one question - DUE TODAY IN 4 HOURS!

ARTICLE IN PRESS

0277-9536/$ - se

doi:10.1016/j.so

� Correspond

E-mail addr

[email protected]

(R.D. Nachtiga

Social Science & Medicine 63 (2006) 1550–1560

www.elsevier.com/locate/socscimed

Rethinking the biological clock: Eleventh-hour moms, miracle moms and meanings of age-related infertility

Carrie Friese � , Gay Becker, Robert D. Nachtigall

Department of Social & Behavioral Sciences, UC San Francisco, Box 0612, 3333 California Street, Suite 455, San Francisco, CA 94118, USA

Available online 19 May 2006

Abstract

Over the past generation, aging and female reproduction have been lodged within the gendered and gendering debates

regarding women’s involvement in the workforce and demographic shifts toward delayed parenting that culminate in

discourses on the ‘‘biological clock’’. Technological solutions to the biological clock, specifically in vitro fertilization, have

led to clinical attempts to assess ‘‘ovarian reserve’’, or qualitative and quantitative changes in the ovary that correlate with

aging and with successful infertility treatment. Rupturing the longstanding historical connections between menstruation

and female reproductive capacity by specifically focusing on the aging of a woman’s eggs, the clinical designation of

‘‘diminished ovarian reserve’’ has come to imply that a woman has ‘‘old eggs’’. This is associated in practitioners’ and

patients’ minds with the eclipse of a woman’s reproductive potential and with hidden harbingers of menopause.

In an ethnographic interview study of 79 couples in the US who conceived after using donor oocytes, we found that

women voiced two different narratives that described their experience and attitudes when confronted with an apparent age-

related decline in their fertility. The ‘‘eleventh-hour mom’’ narrative was voiced by women who initially tried to become

pregnant with their own eggs and turned to donated oocytes as a second-choice option, whereas the ‘‘miracle mom’’

narrative was expressed by women who were generally older, some of whom had entered infertility treatment hoping to

conceive with their own eggs, but some who knew from the outset that it was not going to be possible. Through their

narratives women not only embodied and made meaningful ‘‘diminished ovarian reserve’’ in varying ways that connect

with cultural, social, structural/organizational, symbolic and physical aspects of aging, they reproduced the socio-

biological project of the biological clock, but rooted this social project in the metaphor of ‘‘old eggs’’ rather than

menopause.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Infertility; Age; Donor egg; Biological clock; US

Introduction

A wealth of social science literature focusing on unwanted childlessness and advanced reproductive

e front matter r 2006 Elsevier Ltd. All rights reserved

cscimed.2006.03.034

ing author. Tel.: +1 415 643 4558.

esses: [email protected] (C. Friese),

sf.edu (G. Becker), [email protected]

ll).

technologies (ART) has emerged over the past 20 years that addresses a wide range of topics. These include the experience of infertility and its treatment (Becker, 1997, 2000; Greil, 1991; Inhorn, 1994; Sandelowski, 1993; Thompson, 2005), its pervasive and problematic nature globally (Inhorn, 1994, 2003; Inhorn & Van Balen, 2003; Kahn, 2000), the complexities ART poses for understandings of kinship (Edwards, Franklin, Hirsch, Price, &

.

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–1560 1551

Strathern, 1993; Franklin, 1997; Franklin & Ra- gone, 1998; Strathern, 1992), and the dilemmas arising out of third-party parenting (Becker, Butler, & Nachtigall, 2005; Nachtigall, Becker, Quiroga, & Tschann, 1998; Nachtigall, Tschann, Quiroga, Pitcher, & Becker, 1997; Ragone, 1994; Whiteford, 1989). Yet despite the considerable attention given to these and other ‘‘reproductive disruptions’’ (Van Balen & Inhorn, 2003), limited work has addressed the experience of ‘‘older women’’ who conceive with ART using donor eggs (Becker, 1997, 2000; Thompson, 2005).

For a generation, aging and female reproduction have been lodged within the gendered and gendering debates regarding women’s involvement in the workforce and demographic shifts toward delayed parenting which culminate in discourses on the ‘‘biological clock.’’ The biological clock is a hetero- geneous concept that carries a range of connota- tions, emerging in the 1970s to capture the interconnections and fissures between social and physiological domains regarding women’s bodies and reproduction. Central to the biological clock discourse is the notion that the public domain, organized around paid labor, interferes and com- petes with a woman’s fertile years. By the early 1980s, the biological clock came to be stereotypi- cally identified with a cohort of largely Caucasian, educated, upper-middle class, baby-boom women (McKaughan, 1987). Access to medical technologies and techniques, specifically effective birth control and safe and legal abortions, allowed large numbers of women to voluntarily postpone childbearing. Subsequently, women who chose to have children in their mid-to-late 30s triggered a much-publicized ‘‘infertility epidemic’’ (Aral & Cates, 1983), char- acterized as women anxiously pursing pregnancy before it was ‘‘too late’’ (McKaughan, 1987). Marsh and Ronner (1996, pp. 245–246) observe that the extent of this infertility epidemic is contested because precise historical infertility statistics are difficult to obtain. Nonetheless, there is a predomi- nant belief that infertility is a greater problem now than previously. Some women began to see the biological clock as a kind of deadline as they made decisions about childbearing, a notion through which women have been implicitly blamed for their infertility.

The question underlying the notion of a biologi- cal clock has been: ‘‘How late can a woman wait to have children?’’ Menstruation and reproduction have long been interconnected both physiologically

and socio-culturally. The cessation of menses has been understood to mark the end of female reproductive capability, thereby separating women’s lives into the discrete time frames of menstruating/ reproductive and menopausal/non-reproductive years (Formanek, 1990; Utian, 1990). Yet as increasing numbers of women in their late 30s and early 40s attempted to conceive, it became increas- ingly clear to medical infertility specialists that the later a woman waited to embark on a first pregnancy, the greater the chance that age-related factors would diminish her ability to become pregnant at all, even following the introduction and proliferation of ART (Edwards et al., 1984). This impression has been confirmed by two large data sets, one a widely publicized report from France in the early 1980s (Schwartz & Mayaux, 1982), and more recently a report based on US data that indicated that the chances of a live birth after a cycle of in vitro fertilization (IVF) treatment fall from 1 in 3 for women under age 35, to 1 in 10 for women over 40, to less than 1 in 20 for women over 42 (Centers for Disease Control and Prevention, 2004). This led to the widespread conclusion among infertility specialists that there is an age (arguably older than 43–44) that precludes the likelihood of pregnancy resulting from infertility treatment using a woman’s own gametes.

New reproductive technologies have long been associated with the concept of medicalization, the process by which human experiences are redefined as medical problems (Zola, 1972). This medicaliza- tion process may be initiated either from within biomedicine or by members of the public who seek legitimacy for a social condition (McLean, 1990) and is epitomized by the growth of medical treatment for infertility, a condition formerly viewed as a social problem but now perceived as a medical condition (Becker & Nachtigall, 1992). Moreover, consumers may, and often do, embrace medicalization (Becker, 2000; Becker & Nachtigall, 1992). Clarke and her colleagues have reframed this concept as ‘‘biomedicalization,’’ to encompass its interactive process which engages all the elements of technology development and use, including the roles of biomedicine and consumers (Clarke, Shim, Mamo, Fosket, & Fishman, 2003).

Technological solutions to the biological clock, specifically the use of IVF and its related technol- ogies that employ donor oocytes (eggs) to achieve a pregnancy, have increasingly been at the forefront of medical treatment. Here we see the complexity of

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–15601552

the process of biomedicalization at work. Thomp- son (2005, pp. 90–91) notes that initially a woman’s age was not particularly seen as ‘‘biological’’ despite its correlation with a rapid decline in fertility. However, the growing public and legislative de- mand for clinic accountability with respect to IVF pregnancy rates led infertility specialists to search for criteria that could more accurately predict the likelihood of success of particular ART procedures. Those qualitative and quantitative changes in the ovary that correlate with the probability of a woman becoming pregnant if she undergoes IVF using her own oocytes were referred to as ‘‘ovarian reserve’’ (Scott & Hofmann, 1995). The concept of ovarian reserve is significant because it ruptures the longstanding historical connections between men- struation and female reproductive capacity by specifically focusing on the aging of a woman’s eggs. Furthermore, the traditional clinical emphasis on menstrual regularity and ovulatory function as characteristics of continued fertility has given way to an assessment driven by the consideration of a woman’s suitability as a candidate for advanced reproductive technologies.

It should be noted that although over 13 different procedures have been described for evaluating a woman’s ovarian reserve, the criteria for normal ovarian function is not precise, there is no universal agreement among clinicians about what it might be, and only women embarking on IVF procedures are actually tested for it (Bukulmez & Arici, 2004). Despite these uncertainties, Thompson (2005) notes that the clinical designation of ‘‘diminished ovarian reserve’’ has come to imply that a woman has ‘‘old eggs’’ and is associated in practitioners’ and patients’ minds with the eclipse of a woman’s reproductive potential and with hidden harbingers of menopause. She found that many women experienced these evaluations as an additional insult to their already compromised gender identity and linked the denial of access to treatment using their own (as opposed to donor) eggs to an assault on their biological age.

The medical implications of being identified as having ‘‘diminished ovarian reserve’’ are profound: a woman’s treatment options are reduced to conception using the ‘‘donated’’ eggs of another, usually much younger, woman. At the same time, women in their mid- to late 40s and older—an age traditionally thought of as being menopausal and thereby nonreproductive—are told that not only is pregnancy using a donor egg possible, but that their

chances of pregnancy are equal to those of women 10–20 years their junior. In this article we examine how women who used a donor egg to conceive their child(ren) ascribed meaning to their own aging as they confronted infertility. As the idea of having ‘‘old eggs’’ took root, women incorporated their thoughts and feelings about cultural categories such as gender, aging, and the biological clock in reconstituting their sense of self after infertility.

Methods

Respondents were recruited through 12 IVF centers and one sperm bank in four counties in a West Coast state of the USA to participate in a study addressing the disclosure decision, i.e., how parents of children conceived with donor gametes decided whether or not to tell their children of the true genetic origins. Practitioners sent letters to couples who had conceived using donor gametes alerting their former patients to the study, and those interested sent a postcard to the investigators stating their willingness to consider participation in the study. The criteria for entry into the study were the presence of one or more living children who had been conceived with the use of a gamete donor, heterosexual, and in a marital relationship at the time of the child’s conception. Data collection is complete.

In most cases initial couple interviews were followed by solo interviews with each partner approximately 3 months later. The purpose of doing both types of interviews was to collect data on how couples jointly perceived the process as well as to allow individuals to discuss differences or conflicts without their partner present. Occasionally solo interviews preceded couple interviews. If one but not both members of a couple agreed to be interviewed, those respondents were also inter- viewed. One- to two-hour long interviews were semi-structured with many open-ended questions that focused on how the couple decided on whether or not to tell the child about the use of a donor. Related topics included philosophy of family, family relationships, feelings about having used a donor, and approaches taken to telling children and others. Questions about age were not on the interview schedule but age inevitably arose in the course of many couples’ discussions about their experiences with infertility, parenthood, and disclosure. This was particularly true among couples who used donor egg to conceive their child(ren). Although

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–1560 1553

interviewers did not probe about age systematically, interviewers did pursue questions about age when participants raised related concerns. Interviews were tape-recorded and transcribed verbatim.

Data were divided by whether the child(ren) were conceived by using donor eggs or donor sperm. A specific procedure was followed to further develop the data analysis: core categories that repeatedly reappeared in the data were identified and com- pared with other emergent categories, a process that emerges out of ongoing reading and analysis of transcripts by the entire team. Out of these preliminary core categories generated from mean- ings in the data, an in-depth process of code development was followed. Codes are highly dis- crete categories. Each code is a very specific topic that appears in the data. Sections of interview text are analyzed using all codes so that the multiple meanings of a portion of text can be considered. Successive phases of trial coding were conducted until pairs of coders reached a level of agreement of 95 percent or more. The entire data set was then coded using QSR Nud*ist, a data-sorting software program, resulting in over 100 discrete codes, of which age [of parent] was one. The definition of the ‘‘age’’ code was broadly construed: ‘‘discussion of age of wife and/or husband, as factor in decisions, attitudes.’’ This article is based on an analysis of this code, which was cross-checked by reading tran- scripts from which excerpts had been identified to ascertain that excerpts were not misinterpreted by being read out of context. This approach enabled us to scrutinize all the data on age at the same time rather than focusing only on certain cases, as well as to analyze the data within their broader context. Women discussed age far more often than did men, and this article addresses women’s narratives only. This allowed for an assessment of how age figured into women’s narratives about infertility and parenting as well as how cultural discourses on age informed their experiences. The excerpts in the findings section were taken from this code print-out.

Findings

Findings are based on interviews with 79 couples who used a donor egg to conceive at least one living child. This is a sub-set of a larger sample of 148 heterosexual couples who used a donor gamete to conceive at least one living child. The average age of women at the time of the first interview was 45.8 (range 35–59) with 89% of the women being aged 39

or older at the time of the first interview. The average age of men was 47.5 (range 32–64). The average age of women at birth of first donor egg child was 42.2 (range 32–54) and the average age of men at birth of first donor child was 44.1 (range 30–62). The average age of the first child conceived through donor egg was 3.5. Of the 79 couples, 29 couples (37%) had more than one child conceived by donor eggs. Thirty-three couples (42%) had one or more child(ren) conceived without using donor eggs. Average annual household income for this sub-sample was $185,069.

We found that an important juncture in many women’s narration of their infertility experience involved their recollection of being shown graphs or tables that illustrated sharply declining rates of conception after age 38. Although these tables were usually representations of data derived from women attempting pregnancy by using IVF, for many women, they were interpreted as graphic illustra- tions of the consequences of having ‘‘old eggs.’’ Furthermore, we found that when confronted with the apparent age-related decline in their fertility, women in our study voiced two different narratives that described their experience and attitudes. The first narrative was that of ‘‘eleventh-hour moms,’’ women who initially tried to become pregnant with treatment that utilized their own eggs but were unsuccessful and turned to donated oocytes as a second-choice option. Here, the socio-biological project of the biological clock was reproduced, but now rooted in the metaphor of ‘‘old eggs’’ rather than menopause. The second narrative was ex- pressed by women who were generally older, some of whom had entered infertility treatment hoping to conceive with their own eggs, but some who knew from the outset that it was not going to be possible. These ‘‘miracle moms’’ rejoiced that their bodies had the ability to become pregnant even into the perimenopause and after, an age they previously thought of as ‘‘non-reproductive.’’ Across these differing experiences, women connected the notion of ‘‘old eggs’’ with discourses on gender and the cultural, social, structural/organizational, symbolic and physical aspects of aging.

Eleventh-hour moms

Women who voiced the ‘‘eleventh-hour mom’’ narrative expressed the view that their ‘‘old eggs’’ had, in effect, condensed and shortened their years of potential fertility, making them ‘‘too old’’ to

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–15601554

conceive a child earlier than they had supposed. Women often believed that they were still fertile if they were menstruating regularly and assumed they could in turn get pregnant up until they were approximately 45 years old. One woman, age 40 at her child’s birth, stated, ‘‘I honest to God thought if I was still cycling, life was good.’’ For many, it came as a surprise when they realized that these assump- tions could be wrong. For example, one woman, 44 at the birth of her child, gave this description of her initial meeting with a reproductive endocrinologist:

I ended up at what now is the [infertility clinic]. Total novice. I purely was thinking that I needed a better kind of thing [treatment]. And that was a rude awakening because I started to see some real statistics on what my chances were.y It never occurred to me that age could be an issue because I was still in my thirties. After all, wasn’t that still young? Maybe, but not reproductively it wasn’t.

The treatment trajectory that women experienced was shaped by where they saw themselves in the graphic displays of rapidly declining conception. For example, one woman, 40 at the birth of her child, stated: ‘‘ythen we went to the [infertility] clinic. We had to go through their lecture, which talked about old age and the gray—we were in the gray area. We weren’t in the black yet.’’ Women who saw themselves as being in the gray area often described a treatment trajectory wherein they first used in vitro fertilization in the hopes that they would be able to become pregnant using their own ova and turned to donor egg only after failures, believing that their eggs were too old. Here, the use of donor egg was often configured as a second- choice option that must be rapidly pursued because of having lost time and having reached the end of fertility.

For many women, learning of age-related inferti- lity was the first time they were being categorized as old, which led some to the self-perception that they were themselves both aged and unhealthy. One woman, 39 at the birth of her child, stated in an interview: ‘‘I felt that my infertility—it felt like I was unhealthy, to me. That’s how it felt. And that I was older, and I was trying to get pregnant. So I felt old, a little bit.’’ Martin (1987) has shown how the themes of decline and decay work to negatively evaluate menopause. Here, old eggs are similarly construed, which shapes this woman’s self-percep- tion. At times, this made women feel self-conscious about their pursuit of pregnancy, which is viewed

culturally as a symbol of youth. Another woman, 42 at her child’s birth, stated: ‘‘It’s hard when you’re thinking about having a child—that whole sense is one of youthfulness. The person is youthful and useful if they can bear children. And if you can’t, then you’re old.’’

Lost time and medical care

Women described a condensation, shortening, or curtailment of their reproductive years that was experienced not only as premature aging but as having lost time or being in a state where precious time was constantly slipping away. For some, lost time also implied waste: in time, opportunity, or eggs. Through the notion of waste, one woman blamed herself for her infertility:

I walked around with all these little, bubbling eggs inside me, and I didn’t give it a thought. I didn’t show appreciation. I didn’t give thanks for it. I didn’t think it was something valuable. I just pissed on it, you know. And now, that I want it, it’s gone (43 at birth of child).

Another expression of lost time was the notion that time had sped up after women were told they had old eggs. The notion that women’s ova age in a manner that lowers the chances of pregnancy despite continuing normal menstruation collapses women’s number of fertile years. In turn, time condensation propels a greater sense of urgency in getting pregnant quickly. Procedures like in vitro fertilization require much preparatory time and, for women given an age prognosis, are likely to fail. One woman, who was 37 at the time of her first birth, stated: ‘‘By the standard of IVF stuff, every month is a lot for someone trying to get pregnant that way—every week really, especially after forty. You have to be thrown into the fire.’’

Some women blamed their obstetrician/gynecol- ogist for this lost time and were upset that they did not have proper information to make their repro- ductive decisions. They were resentful of the medical community for not providing them with informa- tion about the ways in which aging eggs have consequences for female infertility. Some women noted that they would have done things differently if they had been provided with this information. For example, one woman recounted how she was given an 8-month supply of clomiphene from her obste- trician/gynecologist to assist her in getting pregnant at the age of 42 after having tried with her husband

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–1560 1555

to become pregnant for over 1 year. After 2 months of taking medication without getting pregnant, she requested a more comprehensive fertility plan and was sent to an infertility clinic. In her first meeting with the reproductive endocrinologist she was told that, due to her age, the only option available for her in achieving pregnancy would be donor egg. She stated: ‘‘So when I was 40 I should have been at the fertility clinic, not 42. And so I feel like I lost those two years and I had a lot of resentment [at being in] that position.’’ Another woman went to see her obstetrician/gynecologist at the age of 38 to find out if she needed to make pregnancy an immediate priority or if she had some time to wait. Her physician said she would be fine unless she waited until she was 44. Because she was in the midst of a number of stressful life events, she decided to wait. When she reached the age of 43 and started trying to conceive, she learned her eggs were no longer viable.

Educating others about age-related infertility

Many women were upset that they did not have adequate information in making their reproductive decisions, and some became vocal advocates en- gaged in educating women about the implications of age and fertility. This was particularly evident among women who gave birth between the ages of 39 and 43, but also among women who delivered before age 39. These women advocated that other women, given the knowledge that they had lacked, have children earlier, were it possible to do so. They believed this would be preferable compared to undergoing the emotional and physical stress associated with invasive infertility treatments. One woman, 35 at the birth of her child, stated:

I tell people, ‘don’t wait too long.’ I wouldn’t wish this on anybody.y I don’t love my daughter any less, and I’m not angry that I had to go through this, but I would never wish this on anybody else. I would not want somebody to have to go through this way of conceiving children. But it doesn’t mean that, in the end, it didn’t turn out okay for me.

Furthermore, some women were concerned that younger women would interpret their successful pregnancies at an older age as a signal that it is possible to get pregnant later in life:

I think they’re creating false hopes for women over forty when other women over forty hear

that these women have had children and they ask, ‘How did you have them?’, and they say, ‘We tried hard and we finally got our child.’ They’re creating false hopes.y I’m sad that this myth is prolonged, that you can do everything in life and still have a child at age forty. They’re probably going to more extreme measures but they’re not telling people (44 at birth of child).

Another respondent, 43 at the birth of her child, noted how easy it would be for her to perpetuate the notion that woman are fertile until they reach menopause, but her sense of social responsibility in educating other women took precedence:

My desire to make this rightyis to put my ego to the side, versus get all the accolades of ‘She’s so beautiful, she’s got your eyes and your hair’ y I would rather have them know the real story and have them say ‘Oh my gosh, you’re kidding,’ and then take that information and again be more beneficial. Versus going, ‘I ran into a 44-year-old woman and she has a baby. Oh, don’t worry. It’s no problem.’

Many women, however, also believed that tech- nological solutions should be available to women and some argued for more and better technologies that could serve as ‘‘back-up plans’’ or ‘‘insurance policies’’ for women who did not have control over the contexts that shaped their reproductive prac- tices. Women defended themselves against those who would blame them for their status as infertile by pointing out that the social practice of delayed parenting is often not a choice and gave reasons for the reproductive decisions they made, including their formerly single status, financial insecurity, or meeting their husband later in life. For these women, delayed parenting was a fact of life and technological solutions were the only means avail- able for contending with their situation. Some women argued for even greater technological intervention in reproduction.

Miracle moms

A second cluster of attitudes and experiences held by women regarding their use of donor eggs reflects a narrative that we call ‘‘miracle moms.’’ A typical example of a ‘‘miracle mom’’ can be seen in one woman’s description of her pregnancy as ‘‘at the edge of miracles’’ and her description of her son as ‘‘definitely a miracle child.’’ Although miracle

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–15601556

moms were generally less prevalent than eleventh- hour moms, through this narrative women de- scribed a novel conceptualization of the relationship between infertility, age, and donor egg that may provide insights into changing notions about the body. Miracle moms asserted that there was not just one biological clock, but rather many clocks that differentially shaped the possibilities of the body. Although women who gave birth at age 45 or later often espoused this view, it was sometimes voiced by women who gave birth between 38 and 44, as well.

Whereas eleventh-hour moms discussed the ways in which new medical concepts about age prema- turely curtail the body’s potentiality, miracle moms expressed relief and surprise in learning all the reproductive functions that women’s bodies are still capable of when a younger egg is used to conceive. One woman, age 50 at the birth of her child, stated: ‘‘yI’m still breastfeeding. I didn’t know you could do that after menopause. They [clinical staff] were very supportive. [They joked] ‘Of course your nipples are sore. They’ve been there for fifty years.’’’ In contrast to the rueful old eggs dialogue voiced by eleventh-hour moms, miracle moms expressed relief in the realization that the use of a donor egg obviates some of the concerns about maternal age, infertility, and infant health. For example, one woman, 41 at the birth of her child, stated: ‘‘I was relieved to think that it was not going to be my advanced, old eggs that weren’t doing me much good right now and how much were we going to try to manipulate these things to try to produce a child.y It really was such a relief.’’

The extension of fertility

Rather than the eleventh-hour mom view of fertility being curtailed by age, miracle moms view fertility as being extended. Many of the women in our study were concerned about the potential health risks to both the woman and the fetus due to their age. They reported learning that age limits a woman’s ability to conceive and older eggs increase the risks to the fetus. However, they also learned that age does not limit a woman’s ability to sustain a healthy pregnancy. One woman recounted:

We were trying to find out from somebody who was an Ob/Gyn [obstetrician/gynecologist] what issues might come up for an older mother. Basically medical [issues], but anything that they wanted to tell us, because there’s just not that

much research out there. And his advice was that there is really no difference. The uterus is still capable of bearing a child to term, even though you’re past menopause (54 at birth of child).

Whereas many eleventh-hour moms extrapolated the old eggs diagnosis to define themselves and their bodies in a holistic manner, miracle moms viewed eggs as one exchangeable part of the body that does not define one’s total self. This represents a more plastic view of the body, wherein exchanging one bodily part can make the whole body operate anew, creating new kinds of possibilities in pursuing social identities across the life course.

In contrast to the eleventh-hour mom perspective of ‘‘lost time,’’ a prominent theme within the miracle mom narrative was the notion that donor eggs allow one to turn back time. Many women discussed their ability to avert the risks associated with older pregnancy by using ‘‘young eggs’’ and making their pregnancy into one that was ‘‘like that of a younger woman.’’ One woman, 44 at the birth of her child, stated: ‘‘Once I was pregnant with her [donor’s] eggs, it’s like you’re a 24-year-old. I didn’t have to worry about amniocentesis. I didn’t have to worry about the risk of miscarriage of 43-year-old eggs. It’s very interesting. There’s a certain relief that comes with having young eggs.y It’s like the fountain of youth.’’

The donor solution

Miracle moms often gave birth at or after the age of 45 and thereby experienced a different clinical trajectory when compared to eleventh-hour moms. Miracle moms were often told right from the start that pregnancy with their own eggs, even using IVF, would be essentially impossible. Women felt that this clinical decision was legitimately supported by the statistical evidence that women have extremely low rates of conception with their own eggs after the age of 43, high rates of miscarriage, and high rates of disability. Some women also entered the inferti- lity clinic when they were menopausal or post- menopausal and thereby ‘‘knew’’ that they could not become pregnant.

As a result, women who gave birth at age 44 or older were presented with fewer options as they pursued pregnancy compared to younger women. Many women noted that their age barred them from adoptive services, which meant that donor egg was the only route through which they could raise a

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–1560 1557

child. Whereas donor egg was frequently viewed as a fall-back option by eleventh-hour moms, donor egg was the only option for miracle moms. One woman stated: ‘‘I didn’t have a problem [with infertility]. I mean, I never had issues with infertility because I wasn’t ever trying to have a baby. When I finally decided to have a baby, I was 48. And we just went right to IVF. I was told that I couldn’t try ‘cause after 44, they won’t let you—they won’t even attempt to have a woman use her own eggs. So we went right to the donor solution.’’

Despite being informed that there were no known physiological reasons for why a woman who is perimenopausal, menopausal or post-menopausal could not sustain a pregnancy using a donor egg, many miracle moms nonetheless experienced some type of stigmatization as a result of this reproduc- tive decision. Some couples were excluded from treatment altogether on the basis of age. Others experienced age-related negative reactions from physicians and/or therapists as they sought infor- mation before pursuing pregnancy. One woman stated: ‘‘One of the clinics said that they used a rule of thumb that if the combined age of the parents was over one hundred, they wouldn’t do a donor egg procedure. We wouldn’t be eligible, which we found kind of ridiculous—more than ridiculous. We found it offensive’’ (49 at birth of child). Another woman stated:

Some medical professionals injected their perso- nal opinions in, and would not always give us medical understanding. Some were very careful to just answer our questions. It didn’t feel like we were trying to do something immoral or im- proper. We just wanted information. We’re quite capable of making the moral decision’’ (54 at birth of child).

Discussion

The fact that new reproductive technologies have made it possible to extend the child-bearing years beyond the traditional historic biologic barrier of the menopause has far-reaching implications for the restructuring of the entire course of life (Becker, 2000). Women have become actively engaged in and even proponents of the biomedicalization of in- fertility and aging as the child-bearing stage of life has been lengthened for an additional 20 years. With the possibility for restructuring the life course so dramatically, the question is raised of why

women seek out and subject themselves to such intensive and invasive medical treatment at this time of life. Considerable literature interrogates reasons for the pursuit of children. Van Balen and Inhorn (2003, pp. 8–9) summarize these as: (1) social security desires, that children are necessary for their later support of aging parents; (2) social power desires, that children serve as a valuable power resource; (3) social perpetuity desires, the perceived need to continue group structures such as lineage; and (4) political investment, as children are used to promote causes and engage in demographic wars. The desires of women and men who are growing older to parent can easily be identified as reflecting concerns about security in old age and continuity through the generations.

It should be noted, however, that biomedicaliza- tion is uneven—that is, it is not a uniform process. That many women felt their physicians, often general obstetrician/gynecologists, had not ade- quately informed them about the consequences of an age-related decline in fertility raises the question of medical ignorance, incompetence, or negligence. These narratives highlight two phenomena: (1) the ‘‘risks’’ of age-related infertility are not adequately assessed and appreciated by either the general medical profession or the popular culture, and (2) the medical evaluation of age-related fertility in the US is almost solely the provenance of a small number of highly specialized reproductive endocri- nologists who provide IVF services to a relatively small percentage of all women experiencing inferti- lity. Furthermore, the medical evaluation of ‘‘ovar- ian reserve’’ is an evolving clinical process that is subject to interpretation and is rarely employed except as a precursor to IVF treatment. Although the concept of medicalization has traditionally been seen as something ‘‘done to’’ patients, it must be noted that women in both this study and in other studies of reproductive technologies wanted more medicalization to ameliorate the problem, not less (Becker, 2000; Inhorn, 2003).

In our study, eleventh-hour moms discussed their infertility trajectory as a deeply disruptive experi- ence that inhibited their pursuit of a desired future. On the other hand, miracle moms had given up the expectation of motherhood, especially with their own eggs, so they retell their stories of conception, pregnancy and birth through a narrative structure in which initially pessimistic expectations are happily overturned. Both of these narrative struc- tures make the evolving concept of age-related

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–15601558

infertility meaningful in a manner that connects with broader discourses on and around the biolo- gical clock. Consistent with the notion of a biological clock, eleventh-hour moms positioned infertility in women’s behavior, specifically in the act of delaying parenthood, but redefined and temporally advanced the endpoint from menopause to the late 30s, coincident with recent observations concerning the age-related decline in the fertilization potential of oocytes. As such, eleventh-hour moms re-ground the biological clock discourse in a different root metaphor, that of old eggs.

The notion of old eggs represents a fissure in both medical and popular discourses and practices that have been created in and through a menses/ menopause model of female reproduction. The sense of surprise women experienced at being told their fertility is challenged by their age and the notion that time has been lost are based on assumptions that follow from the menses/meno- pause model. Eleventh-hour moms reacted to the shifting biomedical perspective on female reproduc- tion from a menses/menopause model to one that is centered specifically upon the aging of ova.

By recapitulating the biological clock narrative, eleventh-hour moms considered their reproductive choices in a context through which they perceived others to be blaming them for their age-related infertility. To defend themselves against this attack on their reproductive decision-making, women who drew on the eleventh-hour mom narrative structure frequently pointed to the fact that there has been changing knowledge about female fertility that precluded them from conducting themselves differ- ently. In other words, women used the changing status of expert knowledge on female reproduction to contend that they themselves are not culpable for their infertility. This narrative reinforces the notion that the etiology of female infertility is embedded in women’s behavior and can work to deem women responsible for their status as infertile. Many women who articulated the eleventh-hour mom perspective engaged with the politics of blame as they discussed aging and reproduction. While women articulated varied responses to politicized discourses that blame women for their infertility, the eleventh-hour mom process is nonetheless engaged with these discourses.

Miracle moms also configured themselves in the context of the biological clock but in a very different way. For miracle moms, the surprising component of the notion of old eggs was that there is not a

single biological clock but instead a variety of biological clocks. These women did acknowledge that there is a physiological deadline for women to conceive with their own eggs. However, they contended that their eggs are just one part of the reproductive process and that the rest of their body is capable of sustaining a pregnancy. By dispersing reproduction, miracle moms did not extrapolate old eggs to mean that their bodies are past reproductive capacity. Indeed, miracle moms rarely considered themselves infertile per se. This fracturing of reproduction problematizes the notion that female fertility has a discrete end and allows miracle moms to consider their reproductive practices outside of the politics of blame. Whereas eleventh-hour moms engaged in the discourses of blame in various forms, miracle moms often bypassed this discourse com- pletely.

Rather, miracle moms often expressed joy and relief in the kinds of possibilities dispersing repro- ductive functioning made possible. Clarke (1995) has discussed how the focus in reproductive sciences is on controlling reproductive bodies in ‘‘moder- nity’’ and on changing reproductive bodies in ‘‘postmodernity.’’ Miracle moms could be under- stood as women’s embodiment of postmodern reproduction, wherein an understanding of bodies as malleable allows for the pursuit of desired social identities. Featherstone and Hepworth (1991) have argued that in postmodernity the life course is de- institutionalized and de-differentiated, resulting in a blurring of what had previously been considered clearly differentiated life stages. Miracle moms fit within what Hepworth and Featherstone (1982) have called the ‘‘new middle age,’’ the baby-boom generation rejoicing in the fragmentation of social expectations associated with aging.

This analysis has shown that two interconnected threads in women’s lives were central to the ways in which they made age-related infertility meaningful. The first thread centered broadly upon the woman’s life course and her (and her husband’s) expectations upon entering the infertility clinic. Specifically, a woman’s own understanding of her body as (in)fertile in relation to age shaped her reception of information regarding the declining quantity and quality of eggs. How women understood their bodies as (in)fertile connected with medico-scientific and popular-cultural discourses and practices around the biological clock and menopause. The second thread occurred when women are presented with data that demonstrated a rapid decline in the

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–1560 1559

response to infertility treatment after the age of 38. Because women between 38 and 41 are frequently counseled to try in vitro fertilization with their own eggs first and then, if unsuccessful, ‘‘move on’’ to the use of donor eggs, they construed donor eggs as a second-choice option within the context of this clinical encounter and frequently felt propelled by a sense of urgency to conceive before time runs out. While loss of time is prominent in narratives about infertility generally (Becker, 2000; Martin-Matthews & Matthews, 2001; Sandelowski, Harris, & Hol- ditch-Davis, 1990), by narrativizing this urgency vis- à-vis cultural discourses on the biological clock, some women discussed their experiences of inferti- lity in a context through which they perceived blame.

It appears from this research that women in the 38–41-year-old age group experienced a more complex infertility treatment trajectory than women 42 and older. This age group commonly tried to use in vitro fertilization with their own ova first but when these attempts were deemed failures and women turned to donor eggs, they felt rushed to achieve a pregnancy. This sense of urgency, in turn, reinforced the notion that reproductive capacity is ending. By turning to donor eggs because they believed they had waited too long, eleventh-hour moms considered their reproductive decision-mak- ing through a discourse of blame. In retrospect, some women felt they had waited too long and cited a variety of reasons (that were beyond their control) that range from lack of readiness for children to time invested in IVF with their own eggs. Dis- appointment in shifting from the anticipation of a biogenetic child to a child conceived with a donor egg is undoubtedly part of the adjustment process women in the 38–41 age group undergo.

On the other hand, women who began infertility treatment after 42 were more often advised to use a donor egg immediately. While severing the genetic connection with their potential child was certainly difficult for many women in this age group, these women did not express the same kind of urgency as they recounted their infertility trajectory because using their own eggs was precluded by the policies of medical practices. These women were apparently able to enjoy their reproductive capacity outside the politics of blame.

In conclusion, the extension of the child-bearing years into later phases of the life course is a complex process that has been growing in scale since the introduction of donor eggs, yet the phenomenon has

been largely overlooked except by those immedi- ately affected. Historical shifts in the twentieth century in how women’s reproduction is viewed, combined with the process of biomedicalization, have led to a new era in how the life course and its potentialities are viewed. Life stages are no longer discrete. They have become much more fluid and indeterminate. In the process, women who use new reproductive technologies are forced to rethink their gender identity in relationship to ideas about what age means for women who reproduce later in life. This research suggests that women’s views about age and infertility shift rapidly during the 38–45 age range as part of this process of reconceptualizing age and gender identity. The narratives of these women speak to the profound social changes that engulf them and provide a window into a social life transition that is occurring globally. The resulting social changes are currently being experienced as upheaval, but it is likely they will be seen in the future as commonplace.

Acknowledgements

This research was supported by a grant from the National Institutes of Health, National Institute of Child Health and Human Development—RO1 HD39117, The Disclosure Decision After the Use of Donor Gametes—awarded to Robert D. Nachti- gall, Principle Investigator; Gay Becker, Co-inves- tigator. The authors would like to express their gratitude to all of the respondents who shared their personal stories to contribute to this study. The working group on the project was invaluable to creating this paper: Anneliese Butler, Julia Duff, Jennifer Harrington, Kirstin Mac Dougall, and Dena Shehab. Special thanks are due to both Jennifer Harrington and Kirstin MacDougall for carefully reading the many iterations of this paper as well as to the three anonymous reviewers.

References

Aral, S. O., & Cates, W. (1983). The increasing concern with

infertility—Why now? Journal of the American Medical

Association, 250(17), 2327.

Becker, G. (1997). Healing the infertile family. Berkeley, CA:

University of California Press.

Becker, G. (2000). The elusive embryo: How women and men

approach new reproductive technologies. Berkeley, CA: Uni-

versity of California Press.

Becker, G., Butler, A., & Nachtigall, R. D. (2005). Resemblance

talk: A challenge for parents whose children were conceived

ARTICLE IN PRESS C. Friese et al. / Social Science & Medicine 63 (2006) 1550–15601560

with donor gametes in the US. Social Science & Medicine, 61,

1300–1309.

Becker, G., & Nachtigall, R. D. (1992). Eager for medicalization:

The social production of infertility as a disease. Sociology of

Health & Illness, 14(4), 456–471.

Bukulmez, O., & Arici, A. (2004). Assessment of ovarian reserve.

Current Opinion in Obstetrics and Gynecology, 16, 231–237.

Centers for Disease Control and Prevention (2004). 2002 Assisted

reproductive technology success rates: National summary and

fertility clinic reports. US Department of Health and Human

Services, December, p. 25.

Clarke, A. E. (1995). Modernity, postmodernity, & reproductive

processes, ca. 1890–1990, or ‘Mommy, where do cyborgs

come from anyway?’. In C. H. Gray (Ed.), The cyborg

handbook (pp. 139–155). New York: Routledge.

Clarke, A. E., Shim, J. K., Mamo, L., Fosket, J. R., & Fishman,

J. R. (2003). Biomedicalization: Technoscientific transforma-

tions of health, illness, and US biomedicine. American

Sociological Review, 68(2), 161–194.

Edwards, J., Franklin, S., Hirsch, E., Price, F., & Strathern,

M. (1993). Technologies of procreation: Kinship in the age of

assisted conception. London: Routledge.

Edwards, R. G., Fishel, S. B., Cohen, J., Fehilly, C. B., Purdy,

J. M., Slater, J. M., et al. (1984). Factors influencing the

success of in vitro fertilization for alleviating human

infertility. Journal of In vitro Fertilization and Embryo

Transfer, 1(1), 3.

Featherstone, M., & Hepworth, M. (1991). The mask of ageing

and the postmodern life course. In M. Featherstone,

M. Hepworth, & B. S. Turner (Eds.), The body: Social

process and cultural theory (pp. 369–389). London: Sage.

Formanek, R. (1990). Continuity and change and ‘the change of

life’: Premodern views of the menopause. In R. Formanek

(Ed.), The meanings of menopause: Historical, medical and

clinical perspectives (pp. 3–41). Hillsdale, NJ: The Analytic

Press.

Franklin, S. (1997). Embodied progress: A cultural account of

assisted conception. London: Routledge.

Franklin, S., & Ragone, H. (1998). Reproducing reproduction:

Kinship, power, and technological innovation. Philadelphia:

University of Pennsylvania Press.

Greil, A. L. (1991). Not yet pregnant: Infertile couples in

contemporary America. New Brunswick, NJ: Rutgers Uni-

versity Press.

Hepworth, M., & Featherstone, M. (1982). Surviving middle age.

Oxford: Blackwell.

Inhorn, M. C. (1994). Quest for conception: Gender, infertility,

and Egyptian medical traditions. Philadelphia: University of

Pennsylvania Press.

Inhorn, M. C. (2003). Local babies, global science: Gender,

religion, and in vitro fertilization in Egypt. New York:

Routledge.

Inhorn, M.C., & Van Balen, F. (Eds.), (2003). Infertility around

the globe: New thinking on childlessness, gender, and repro-

ductive technologies. Berkeley, CA: University of California

Press.

Kahn, S. M. (2000). Reproducing Jews: A cultural account of

assisted conception in Israel. Durham, NC: Duke University

Press.

Marsh, M., & Ronner, W. (1996). The empty cradle: Infertility in

America from colonial times to the present. Baltimore, MD:

The Johns Hopkins University Press.

Martin, E. (1987). The woman in the body: A cultural analysis of

reproduction. Boston: Beacon Press.

Martin-Matthews, A., & Matthews, R. (2001). Living in time:

Multiple timetables in couples’ experiences of infertility and

its treatment. In K. J. Daly (Ed.), Minding the time in family

experience: Emerging perspectives and issues (pp. 111–134).

Oxford, UK: Elsevier Science.

McKaughan, M. (1987). The biological clock: Reconciling careers

and motherhood in the 1980s. New York: Doubleday.

McLean, A. (1990). Contradictions in the social production of

clinical knowledge: The case of schizophrenia. Social Science

& Medicine, 9, 969–985.

Nachtigall, R. D., Becker, G., Quiroga, S. S., & Tschann, J. M.

(1998). The disclosure decision: Concerns and issues of

parents of children conceived through donor insemination.

American Journal of Obstetrics and Gynecology, 178,

1165–1170.

Nachtigall, R. D., Tschann, J. M., Quiroga, S. S., Pitcher, L., &

Becker, G. (1997). Stigma, disclosure, and family functioning

among parents of children conceived through donor insemi-

nation. Fertility and Sterility, 68, 83–89.

Ragone, H. (1994). Surrogate motherhood: Conception in the

heart. Boulder, CO: Westview Press.

Sandelowski, M. (1993). With child in mind: Studies of the

personal encounter with infertility. Philadelphia: University of

Pennsylvania Press.

Sandelowski, M., Harris, B. G., & Holditch-Davis,

D. (1990). Pregnant moments: The process of conception in

infertile couples. Research in Nursing and Health, 13(5),

273–282.

Schwartz, P., & Mayaux, M. J. (1982). Female fecundity as a

function of age. New England Journal of Medicine, 306, 404.

Scott, R. T., & Hofmann, G. E. (1995). Prognostic assessment of

ovarian reserve. Fertility & Sterility, 63, 1–11.

Strathern, M. (1992). After nature: English kinship in the

late twentieth century. Cambridge: Cambridge University

Press.

Thompson, C. (2005). Making parents: The ontological choreo-

graphy of reproductive technologies. Cambridge, MA: MIT

Press.

Utian, W. H. (1990). The menopause perspective: From potions

to patches. In M. Flint, F. Kronenberg, & W. Utian (Eds.),

Multidisciplinary perspectives on menopause (pp. 1–7).

New York: The New York Academy of Sciences.

Van Balen, F., & Inhorn, M. C. (2003). Interpreting infertility:

A view from the social sciences. In M. C. Inhorn, & F. van

Balen (Eds.), Infertility around the globe: New thinking on

childlessness, gender, and reproductive technologies (pp. 3–32).

Berkeley, CA: University of California Press.

Whiteford, L. M. (1989). Commercial surrogacy: Social issues

behind the controversy. In L. M. Whiteford, & M. L. Poland

(Eds.), New approaches to human reproduction: Social and

ethical dimensions (pp. 145–169). Boulder, CO: Westview

Press.

Zola, I. K. (1972). Medicine as an institution of social control.

The Sociological Review, 20(4), 487–504.