Readers Write In #521: The Elephant in the Room

Posted on November 5, 2022

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By ​Eswar

On Rohini S.Rajagopal’s memoir of infertility – ‘What’s a lemon squeezer doing in my Vagina?’.

In an article about stillbirth, Emily Oster, an American economist, made the following observation: ‘Like miscarriage or birth trauma or countless other parts of pregnancy and parenting, [stillbirth] is not a topic that’s easy to discuss. The result of that lack of ease is a lack of discussion. But the lack of discussion can leave people feeling unprepared and alone in loss. It also makes it more difficult to think about interventions that might change outcomes’. This observation is valid for yet another aspect of pregnancy and parenting – infertility.   

A few years ago, someone asked in Quora about things you should know before getting married. I responded by saying people looking to start a family should consider checking whether they are able to have children. The intention is not to make the entire relationship about having children but to avoid disappointment and suffering in the future. We see parents everywhere around us, but we do not give enough thought to the physical conditions required to become a parent. We presume everyone can become a parent. When reality turns out to be different, couples can often be at a loss.

Rohini S. Rajagopal is happily married to Ranjit. A few years into the marriage, their life changes when they plan to start a family. Delay in getting pregnant leads them to the world of infertility treatment. The shock, the pain, the suffering and the bundle of joy they eventually welcome is narrated courageously in the book – What’s a lemon squeezer doing in my Vagina?

Like the title of the book, the experience is candidly laid out, sometimes humorously. Still, there is always an element of shock to the reader, and the underlying pain does not go unnoticed. The pain of not bearing a child and the resulting social stigma is generally known. The unknown is what it means for a couple, especially the woman, to go through the fertility process in a clinical setup. Even when someone very close to us goes through the process, the conversation rarely goes beyond cursory inquiries. An unsaid but accepted awkwardness prevents everyone from discussing the topic further. What really happens inside those scary, cold rooms of the fertility centres? 

Medicine, as a field of science, is continuously evolving. Still, the terms of diagnosis, prognosis, procedures and treatment for some conditions are nascent. For example, consider cancer treatment. After many years of research, some types of Cancer are still incurable. Certain types of Cancer require the removal of body parts resulting in trauma and disfigurement of patients. In this regard, Cancer treatment is still in a developing stage. When reading this book, infertility treatment also comes across as if it is in its early stages.

The Wikipedia description of In Vitro Fertilisation(IVF), a type of infertility treatment, makes it look simple. ‘The process involves monitoring and stimulating a woman’s ovulatory process, removing an ovum or ova (egg or eggs) from her ovaries and letting sperm fertilise them in a culture medium in a laboratory. After the fertilised egg (zygote) undergoes embryo culture for 2–6 days, it is transferred by catheter into the uterus, with the intention of establishing a successful pregnancy.’  The actual process, though, could not be more complicated.

The treatment requires medication, blood tests, scans and invasive procedures, and every step is often repeated multiple times. In the book, this is compared to ‘watching a food show on TV and then trying to recreate the dish at home. There is a lot of trial and error’. There is uncertainty in the outcome. Some procedures are shocking even to read. One of the stages involves a Speculum, a metallic tool about the size of a lemon squeezer. In Intrauterine Insemination, a type of infertility treatment, the speculum is inserted into the vagina to expand the opening, and the sperm is injected using a catheter. For Rohini, the pain is not just physical. ‘The ninety seconds it must have taken to fix the speculum and inject the semen were excruciating and not just because of the physical hostility of the act. Not just because it felt raw or sore or I was bleeding. But because it was a breach of my already fragile self. It tore through the membranes of my defences, leaving me exposed and helpless.’ 

Some other medical treatments and procedures are even more daunting physically and mentally than the cycles for treating infertility. The difference here is in the reasons for getting treated. In other conditions, people endure treatments since the disease is often life-threatening or severely impacts everyday life. These patients are often left with no choice. In the case of infertility, couples do have an option to not take up the treatment because of its nature and success rate. When there is a choice, what drives them to undergo treatment? Is it a personal decision arising from a natural desire to bear a child? Or is it a decision triggered by social pressure?

Even though I say couples, often, it is women who go through the treatment. Rohini says that one reason for this is to do with human biology. ‘In IVF terms, an egg is a far more prized commodity than a sperm. Getting one good quality sperm cell is relatively easy – you have millions to pick from – while the stock of the eggs is a hastily diminishing resource’. For this reason, Rohini believes fertility treatment is centred on the woman and her eggs. Even when the egg is fertilised in a lab, the remaining steps – implantation, pregnancy, and labour – happen inside the female body. Even for male infertility, women undergo the process once the sperm is extracted. Though neither of them had any issues, it was Rohini who went through the process. ‘Infertility is not an equal-opportunity employer’, Rohini observes wryly. Since the treatment was centred on Rohini, she had more visits to the clinic. She was often on her own when it came to knowing the treatment procedures and making decisions. This may seem less of an issue in the beginning. But day in and day out, when only one person takes the brunt, it gradually affects their relationship. Fortunately, the couple endured these troubles without giving up on the treatment or sacrificing the relationship.

Finally, one treatment cycle succeeds, and the pregnancy is well into the trimester. When sharing the news with relatives, one conversation shocks Rohini.

‘Was it IVF?’

‘No’, The reply comes spontaneously.

‘Not IVF? You didn’t seek any treatment?’

‘No nothing.’

‘It happened naturally?’, the relative persisted.

‘Yes’, Rohini mumbled, wishing the interrogation would end. 

‘Okay, then. Congratulations!’

What shocked Rohini was not the directness of the questions but her instinctive denial. Her replies made her wonder why she had to lie as if she had done something wrong or a dishonourable deed. She discovers that the shame she felt towards her body made her lie. That is when Rohini realised what she really felt about it – ‘Infertility was a dirty secret. I only wished to get past infertility and pretend it never happened’. That realisation is the seed for the book. From being unable to talk about infertility and treatment in a private conversation, Rohini grows into a person who can discuss this publicly. The transformation is visible in her writings when she discusses the condition and treatment openly and comfortably without feeling shame or self-pity. 

The book is not a guide for infertility treatment. It is a personal memoir. We get to know the procedure through the person going through it. The style makes the reader relate to the experience rather than becoming a know-how guide to treatment. The story interweaves the author’s upbringing, her family, the environment she grew up in, and the decisions taken in other areas of life. Through them, we not only get to know the person but also are able to understand the choices the person makes when dealing with infertility. 

There are some aspects of life that we can never experience ourselves. Even if we can, we wish we never encounter them. Still, some people go through them by choice or lack of one. The only way to know at least a little about those experiences is through those who have encountered them. Why should one need to be aware of these experiences? In the context of infertility, there are two reasons. First, to question ourselves if we are glorifying parenthood to the point where there is an unnatural expectation for everyone to become a parent. Second, to comfortably discuss infertility without awkwardness like other human conditions. Ability to discuss openly about infertility could help prevent people from suffering on their own and help with their decisions and treatment choices. Through this memoir Rohini S. Rajagopal has laid a foundation for this discussion.

The story ends well for Rohini and Ranjit. But as I finish reading this book, it is hard not to think about those couples who are going through this silently and others who may never see the light at the end.