The Politics Of “Fertility Fog” Ctd

A reader summarizes his email upfront:

Testosterone doesn’t boost sperm count like your one reader hinted.  It’s quite the opposite  (see here). At the very least, please clear that issue up so others aren’t misled.

Also, below is my story of how testosterone replacement made me sterile and almost left my wife and me needlessly childless.  It’s a story worth sharing so others aren’t disappointed when they decide to have kids.  Testosterone is given way too freely without mention of the fertility side effects and without dealing with underlying conditions.

I have read with interest your posts on fertility, especially the recent comments from men.  Regarding the 42-year-old fellow with low sperm count, he noted the issues of stress and other factors that impacted sperm quality – this is all very true.  He also mentioned that the doc said “to keep trying and come back in 8 months…If we weren’t pregnant, he’d give me a shot of testosterone to boost my system as another step in fixing my sperm count issues. “  Testosterone does NOT boost sperm count – it can actually reduce it.  In fact, testosterone is a prime candidate for what some hope will be the first male-oriented hormonal contraceptive. He’s probably thinking HCG or human chorionic gonadotropin, which is used to boost male fertility.  Why do I know this?  I was given testosterone but never told the impact it could have on fertility – until it was almost too late.

About 5 years ago I presented to my doctor with erection and low energy problems.  He tested and found I had low testosterone and prescribed testosterone gel, which I used for a few years.  After grad school and at the ripe old age of 40, we decided it was time.  After a few months of trying I tested my sperm with a home test kit.  It’s pretty cool; it comes with a microscope, slides, and everything else you need to do a basic test.

There was nothing moving on the slide.  A visit to a fertility clinic confirmed that I was 100% sterile.  It was then that I did some research and discovered that a side effect of testosterone replacement is infertility.  An endocrinologist switched me to HCG, which has the dual benefit of boosting testosterone AND sperm production.  Today I am 43 and have a 12-week-old daughter at home.

Turns out doctors prescribe testosterone all the time without considering the root cause and without explaining the fertility impact.  In my case, I actually had sleep apnea that was only discovered after yet another endocrinologist insisted I check it to rule it out before continuing HCG after my wife got pregnant.  I’m fit and otherwise healthy – sub 1:50 half marathoner – and yet I still have sleep apnea.

Bottom line, if a man wants to get his significant other pregnant, stay away from testosterone.  And if a doctor suggests testosterone, insist on a full workup to rule out apnea, pituitary problems, and other issues before taking the stuff.  You might find yourself infertile otherwise and, perhaps, overlooking a more serious medical condition.

The Politics Of “Fertility Fog” Ctd

A reader from the other side of the reproductive struggle broadens the discussion:

I’m not sure if you’ve received many responses from male readers on this issue, but I’d like to add a male’s perspective. Oftentimes the discussion about having a child and fertility usually revolve around the woman’s reproductive health, and more often than not the male partners either don’t think about their own health, get tested to see if they’re producing healthy sperm, or consider their own health as an essential part of the equation.

I’m 42 years old, my wife is 31. We’re in the process of trying to start a family. She got off birth control over a year ago because her sister, who’s an obstetrician, recommended at least six months to a year of being off birth control before really trying to get pregnant. Of course none of our family knows about these things and yet I’ll share my perspective here anonymously to further the discussion.

I scheduled a check up with my urologist and reproductive specialist last September, which meant a full checkup and measurement of my testicles, a full history of my sex life, prior conceptions (there was with my first wife that ended in a miscarriage) and then providing the requisite sperm sample there in the office. There is nothing more romantic than locking yourself in an exam room with clinic-provided skin-mags from the early ’90s and trying to provide a sample while clinicians wander the hall outside. Thank God for smartphones, an unlimited data plan and online porn to ease my situation.

I subsequently found out that I had a low sperm count that was impacted by a high white blood cell count that resulted from trying to heal from a massive leg contusion. My initial response was despair at being nearly infertile.

But my doctor encouraged me that they would try a few things before making any decisions. A heavy round of antibiotics, 60-day supply of motility vitamins, and more frequency between ejaculations. At the follow-up exam and sample in hand, I was on the road to healthier motility and sperm count but still a cause of mild concern for my doctor. He said to keep trying and come back in 8 months. If we weren’t pregnant, he’d give me a shot of testosterone to boost my system as another step in fixing my sperm count issues.

What most doctors don’t tell you is that there are many aspects that affect a man’s reproductive health even on a day-to-day basis. My wife and I are both architects and have stressful project loads. Couple that with running our lighting business, everyday life and the stress factor can wear on you. Most doctors recommend 6 months of really trying before seeking out fertility help.

Tracking that narrow window of opportunity when your wife’s ovulation cycle is at its peak and hoping that your both feeling “in the mood”, the very act of trying to conceive becomes yet another layer of stress in trying to do everything correct. Hoping the stars align, you’ve had a healthy few days prior to the main event, you haven’t waited too long between efforts to maximize motility, factoring in the natural chances of getting pregnant on any one try, adding in that conception is very difficult to begin with all adds to the stress of trying to conceive. And while most couples we know have tried for longer than a year or two, we’re seeing many younger couples with fertility issues leap in with IVF or other treatments and getting pregnant quickly.

And while my wife and I continue to make the effort to chart her temperatures, map the moon cycles, keeping my junk primed but not backed-up, getting each other in the mood, generating the energy to do it when we don’t feel in the mood, and then her getting depressed, then my getting depressed at each month we miss an opportunity, and these all feed back into a temporary loop of despair about thinking that we will never get pregnant. We have to gently remind ourselves that it will take time and effort every month and we’ve barely just begun trying.

We get questions from friends and family about when we’re having kids or if we’re having kids. We euphemistically say we’re “working on it” and tell ourselves that it will happen when it happens.
For most men the pressure of having children is less of a burden than it is for women. Of course we’re told that men can keep reproducing into their 70s ala Charlie Chaplin. But I know this is unrealistic and unfair to burden my future children with a geriatric father. As a guy fast approaching 43, my own urge to have children increases and my desire to not be in a wheelchair and being mistaken for my kids’ grandparent at their college graduation adds a level of urgency to the equation too.

As a guy, wandering in the “fertility fog” now, I’d just like to say it’s not just a woman’s issue and it shouldn’t be a burden that just women should have to carry. I hope more men are open and honest about their own reproductive health with their doctor, spouse and especially themselves. For many men who want to start a family, the mere thought of being infertile or having low sperm count, the initial response to hearing that news can be depressing and create the idea of being “less of a man” because you might be incapable or have difficulties conceiving. I know I did when I first found out my predicament. But I also found out that it’s easier to fix my issues first. Fertility is complicated for both sexes and having that frank discussion is relevant to women and men.

Another man:

I was diagnosed with testicular cancer, seminoma, when I was 36 (quite old for seminoma), when my wife and I married less than one year.  It’s really a great cancer, from one point of view – very high cure rates of approximately 99+% from either radiation or chemo, so presumably >99.9% from either one followed by the other if necessary.  Given this choice, and despite being an expert in the chemo treatment (which he had devised; this was a world-renowned expert in the field), my urologist urged radiation because “the side effects of nausea and vomiting were fewer and milder”.

But as my wife and I were talking to the radiation oncologist prior to my first treatment, we mentioned to her that we planned to start a family one day, asking her advice on how long to wait after the radiation.  She got a horrified look on her face, and said: “Oh, no.  After the treatments you’ll certainly be sterile.”

The urologist also knew that we planned to start a family; upon further discussion I came to the conclusion (possibly incorrect and unfair) that to him sterility wasn’t a side effect worth mentioning or even considering. So it’s not just women who miss physician education on fertility.

Well, I had the chemotherapy, the cancer was cured, we later had two GREAT kids before getting a vasectomy. My wife and I are approaching our 29th anniversary.  Sounds like a happy ending.  However, I also got “chemo-brain” which is yet ANOTHER side effect that wasn’t mentioned – a permanent diminution of intelligence, concentration, etc, that has profoundly affected my entire life from that day forward (I’m a scientist).  I love my children beyond measure, but if I had known about chemo-brain in advance, and not knowing in advance the great kids I would later have, I would have chosen sterility and we would have adopted.

The Politics Of “Fertility Fog” Ctd

Several more women tell their stories:

Ugh, that last letter you published, which included this phrase “I, and many of my Ivy League, high-income friends” was HORRIBLE. Here’s what I have to say: Ladies, don’t be so selfish. If you choose to focus on yourself (and there is nothing wrong with that) for the first 20 years of your adult life, don’t COMPLAIN when you then have the a) money, and b) time to pursue IVF. Be HAPPY that you are so fortunate.

I’m 31, do not have children of my own. I am in a relationship with a man who has a 6 year old and an 8 year old. We live together and he has shared custody of his kids. I am there too, doing homework, helping out with dinner. Some might say I have a family – and in some ways, yes, I definitely do – but they are not my children and never really will be. He and I have discussed having one of our own someday, but honestly, I don’t know that it will happen. But that’s ok.

Because I made a CHOICE. Just like that Ivy-League educated, rich lady did. We make choices. These choices involve tradeoffs. She’s lucky to even be able to MAKE that choice. She had access to birth control to avoid pregnancy, and enough education and income to have a “pretty freaking awesome” life. So have I – but I am owning up to the fact that I prioritized awesomeness in my 20s over procreating, and perhaps that means I may not reproduce.

Don’t make a choice and then complain about the result of your choice.

Another is “really shocked and saddened to read these stories about doctors avoiding discussing fertility with their patients”:

It makes me even more grateful for my OB/GYN who, when I was 36 (and still single), directly addressed the subject at my annual appointment:

Her: “Do you want to have children?”
Me: “Hmm.  I haven’t really thought about it.  I guess so.  At some point.”
Her: “Well, if you do, here’s the name and address of a fertility clinic.  You shouldn’t wait any longer.”

And when I walked out of her office,  it hit me – yes, I did want to be a mother, and yes, it was about time to do that.  And thanks to her (and an anonymous sperm donor), I have spent the last sixteen years being a mother, and I can’t believe that I almost missed this experience and this life that I love were it not for the not-very-subtle prodding of my OB/GYN.

Another reader reminds us:

The risk of Downs’ syndrome and some kinds of birth defects increases with the age of the mother, others with the age of the father. The mother – from the CDC:

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On the other hand, risk of gastroschisis (intestines outside the body) decreases with age of the mother. For fathers, their increased age is associated with increased risk of bipolar disorder, schizophrenia, and autism.

Another reader tells multiple stories:

I can tell you all about fertility fog. (Sorry this got really long.)

When I was about 34, in a serious relationship with a younger man, but not engaged, a friend told me she wanted to talk to me about something serious.  She told me that I shouldn’t wait to have a baby, that she’d had age-related fertility problems at 35 and didn’t want the same thing to happen to me.  It was upsetting, because I wasn’t in a position to go home and try and get pregnant that night. But I didn’t dismiss her.  I told my boyfriend (now husband) what she’d said, and that, while I wasn’t giving him an ultimatum, I couldn’t wait forever because I wanted a family.  When I started openly talking about adoption or donor sperm, he got the hint, and we got engaged. I was married just before turning 35.

Lo and behold, I had problems getting pregnant (which may not actually have been caused by my age, but being older didn’t help).  I learned a lot about infertility and was very quick to seek aggressive medical help when it didn’t happen right away.  With lots of medical help, I was able to have three children, including twins.  (By the way, my gynecologist acted like my age was a non-issue, and if I’d left it up to her, I would have waited a lot longer to seek help from a fertility specialist. I am very grateful to my friend for lighting a fire under me.)

I was quite open with my friends, all career women, about our struggles, and very clear about the perils of waiting. They were mostly skeptical that fertility really starts to decline in your late 20s, and falls off a cliff after 35.  They latched on to the stories that comforted them. They would read about celebrities seeming to get pregnant very easily in their mid to late-40s and assumed that they would also be able to do so.  They seemed to think I was just bitter when I assured them that the celebrities were almost certainly using donor eggs.  I can’t tell you how vindicated I felt when it was revealed in Cheryl Tiegs’ divorce that she had indeed used donor eggs to have her children at 52.  She had gone around on talk shows telling people that the twins had been conceived using her eggs and her husband’s sperm because she’d taken such good care of herself that her reproductive organs were “young.”  (I know for a fact that her doctor would be asked at infertility conferences to do for these regular women what he’d done for Tiegs.  He couldn’t tell the truth, of course, because of doctor/patient confidentiality, but he hinted.)

Anyway, two stories.  One friend seemingly took me seriously.  When she got engaged in her late 30s, she planned a short engagement, and we had a sit down where I told her everything I knew about how to up her odds of getting pregnant quickly.  She was quite worried.  Lucky for her, she got pregnant easily and had a healthy baby.  I think she probably felt I’d made her panic for nothing.  She also apparently thought that her pregnancy cured her of her age.  Instead of trying quickly for a second child (she wanted several), she decided it would be ideal to have at least two years between children, and although she was now in her 40s, decided to wait that long to start trying again.  I tried to gently hint that she might not want to wait, all the same issues applied, but, to my regret, I wasn’t pushy about it, and didn’t tell her she was an idiot for waiting (even though that’s what I thought).

Well, she did get pregnant again after a while and miscarried.  She miscarried several times. Her miscarriages were almost certainly as a result of her older eggs.  But she refused to believe it and refused any treatment that might increase her odds of success.  She even called me crying once to tell me that her new doctor had told her that her miscarriages were the result of her age, and that she should see a fertility doctor right away while there was still some hope.  I told her the doctor was being reasonable, but it was like she was deaf.  She switched doctors!  She never had another child and was sad about it for many years.  I always have felt badly that I did not push her harder not to wait.  But I don’t think she would have heard me.  If she wouldn’t hear a doctor, why would she hear me?

Second story.  A friend was having no luck meeting a guy, so decided to go the donor sperm route.  She got all set up, picked the clinic, the donors, the whole thing, and was ready to begin.  Then one day we were having lunch and she told me she’d decided to wait at least another year.  (She was in her late 30s.) I again tried to gently encourage her not to wait.  I remember asking her whether, if she knew that by waiting she wouldn’t be able to have a child would she still wait and she said yes. She also said she would never pursue treatment.  I left it at that.  She knew my story.

A year or so later, she finally tried to get pregnant and it didn’t work.  She had tests done and the results were not great, her likelihood of success not good, but she decided to do IVF (which she said she’d never do) anyway.  Her several attempts failed pretty miserably.  And she told me that I “should have told her that it was a mistake to wait”!!!   I felt awful, but also a little pissed.  I did tell her.  I just didn’t TELL her.  It was probably already too late anyway, to be honest.  She ended up adopting a child, eventually married, has stepchildren and is very happy.  I don’t think she has any regrets now, so it worked out for the best, but there was a lot of heartache in between.

The Politics Of “Fertility Fog” Ctd

A few readers write in:

I read Amy Klein’s article (and your accompanying post) with great interest. Whenever the fertility issue arises in my group of friends (as it does often, given that we are a group of professional women in our mid- to late 30s), I inwardly cringe. On the one hand, it would be viewed as incredibly anti-feminist and mean to say, “Maybe you SHOULDN’T wait to have a baby.  Maybe you SHOULD put your career on hold for a year or two. You’re 38.  All the statistics show that the chances of having a baby drop precipitously from here on out.” On the other hand, it’s incredibly dishonest to say what I’ve learned you’re *supposed* to say in these situations: “You have plenty of time! Don’t worry about it! Look at (insert celebrity)! She had a baby at (age over 45)!”

It becomes a political issue at work, as well.  Several years ago, I became a professor.

My husband and I already had one child and we wanted a second.  Our strong inclination was to try for the next baby right away given that we were in our mid-30s.  Every single one of my female mentors and peers on the faculty, however, STRONGLY dissuaded me from doing so. “Wait until you get tenure,” everyone cried, “No one will take you seriously if you have a baby so early in your career.”

My desire to avoid fertility issues won out, though, and I became pregnant at the end of my first year of at the university.  While having our second child has not impacted my productivity at work, a number of my female colleagues have treated my childbearing almost as a personal offense.  One colleague, in particular, who waited to have children until she attained tenure and who is currently in the midst of a difficult battle with infertility, seems incredibly resentful.  I’m convinced that I made the right choice, but I didn’t anticipate the political fallout from women who have negotiated the fertility minefield differently.

Another woman:

Just as doctors are sometimes reticent to talk to patients about obesity, I get how the fertility topic can seem like a third rail. This to me is total bullshit from a medical perspective and a real disservice to women. A lot of women don’t think about their fertility at all. In fact, as a young woman, I spent way more time trying to make sure I avoided pregnancy.

My husband and I are currently embarking on IVF (I’m 39, he’s 44) and it’s just plain hard. Injections, appointments, copious blood work – just to name a few of the things you have to go through (multiple transvaginal ultrasounds anyone?). I, and many of my Ivy League, high-income friends, really didn’t give our fertility the weight it deserved relative to work, school, travel and even mate selection (e.g. “Hey, maybe I shouldn’t be selecting guys based on cuteness or income but rather paternal fitness”).

I don’t regret my life, because it has been pretty freaking awesome, but dammit I really would have appreciated looking at these charts and having an honest dialogue about what my future options would be.  To a person, all the women in my circle totally underestimated what it would take to get pregnant over the age of 35. I work in science, so yes, I always knew IVF was an option, but to be candid, my present self would gladly skip all these steps to do something my body (and my husband’s, for that matter) were much better suited for 10-15 years ago.

That quote from NOW you cited is why I’m in conflict with organized feminism. By all means women should be free to pursue their academic and professional goals, but that doesn’t reflect a holistic representation of womanhood. I want to be a mother, and it’s hard to accept that now something that should be natural has to happen so unnaturally.

The Politics Of “Fertility Fog”

Amy Klein investigates why many women remain steeped in misinformation about their reproductive health:

The Committee Opinion [of the American Congress of Obstetricians and Gynecologists (ACOG)] recommends education about age and fertility for ‘the patient who desires pregnancy’ – and that is a quote. In other words, only women who are already trying to get pregnant or thinking about it should be counselled about how age affects fertility.

But what about the other women – the ones who do not realise their fabulous health might not protect them from age-related declining fertility; the ones who might want to start thinking about freezing their eggs while they’re still young enough; the ones who are waiting for one reason or another to have a baby and don’t know that perhaps, like me, they don’t have that much time. Does ACOG believe it’s the doctor’s responsibility to bring up the subject?

‘We feel that women should be able to talk to their ob/gyn about fertility,’ said Sandra Carson, ACOG’s vice president for education. ‘We certainly want to remind women gently that, as they get older, fertility is compromised, but we don’t want to do it in such a way that they feel that it might interfere with their career plans or make them nervous about losing their fertility.’ In other words, there are no guidelines for talking to a woman about her fertility unless she herself brings it up.

All this talk of ‘gentle’ reminders and ‘appropriate’ counselling has a history – a political one. Back in 2001, the [American Society of Reproductive Medicine (ASRM)] devoted a six-figure sum to a fertility awareness campaign, whose goal was to show the effects of age, obesity, smoking and sexually transmitted diseases on fertility. Surprisingly, the US National Organization for Women (NOW) came out against it. ‘Certainly women are well aware of the so-called biological clock. And I don’t think that we need any more pressure to have kids,’ said Kim Gandy, then president of NOW. In a 2002 op-ed in USA Today, she wrote that NOW ‘commended’ doctors for ‘attempting’ to educate women about their health, but thought they were going about it the wrong way by making women feel ‘anxious about their bodies and guilty about their choices’.

Although the ASRM denies the backlash is connected, its spokesman Sean Tipton says the organisation has not done a fertility awareness campaign since.