Of the hundreds of families Dr. Jane Frederick has helped conceive, Bob and Bonnie Castell are a unique success story. Facing multiple fertility challenges, they gave birth to three healthy kids in five years.
I visited the Castells on a hot Friday in August. With a baby in one hand and a bottle in the other, Bonnie invited me in to the cool, controlled chaos of her suburban home. The Castell’s oldest child, Morgan, is five. Madeline is twenty months. And Jason is just nine weeks old. But Bonnie exudes calm. She is forty-five years old, and had given birth to Jason by caesarean section.
When I remarked on how exhausted I had felt recovering from a c-section, with just a single baby, she shrugged.
“That’s the great thing about having three”, she said. You’re too tired to think about how tired you are. If you stop for a minute, everything will fall apart, so you just keep going.”
I couldn’t help but laugh at her accurate summary of early motherhood. If there’s one universal truth about family life it’s that once you become a parent the notion of self-determination becomes abstract. Your life is governed, moment to moment, by external requirements, and will be for many years.
A Host of Challenges…
When the Bonnie and Bob met, they were both busy with their careers, and not thinking about having children. This was pretty much a fait accompli anyway, since Bob had had a vasectomy after raising two kids with his former wife, and Bonnie suffered from endometriosis, which can damage the fallopian tubes. But with Bonnie’s fortieth birthday approaching, not having a child suddenly seemed like a decision they might regret.
Although a vasectomy is a simple procedure, reversing one is not. After a vasectomy, the testes continue to make sperm, which can cause internal scarring, and trigger an autoimmune response that destroys new sperm. The best success rates for reversal are within three years after vasectomy. It had been five years for Bob. But his sperm count rebounded after surgery, and Bonnie and Bob began checking the calendar, making love when she was ovulating. But after a year, they’d had no luck. Bonnie was forty and the window of opportunity was closing fast.
Bonnie’s gynecologist recommended reproductive endocrinologist Jane Frederick, who performed tests which confirmed that Bonnie’s tubes were scarred. The most effective method of conception for a woman with tubal damage is one that bypasses the tubes altogether – in vitro fertilization.
Doctors estimate that as many as 26% of couples trying to conceive suffer from infertility. IVF, pioneered in the 1970’s, has provided a solution for a wide range of male and female fertility problems. For many couples, IVF has made the impossible possible, facilitating the births of over five million babies worldwide.
During IVF, doctors manipulate the reproductive hormones, causing the ovaries to produce multiple eggs. The eggs are then fertilized outside of the body, and one or more embryos are transferred into the uterus to develop. If all goes well, fetal heartbeats can be detected by ultrasound about five weeks after the transfer. The full cycle, from the first blood tests to the fetal heartbeat, takes about three months.
Since Bonnie was already forty, they began immediately. After fourteen days of birth control pills, Bonnie began the first series of injections. They were painless but after each one, her mood would seesaw dramatically. Each morning she and Bob would laugh about the drama of the night before and she would thank Bob for being such a patient man.
On the 3rd day, Bonnie began shots to stimulate multiple ovarian follicles. She tried giving herself the shots, but the medication burned. Instead, Bob began giving her the shots, speaking soothingly while Bonnie forced herself to sit still, turning her face away and cursing under her breath.
By the eighth day of stimulation, Bonnie had produced eight follicles, excellent for her age. That evening Bob gave her the “trigger” shot to induce ovulation. The timing of this shot is critical. If given too early, the eggs will not be mature. If given too late, they won’t fertilize. Thirty-six hours later they went to the clinic for the egg retrieval.
Bonnie was nervous about the retrieval. Having a long needle inserted through the wall of her vagina into her ovaries did not sound like fun. But it was a breeze. Bonnie closed her eyes as the anesthesiologist inserted an IV needle into her arm. When she opened them she was in a comfortable room and Bob was smiling down at her.
Given the challenges Bonnie and Bob had already faced, Dr. Frederick opted to perform a procedure called ICSI, injecting a single healthy sperm into each egg to give it the best odds of fertilization. The next day the clinic called with good news. Six of the eggs had fertilized. Five days later Dr. Frederick transferred the two best embryos into Bonnie’s uterus, a simple, painless procedure. After four weeks, the ultrasound showed two heartbeats. Bonnie looked at Bob nervously, but he was smiling broadly at her. Twins? Sure, why not!
From that point one, Bonnie was in the care of an obstetrician. She felt great, her skin blooming and her mood confident. During the tenth week a second ultrasound showed only a single heartbeat, strong and healthy. The obstetrician explained that Bonnie had had a “vanishing twin”, a common occurrence in IVF, and reassured her that this was good news. Pregnancies with twins are far more prone to complications, especially for a woman over forty.
Bonnie’s pregnancy went smoothly, almost effortlessly, and she gave birth to Morgan, a healthy boy, just before her forty-first birthday. She and Bob were happy with their little family and didn’t plan on having more kids.
Bonnie and I were still talking as the kids began to wander in for lunch. Five year old Morgan examined me solemnly, trying to decide if I was a friend or a rival. Madeline simply plopped down next to me and started chatting. Jason was still in Bonnie’s lap where he had slept for most of the morning.
Bob was home early from work and he immediately kicked into gear, changing Jason’s diaper and giving him a warmed bottle. He was still in his suit and tie, but relaxed and gentle with the kids and obviously happy to be there.
“I love being a dad again,” he told me. “I feel so much calmer than the first time. So when Bonnie wanted a second baby I thought, ‘Why not?’”
“The second IVF didn’t go well though,” Bonnie said. “We hadn’t planned on having more kids, so we didn’t freeze our extra embryos the first time. I didn’t get pregnant on the second cycle. Because of my age, Dr. Frederick suggested we use an egg donor. But that was really hard for me”, Bonnie confessed. “Knowing that our baby would be Bob’s biological child, but not mine.”
“Eventually we found a donor we both liked a lot”, Bob said. “She was a lot like Bonnie; smart, tall, blond and athletic.” As he spoke, Madeline, conceived from the donor’s egg, climbed into Bonnie’s arms and wound her fingers into her mom’s long blond hair. She really did look a lot like Bonnie.
The donor was an excellent choice, producing fourteen healthy eggs. Of the fourteen, six fertilized, and again Bonnie became pregnant with twins. As with her first pregnancy, one of the heartbeats vanished in the tenth week of pregnancy. Shortly after, Bonnie began bleeding heavily from a tear in the placenta and Dr. Frederick put her on on bed rest. The remainder of the pregnancy went smoothly, and Madeline was born, healthy and beautiful, at full term.
This time, Bob and Bonnie had frozen the remaining four embryos. We all laughed as Bonnie told me about those last embryos, irresistible and adorable, just waiting to be thawed. Although Bonnie and Bob had planned to stop at two, the siren song of those embryos was too strong. When Madeline was six months old they went back for one more cycle.
The first attempt didn’t work, but six months later, using their last remaining embryos, they again became pregnant with twins. One twin vanished around the tenth week, but there were no other complications, apart from Bonnie’s intense fatigue. By the third trimester she was feeling better, and they took a family vacation in Cancun. Jason was born soon after they returned.
“Life is full of surprises,” Bob laughed ruefully, as we sat surrounded by their brood. “I thought that most of my responsibilities were done and the rest of my life would be a breeze. Having a new family was a huge act of faith.”
“And how does it feel now?”
“I’m glad we’ll never do another IVF cycle! And three kids are very different from two; there are always jealousies. But this time I feel much more relaxed, like I know how to do this. And the best part is doing it with Bonnie.”
At that Bonnie smiled at him, and resettled Madeline, who had drifted off to sleep in her arms.