July 4, 2023

The female reproductive experience is an endless morality tale. To try for a baby is to watch yourself constantly, knowing each stage of the process involves a judgement, if not on the performance of your body, then the legitimacy of your desires. In this context — one in which there is a right time to conceive, a right way to be pregnant, a right way to give birth — infertility means more than personal loss. It has a moral dimension. You are encouraged to feel that you must have done something wrong. Perhaps it is something precise: you got too old, you should have settled down sooner, you shouldn’t have had that termination all those years ago. Or maybe it’s vaguer than that. You were arrogant to trust in your female body. Of course you’d be punished for that.

The new Serial podcast, The Retrievals, tells the story of patients attending a Yale fertility clinic. All of them experience extreme pain during an egg retrieval procedure, and all of them see their pain trivialised and dismissed. It later transpires that a nurse at the clinic has been replacing the Fentanyl that should have been used for the procedure with saline. What comes through most powerfully in the first episode, which tells the patients’ stories, is these women’s impulse to blame themselves. Having been told they received the maximum dose of pain relief, they reach for stories to explain their responses: “I’m immune to Fentanyl. It’s my fault. It’s supposed to be painful”. “There’s nothing like feeling shame,” says one patient, describing her distress at hearing women who’d experienced egg retrieval at other clinics refer to their experiences as relatively painless. “I started shutting down after hearing those stories, like this was on me. Something wasn’t right with my tolerance and my ability to handle this.”

There has been a flurry of recent books, including Elinor Cleghorn’s Unwell Women and Pragya Agarwal’s Hysterical, which explore the way in which female experiences of pain are minimised and dismissed. This is true in general terms; as podcast presenter Sarah Burton comments, “there’s a balance you have to strike as a woman patient. You have to complain just the right amount to be taken seriously, but not so much that you seem shrill. Still, your pain is more likely to be underestimated than men’s.” In this instance, however, there’s an additional level of judgement. The women attending the Yale clinic compare themselves, but not to men, and not just, as in the example above, to other women undergoing fertility treatment. They compare themselves to women who do not need to access the treatment at all.

One patient, Leah, is described as having “internalised the narrative that her body was to blame. Her body was inadequate, deficient. Her body had had miscarriages. Her body didn’t make enough eggs. Her body couldn’t cooperate long enough to get through a critical procedure”: “Oh God, my body was like, here it goes again. Not only can I not have a baby, I also can’t even just lay still with the right amount of Fentanyl.” This is not just about gendered perceptions of pain tolerance. It’s about the censure that surrounds the whole issue of female fertility: which women can get pregnant, which can’t, which women can stay pregnant, which can’t.

Much of the time, infertility and recurrent miscarriage are unexplained, but like the women who cannot understand why their maximum dose of opiates is not working, we invent reasons for then, and whatever reasons we invent tend to make women themselves the culprit. A toxic combination of ignorance and misplaced guilt then makes it easier for the fertility industry to mistreat women. Patients arrive in an already weakened state, weighed down by the fear that they have “let down” both themselves and those around them: their partners, potential grandparents, any future babies, maybe even feminism itself.

Like cosmetics, fertility is a multi-billion pound industry that capitalises on female shame. It can be an intense, multi-levelled shame — particularly for the kind of liberated, professional woman who visit clinics such as that at Yale. On the one hand, you have failed to do what is, according to the traditionalist, a woman’s main purpose; on the other, you have failed to prove the traditionalist wrong by having a baby on your own terms, in your own time. In an era that prizes freedom and choice, you are subject to the restriction and unpredictability of your own body. Your “failure” is shameful, but so, too, is your desire, a desire that is so strong that you will throw yourself at the mercy of an industry whose success rates are shockingly low.

According to the NHS website, the percentage of IVF treatments that result in a live birth is 32% for women under 35. However, this goes down to 11% for women over 40, and 5% for those over 43. Statistics for egg freezing — now increasingly promoted as a workplace perk — are even more depressing. Data from 2016 puts the pregnancy rate from thawed eggs at a mere 1.8%. Women suffer a great deal of physical and emotional pain for outcomes that are in no way assured. In the Yale case, the patients do this repeatedly, even before the Fentanyl issue has been exposed, enduring the agony of retrieval multiple times. “The women gear up for second, third retrievals,” we are told. “They change their diets. They cut chemicals out of their home… Despite these efforts, some of the women miscarry… It’s the cycle of hope and loss. It just clobbers you, and the longer you stay in it, the more that drugs mess with your head.”

What happened at Yale was a scandal because of the specifics: a drug-addicted staff member, victims gaslighted and disbelieved. But it also describes, in heightened form, the patriarchal attitudes that underpin the medicalisation of the female reproductive system. “A man’s life proceeds in smooth continuity,” wrote the gynaecologist Robert Wilson in the Sixties pro-HRT manual Feminine Forever. “How different is the fate of woman. Though modern diets, cosmetics, and fashions make her outwardly look even younger than her husband, her body ultimately betrays her. It destroys her womanhood during her prime.” The alleviation of specifically female pain becomes indistinguishable from the drive to “correct” women who are not fulfilling their designated role. “For centuries”, writes Cleghorn, “many medical ‘cures’ for women’s apparent deviancy and defiance had been punishments masquerading as therapies.” Fertility treatment is not a punishment, but it sometimes mis-sells hope. It sometimes downplays costs.

In criticising any aspect of the process, I feel unpleasantly unsisterly and finger-wagging. After all, it’s easy for me to say: I already have children. My experience of the pain of being denied is very limited. My first pregnancy ended in miscarriage, which prompted panic that any subsequent pregnancies would end this way, plus a kind of bewilderment. I’d “followed the rules” — I was under 35! My career wasn’t high-powered! I’d even given up coffee! — yet still lost out. I pored over miscarriage statistics and compared myself constantly to women who’d “managed” to stay pregnant. At times, I experienced the fact that every single person who has ever lived is the result of a successful pregnancy as a personal insult. Beneath my anger, though, was guilt. I must have done something, otherwise it made no sense. Like the Yale patients, I knew this was irrational. It didn’t alter my need for a story.

Since then, I have had three healthy babies, my last being born when I was 40. There is no moral, just a randomness to it. It’s one of two things those of us who obsess over making the world fairer for women — the feminists, the progressives — do not like: limitation and chance. It feels politically uncomfortable, and also regressive.

This is particularly the case at a time when a feminist politics rooted in the realities of the female body is being pitted against claims that sex is as socially constructed as gender. The latter position, which insists we interpret our own bodies regardless of the sex they have been “assigned”, implies endless possibility – you are whoever you say you are! – while also insinuating that those who continue to politicise the female body create the very limits it imposes. As Catherine McKinnon recently wrote, “women are not, in fact, subordinated or oppressed by our bodies”: “It is core male-dominant ideology that attributes the source of women’s inequality to our nature, our biological sex, which for male dominance makes it inevitable, immutable, unchangeable, on us.”

This is true in regard to socially constructed inequality — what men choose to do to women — but not in regard to what our bodies are in relation to us. They do not always do what we want them to do. It is cruel to make us feel we can think ourselves beyond our own flesh. Some things are unchangeable. Yet a feminist politics that points this out — that explores both the possibilities and the boundaries, to the point of admitting that not everyone can get pregnant — will inevitably sound mean. By contrast, the false promises of the fertility industry, like those of the cosmetic surgery industry, will sound kind.

Patriarchal narratives which situate fertility in relation to virtue and women’s “natural” role are set in opposition to social justice narratives which prize the right to be and do whatever you want, with neither side accommodating the reality of women’s bodies. Sex difference has so often been presented as the justification for restrictions that are cruel and arbitrary — and the threat of infertility so often used as a stick with which to beat women who might otherwise become too liberated — that it has become very difficult to speak the truth.

We forget that the morality tales we impose on our reproductive lives are just that. Overwriting supposedly conservative narratives with apparently progressive ones is meaningless when the supposedly guilty party is at all times the female body. The betrayal of the Yale patients is symptomatic of a culture that profits from women’s self-blame at the expense of allowing them the space to grieve. A compassionate, honest fertility industry would tell the truth, and spare women further pain.