months if a woman is 35 or older).” The label can also apply to “women who can get pregnant but are unable to stay pregnant.” Six million-plus American women fall into at least one of those categories.

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After trying unsuccessfully to get pregnant for a year, we turned to in vitro fertilization. Over the next three years Jill got pregnant repeatedly, but most resulted in miscarriage after just six weeks or so. The longest lasted 20 weeks, until a weekend in November 2007 when Jill began to feel terrible cramps. She was in premature labor. An ultrasound in the emergency room revealed our son had no heartbeat.

We went home the next morning wrecked and bitter and empty-handed, hoping that those religious relatives of ours, including my father, a pastor, would wait a long time before calling to tell us how much God cares.

We learned later that the premature labor was the result of Jill’s cervix giving way too early. She’s among the 2 percent of women diagnosed with something called “incompetent cervix,” a condition in which the cervix, the gateway from the uterus to the vagina, weakens too soon. Typically a fetus older than 20 weeks will simply become too heavy for the mother to hold in the uterus.

We kept trying. In 2010, when Jill was 18 weeks pregnant, her cervix started to give way again. But this time the doctors were ready and placed her in the hospital on strict bed rest, where she remained for the next 97 days.

Ninety-seven days of Jill not being able to sit upright, of being bathed by nurses, of being rushed to the cardiac ward because she had an irregular heartbeat. Ninety-seven days of me sleeping on the couch next to her bed, of hoping no news happened during my newspaper shifts, of being grateful for my mother-in-law and my parents, who took care of our house and pets. When Jill was finally allowed to stand up, she only had the strength to walk a few steps at a time.

Still, it worked. Our son, Max, now nearly 21 months old, is a screaming, foot-stomping, curious, bright sweetheart of a testament to it working. So I know why Jill wants another baby — I do, too — but I wonder whether medical science is up to the task of us trying it all over again.

***

  

IN ADDITION TO THE NORMAL WORRIES of most pregnant couples — will the baby be healthy? Can we afford the expense? — Jill and I have to consider our track record with miscarriage, try to predict whether a pregnancy will require another months-long hospital stay, as well as if it could put Jill’s life in jeopardy. We’re far from alone in this.

Davina Fankhauser, a 41-year-old in Newton, lost eight pregnancies to infertility complications. “I don’t think people who haven’t experienced this understand just how much the list of things you have to think about grows once you either suffered a pregnancy loss or have had to have your life turned upside down by being told your pregnancy is high risk,” she says. Fankhauser spent months in bed during her pregnancies with her now 6-year-old daughter and 4-year-old son, and they still were born early.

The medical treatment worked. Max is a screaming, foot-stomping, bright sweetheart of a testament to it working.

photograph from the Burnett Family

The medical treatment worked. Max is a screaming, foot-stomping, bright sweetheart of a testament to it working.

In 2011, Fankhauser cofounded a nonprofit called Fertility Within Reach to help couples connect to resources and funding programs, including IVF surrogacy (which involves a host female carrying an embryo created from the egg and sperm of the genetic parents). Fankhauser recently testified before the Massachusetts Division of Insurance. “I explained to them that had my insurance company covered a $7,000 bill for IVF surrogacy,” she says, “they wouldn’t have had to cover a $99,000 NICU bill” when her son was born prematurely.

In many ways, Massachusetts is a great place for couples struggling with infertility. In Florida, where Jill and I lived until 2011, we spent more than $50,000 on fertility treatments. Much of those costs would have been covered had we lived in Massachusetts, which passed a landmark infertility mandate in 1987. Still, almost no insurance companies here cover IVF surrogacy. The cost of it, together with those associated with caring for the surrogate, can sometimes soar into the six figures.

But there’s another option that can help a woman with an incompetent cervix carry her own children. Two years ago, Brigham and Women’s Hospital opened a Pre-Term Birth Clinic, one of the first of its kind in New England. The clinic refers patients to Dr. Jon Einarsson, director of the hospital’s Division of Minimally Invasive Gynecologic Surgery, who has been working on a procedure that seems to hold promise: laparoscopic abdominal cerclage.

A vaginal form of cerclage, which involves sewing a stitch around the cervix in the early stages of pregnancy to keep the uterus closed, has been around for decades. Doctors have a success rate of 85 percent with it, according to the American Pregnancy Association, but the procedure just isn’t enough for couples like us.

Enter Einarsson, whom Jill and I met with not long ago. His procedure, usually done before conception, involves keeping the uterus closed by stitching higher up on the cervix, where it is stronger. And since it’s done laparoscopically, there’s a faster recovery than with traditional abdominal cerclages, which is comparable to a caesarean section in recovery time. Often women can go back to their daily lives within a week, rather than a month or more. And having the procedure usually means a woman can be spared spending extended periods in bed under observation, the way Jill did. “The goal here is to free women from that confinement,” Einarsson says, “and to free families from the worry that comes from not knowing how their lives will change during pregnancy.”

Einarsson has performed the procedure on more than 50 women in recent years and about half of them delivered healthy children. That’s a far more impressive statistic than it might sound. For one, the surgery only helps pregnant women stay pregnant, and about half the women haven’t been able to conceive yet. “Out of the ones who’ve gotten pregnant, we have over a 90 percent success rate,” he says. And after all, Einarsson sees the toughest of the tough cases — it was not that long ago that many of his patients could not have delivered children at all. The few who could would likely have had to spend months in bed.

After the exam, Einarsson concluded that Jill was a good candidate for the procedure. But as with so much else connected with this issue, the two of us had mixed feelings. The fact remains that even with the most modern procedures and treatments, the kind you get in what is arguably the best medical city in the world, there are no guarantees for couples facing the most difficult fertility challenges.

So we’ve also begun looking into adoption. It’s expensive — $25,000 or more, we’ve been told — but at least Jill’s health wouldn’t be threatened, and we wouldn’t feel responsible for a surrogate’s health. Besides, when we were struggling to keep Max, we made a promise to whomever was listening that at some point we’d try to adopt a child who needed parents.

Whether we go a medical route or the adoption one, it’s comforting to have options. I think I might be able to handle hearing “I want another child” again; I just hope I don’t have to hear it at 3 a.m. too often.

James H. Burnett III is a Boston Globe reporter. E-mail him at james.burnett@globe.com and follow him on Twitter @jamesburnett.

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