NOVA

S48 E5 | FULL EPISODE

Fighting for Fertility

What causes infertility, and how can assisted reproductive technologies help? Follow the journeys of people navigating fertility challenges from structural inequalities and racism to falling sperm counts, egg freezing, and IVF.

AIRED: May 12, 2021 | 0:53:06
ABOUT THE PROGRAM
TRANSCRIPT

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.

(birds chirping)

ERIN LEVIN: Infertility just feels like a special little corner of hell

that just goes on and on and on.

TIFFANY HARPER: Every community has that taboo subject,

that thing they just don't talk about at the dinner table,

and fertility is ours.

STACEY EDWARDS-DUNN: Black women are struggling with infertility

at almost two times the rate as

our Caucasian brothers and sisters.

AIMEE EYVAZZADEH: 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.

SHANNA SWAN: Men from the general population, we found that their sperm counts

had dropped 50% in 40 years.

JAMES GRIFO: There's no embryo that has all normal cells.

Mother Nature's all about spectrum.

If you want to see the belly,

I'm actually wearing a whole, like, belt underneath my shirt.

One thing that people would always say

is that two men can't make a baby.

And so, I'm sort of like,

"Watch us."

(laughs)

CINDY DUKE: 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.

I don't like to say that it's a miracle.

Because that doesn't have the smack of truth to it.

She is the spoils of war.

(baby fussing)

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: 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: And 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: 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,

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. (both chuckle)

So, he waited for about six more months.

So, I thought there's nothing wrong.

There can't be anything wrong.

That would be crazy that something was wrong.

CASSIE: 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...

(voice breaking): we heard it.

AARON MILBANK: Having no sperm

is not very uncommon.

But most of the time there's an obvious cause--

a man who's had a vasectomy,

men who are taking testosterone.

So, in Zack's case,

unexplained no sperm with no blockage

is relatively uncommon.

Sometimes, we find genetic reasons.

That's not the case in Zack's case.

When you're told you don't have sperm,

you feel like you're 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?"

Dr. Milbank, you're in good hands. I know.

I just have to have faith that everything is going to work out.

(voiceover): 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.

KARINE CHUNG: 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.

DR. AARON MILBANK: Very good.

All right, Jeff, find something good.

TECH: Okay.

So, we want sperm that has

a 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.

MILBANK: Found one?

TECH: Yeah, there's a few sperm in here.

MILBANK: Nice!

This is a sperm that really has a nice head, midpiece, and tail.

You can see it right kind of here at the center.

MILBANK: So, if you think in terms of what

Zack's chances are of having a child

without any intervention, it's zero.

We have moved him from zero percent success to,

at this point with sperm in the lab,

probably about a 50% chance

of having a child that is genetically his.

I love you.

I love you, too.

ZACK: 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% 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.

(lighter clicks)

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 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.

SWAN: The consequences,

one of which is lowered 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.

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's 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.

KARINE CHUNG: 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.

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%.

Here we are. Yeah, here we are.

My turn.

CHUNG: 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 Americans

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.

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.

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 a number of 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 key issues

with a lot of couples,

especially minority couples, is financial.

It's financial, it's expensive.

WANDA BARFIELD: Assisted Reproductive Technologies, or A.R.T.

does relate to socioeconomic status

because fertility treatments are relatively expensive.

DUKE: I.V.F. could cost anywhere between $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 the more affluent neighborhoods.

For many people, it's cost prohibitive.

HANK GREELY: 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.

DUKE: The good news is more and more states in the United States

now provide what we call mandated coverage,

which is a strong requirement or recommendation

that employers and 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.

EDWARDS-DUNN: So, 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-changer for every doctor that had seen me.

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.

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.

EDWARDS-DUNN: In our community, I hear it all the time.

When we go to doctors,

many doctors do not take us seriously.

Many doctors have provided diagnosis

oftentimes that's incorrect.

(lighter clicks)

NARRATOR: Reverend Stacey came to see the first six years

of her private fight for fertility

as her season of delay.

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.

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 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

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 of 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.

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.

(mouse clicks)

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.

It's so difficult... WOMAN: Yeah.

And it's very difficult to be, like,

told this basic lie your whole life,

that it's just... everything's going to work out

and it really isn't.

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.

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.

We're believing and we're cheering you on

till the end. Yes.

Black women in particular,

we have experienced generations of oppression.

We carry generations of stress.

Someone says that,

you know, this stress and this trauma is also cellular,

and it particularly impacts us on this infertility journey.

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.

Your stress hormones, cortisol, your fight-or-flight hormones

known as catecholamines or epinephrine, norepinephrine,

those hormones actually should only be present

at 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 impacts

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.

(gospel singing)

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% 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.

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,

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.

BATCHELLER: 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 into each one 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.

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.

24.

NARRATOR: In the room next door,

the embryologist will isolate Cassie's eggs

and try to fertilize them with Zack's sperm.

BATCHELLER: Fertilization is probably

our biggest hurdle that we have here

because of Zacks's sperm challenge.

In this case, because Zach'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 a ICSI 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.

Oh... All right.

Okay, I know, right?

NARRATOR: Within 18 hours, Zack's sperm and Cassie's eggs

create three embryos.

From there, it is an anxiety-provoking

five or six days while we wait for the embryos

to grow and divide.

CASSIE: 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 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?

(chuckles)

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.

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 PCOS,

a hormonal disorder that if left untreated,

can have long-term consequences.

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 PCOS 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 ten percent of women

and takes an average of six to eight years to diagnose.

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.

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.

GRIFO: Eggs are aging as you get older.

And they don't release the chromosomes

until they're ovulated and fertilized.

And that's, you know, 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, 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.

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.

CHUNG: I'm asked all the time

what is the ideal age to freeze eggs.

And I think that somewhere between 28 and 34.

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.

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 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.

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

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,"

you know, 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.

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: 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 spiderweb.

You know, you pull on one piece and everything else goes.

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.

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.

(birds singing)

(bee buzzing)

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 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.

Did you concentrate?

Concentrate means you work very hard...

TRYSTAN: 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: Many people like me

don't ever have the opportunity

to have a kid that is biologically connected to them,

either because the reproductive systems don't match up

or they don't have the resources.

And 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." (laughs)

NARRATOR: How do two men make a baby?

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.

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.

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.

If you want to see the belly, I'm actually wearing a whole...

NARRATOR: Trystan had been taking testosterone for 12 years

before trying to get pregnant.

After experiencing a miscarriage,

he soon became pregnant with Leo.

... gigantic giant. (laughter)

Leo looks so much like you that people just assume

that I wasn't involved at all.

(laughs)

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.

It was me, I was my own surrogate.

Trystan was the surrogate.

TRYSTAN: How do you navigate pregnancy

as a transgender man?

Maybe you feel conflicted about

or even negative about having breasts.

But now, that's being used to nourish a human.

Maybe you felt conflicted about having a uterus to begin with,

now it's being used to grow a person--

you're 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.

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: 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 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.

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.

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.

CHUNG: What the research has shown is that

at least 50% of transgender men and women

do wish to have children or have a family in the future.

Okay, Leo...

TRYSTAN: Change comes from moving into the place that's 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.

(Leo chattering)

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.

BATCHELLER (on phone): 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 CCS results back

and that both of these embryos are normal

and available for transfer, which is pretty exciting.

CASSIE: 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.

Our embryo today is a 5BB, that's the grade of it,

and frozen embryo transfer and it's a baby girl.

And then Jos... baby Joseph, January 2020.

So today's the day,

we waited four years for this, so we're over the moon excited.

Are you guys ready?

Yes. Yes.

All right, I'm ready too.

So, we're 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.

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.

(bird singing, water trickling, Erin shushing)

I don't like to say that it's a miracle

because that doesn't have the smack of truth to it.

She is the spoils of war.

(chuckles) 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.

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.

EYVAZZADEH: 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% of patients

and can cost between $1,500 to $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: We had four embryos left.

One of them was abnormal,

two of them were normal,

and one of them was mosaic.

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: 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. Right.

Because there was 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: Fortunately, we got positive pregnancy results.

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

and that it had implanted,

we assumed that we were having a boy.

(baby heartbeat)

NARRATOR: A blood test revealed a girl.

The mosaic embryo had implanted.

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 miscarriage.

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.

That throws you into a whole other world

that you have to get expertise in

to decide if that's going 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.

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: 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.

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's 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.

Yes, go, go!

GRIFO: Mother Nature's all about spectrum, all about continuum.

So, there's no embryo that has all normal cells.

If 70% of the cells are abnormal,

those are called high-level mosaic.

If only 30% 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.

There seems to be a better outcome

with the lower level mosaics over the high-level mosaics,

but we're still learning that.

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.

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.

CHAVEZ: They have a significant amount of DNA 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 DNA is highly damaged."

I really like to point out 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.

If a woman only produces mosaic embryos,

most clinics don't want that liability.

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.

EYVAZZADEH: Finally, in August of 2020,

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: Don't let a clinic or a 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.

(baby fussing)

CASSIE: 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 HCG level,

which is the indicator of your pregnancy, went down.

And then it was confirmed that I...

we had a miscarriage.

One in four women of reproductive age will experience

a pregnancy loss

at some point in her reproductive lifetime.

That means 25% 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.

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.

Are you sleeping...

NARRATOR: Cassie and Zack have one remaining embryo to transfer.

CASSIE: For the next frozen embryo transfer, I'm nervous.

I have one more embryo left.

ZACK: 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.

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.

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!"

(voice breaking): 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,

I said, "Let's try one more time,"

because I think I had a good feeling.

Our bonding together, our faiths together,

that, that whole collectiveness.

EDWARDS-DUNN: On January 2, 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."

(laughter and giggling)

Our daughter that... Shiloh,

that was born on September 11--

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.

ANNOUNCER: To order this program on DVD, visit ShopPBS

or call 1-800-PLAY-PBS.

Episodes of "NOVA" are available with Passport.

"NOVA" is also available on Amazon Prime Video.

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