On a cold night in mid-October, a couple hundred bejeweled women in gowns file into the Pierre with their dates for a very special 50th-birthday party. Before retiring to a three-hour lobster-and-steak dinner in the hotel’s main ballroom, they collect oversize spoons of foie gras as Gloria Gaynor’s “I Will Survive” blasts from overhead speakers in a robin’s-egg-blue reception room, with a bar festooned with the kind of miniature silver stars that teachers give exemplary students. Neat stacks of East Village party napkins with illustrations of women in vintage clothing rest next to rows of Champagne glasses, each with a different quip at the bottom: “Let’s ignore our mother’s well-meant advice,” says one; “She thought of him fondly as ‘Plan B,’ ” says another; and a wide-eyed Lucille Ball covers her mouth with a yellow-gloved hand in shock at some mishap on the next, asking, “Has anyone seen my hormones?” In the middle of the room, on a tall pedestal, there’s an enormous cake, with lettering that spells out ONE SMALL PILL. ONE GIANT LEAP FOR WOMANKIND. ONE MONUMENTAL MOMENT IN HISTORY.
Yes, the birth-control pill, approved by the FDA in 1960, is the “birthday girl” at tonight’s gala, which is sponsored by Israeli company Teva Pharmaceutical, the biggest maker of generic drugs in the world. Medications don’t usually have their own black-tie events—there aren’t galas for antibiotics, or chemotherapy, or blood thinners—but the Pill, after all, is so much more than just a pill. It’s magic, a trick of science that managed in one fell swoop to wipe away centuries of female oppression, overly exhausting baby-making, and just marrying the wrong guy way too early. “The Pill created the most profound change in human history,” declares Kelli Conlin, president of the National Institute for Reproductive Health, grabbing the mike on a small stage draped with black curtains dotted with a larger version of the same silver stars from the bar. “Today, we operate on a simple premise—that every little girl should be able to grow up to be anything she wants, and she can only do so if she has the ability to chart her own reproductive destiny.”
A series of toasts follows, from Kate White, the editor of Cosmopolitan magazine, who talks about “vajayjays,” to Dr. Ruth, who, though considerably shrunken from her heyday in the mid-eighties, still giddily declares that tonight’s event is “better than sex!” Even the grandson of Planned Parenthood founder Margaret Sanger has stopped by to collect his award, an “honorable mention.” “What a treat!” says Alexander Sanger, jumping onstage. “You know, Margaret thought two or, at the outside, three children was the exact right number. Now I’m fourth of six. When my mom told Margaret the news, there was a long pause as she did the math. Then she said, ‘You’ve disgraced me. I’m going to Europe.’ ” The crowd laughs loudly. “And let me add one thing,” says Sanger, his voice rising triumphantly. “I think it’s time we had a male Pill also. I’d like to be around for that pill’s 50th birthday!”
It’s an endless parade of speakers, actually, with the hullabaloo lasting until 10 p.m., including a slideshow of female icons—Jackie O., Wonder Woman, Murphy Brown, Hillary, Oprah, Sarah Palin—and a constant stream of jokes from buoyant mistress of ceremonies Cybill Shepherd, in a red off-the-shoulder pantsuit that could be from her Moonlighting days. “When I grew up in Tennessee, everything I learned about sex my mother told me,” she says, wiggling this way and that. “She said, ‘It’s disgusting, and you’ll hate it, and whatever you do, don’t do it before you get married.’ Did I mention ‘disgusting’?” She shakes her head. “Nevertheless, I became sexually active as a teenager. One day, my mom took me to my family doctor. He wrote something on a prescription pad and said, ‘Take one of these every day, and all your periods will be regular.’ ” She laughs heartily. “What a thrill! He didn’t even tell me it was birth control.”
Shepherd pauses for dramatic effect. “Can you imagine how different my life would have been if I hadn’t gotten the Pill?” she says. “In the South in the sixties, you had limited choices—you could be a wife, a mother, a nurse, or a teacher. If you were really lucky, Miss America.” She cocks her head. “Wasn’t I Miss America? There’s a lot I can’t remember. Oh, right, Model of the Year.” Soon, she passes the mike to The Daily Show’s Samantha Bee, who raises yet another glass. “Today, even though we have pills for everything—to make you calm, make you sleep, and engorge your genitals beyond comprehension—you, the Pill, are so important,” says Bee. “So here’s to my tiny daily dose of freedom, and also estrogen and progesterone. A combination of the three, really.” She smiles, a little bit knowingly. “Interestingly, it’s the freedom that causes the bloating.”
Even if it is laid on a little thick, there’s no question that these women are right: The Pill changed the world. These days, women’s twenties are as free and fabulous as they can be, a time of boundless freedom and experimentation, of easily trying on and discarding identities, careers, partners. The Pill, which is the most popular form of contraception in the U.S., is still the symbol of that freedom. As a young woman, you feel chic throwing that light plastic pack of dainty pills into your handbag, its retro pastel-colored wheel design or neat snap-to-close box sandwiched between lipstick and cell phone, keys and compact. It’s easy to believe the assurances of the guests at the Pierre gala that the Pill holds the answers to empowerment and career success, to say nothing of sexual liberation—the ability to have sex in the same way that guys always have, without guilt, fear, or strings attached. The Pill is part of what makes one a modern woman, conferring adulthood and cool with the swipe of a doctor’s pen. “I started taking the Pill when I was a freshman in college, before I even was having sex,” says Sahara, 33. “Everyone else was doing it, so I wanted to do it, too.”
The Pill is so ingrained in our culture today that girls go on it in college, even high school, and stay on it for five, ten, fifteen, even twenty years. It’s not at all out of the ordinary for a woman to be on the Pill from ages 18 to 35, her prime childbearing years. While it is remarkably safe, almost like taking a vitamin, that’s a long time to turn one’s body into an efficient little non-procreative machine. The Pill (and other hormonal methods of birth control, like the patch and the ring) basically tricks your body into thinking it’s pregnant. The medicine takes control of your reproductive processes, pulsing progesterone and estrogen to suppress ovulation. On the Pill, every woman’s cycle is exactly the same, at 28 days, even though that is rarely the case in nature, where the majority of periods occur every 26 to 32 days but can take up to 40 or even 50 days. This is a nice effect, but it’s not real. And there’s a cost to this illusion, one that the women at the Pierre weren’t discussing.
The fact is that the Pill, while giving women control of their bodies for the first time in history, allowed them to forget about the biological realities of being female until it was, in some cases, too late. It changed the narrative of women’s lives, so that it was much easier to put off having children until all the fun had been had (or financial pressures lessened). Until the past couple of decades, even most die-hard feminists were still married at 25 and pregnant by 28, so they never had to deal with fertility problems, since a tiny percentage of women experience problems conceiving before the age of 28. Now many New York women have shifted their attempts at conception back about ten years. And the experience of trying to get pregnant at that age amounts to a new stage in women’s lives, a kind of second adolescence. For many, this passage into childbearing—a Gail Sheehy–esque one, with its own secrets and rituals—is as fraught a time as the one before was carefree.
Suddenly, one anxiety—Am I pregnant?—is replaced by another: Can I get pregnant? The days of gobbling down the Pill and running out to CVS at 3 a.m. for a pregnancy test recede in the distance, replaced by a new set of obsessions. The Pill didn’t create the field of infertility medicine, but it turned it into an enormous industry. Inadvertently, indirectly, infertility has become the Pill’s primary side effect.
And ironically, this most basic of women’s issues is one that traditional feminism has a very hard time processing—the notion that this freedom might have a cost is thought to be so dangerous it shouldn’t be mentioned. Earlier this decade, there was an outcry when the American Society for Reproductive Medicine commissioned an ad campaign on New York City buses featuring a baby bottle fashioned as an upside-down hourglass (around the same time, Sylvia Ann Hewlett, an economist, made headlines with a suggestion that women would be better off having their kids in their twenties and entering the workforce a half-dozen or so years later). The National Organization for Women called the city bus ads a “scare campaign.” NOW’s president even wrote an editorial claiming that “women are, once again, made to feel anxious about their bodies and guilty about their choices.”
The Pill should be defended from attacks. An absurd fight is beginning on Capitol Hill to try to boot it from the category of “preventative care” in the health-care bill—“as though the Pill isn’t the very definition of preventative care,” says Vanessa Cullins, vice-president for medical affairs at Planned Parenthood, drily. In its intimacy, the Pill and its consequences are hard to talk about in public: The publicist for the Pierre gala confesses that she’s never had a harder time booking celebrities for an event than this one, and the stars that do attend, like AnnaLynne McCord, of the CW’s 90210, can be heard wondering what they should say on the red carpet. “Should I be honest about this?” McCord whispers to her publicist before confessing publicly that she went, alone, to Planned Parenthood for birth-control pills against her family’s wishes at age 17. “I don’t want any of my fans to go through what I had to go through,” says McCord, blinking rapidly. “So tweet me, guys, if you want to talk.”
But there’s also no reason not to talk about the more complex changes long-term use of the Pill has wrought, instead of finger-pointing over compromising women’s choices. After all, these days, there’s not as much pressure to procreate as one may imagine. Most mothers, who were at least tangentially part of feminism’s early waves, know better than to stress women out about when they’re having children, even if an aunt puts her foot in her mouth from time to time. And, of course, bosses would rather women were around all the time, thumbing their BlackBerrys in the off-hours. “There’s a strain of feminist thought that’s still trapped in the mind-set that the male patriarchy wants women pregnant and has been withholding things like abortion and contraception from them because of it,” says Liza Mundy, author of Everything Conceivable, a comprehensive book about fertility treatments in America. “To me, that’s a laughably simplistic view of the world.”
The whole point of the Pill from the beginning has been population control. Even though America was consuming more than 50 percent of the world’s resources in the late fifties (with 6 percent of the world’s population), eugenicist fears of the developing world’s excessive procreation ran rampant during the Cold War. According to Andrea Tone’s fascinating history of contraception in America, Devices and Desires, Cold War–era birth-control proponents used the terms family planning, birth control, and population control interchangeably. Women’s rights weren’t the primary impetus to approve the Pill, but they were part of the package, too, of course. “The Pill symbolized the redemption of science,” writes Tone, “showing it capable of developing a technology to stabilize a world order that it simultaneously threatened to destroy.”
The Pill wasn’t the world’s first attempt at contraception. Egyptians fashioned vaginal suppositories for themselves out of crocodile dung and gum, West Africans used plugs of crushed root, and Greeks in classical times coated their cervices with olive oil. Casanova even wore condoms made of animal intestines, though he reported that he was revolted by “shut[ting] myself up in a piece of dead skin to prove I am perfectly alive.” Some women even relied on the rhythm method, though they had the science wrong: For years, the medical community thought ovulation occurred during menstruation. It wasn’t until the twenties that everyone realized that women are fertile in the middle of their cycle, not at the end.
In nineteenth-century America, home-brewed abortifacients made from pennyroyal were eventually replaced by an amazing array of contraceptives made from Charles Goodyear’s vulcanization technology, like mass-produced condoms, IUDs, and “womb veils,” as diaphragms were called at the time. But this freedom was not to last for long. By the 1870s, in the midst of the burgeoning social-purity movement, the delivery of contraception through the mail was abolished, and there were crackdowns on prostitution, gambling, and alcohol, enforced by the New York Society for the Suppression of Vice, backed by powerful New Yorkers like J. Pierpont Morgan and Samuel Colgate. These laws remained in force from 1873 till 1918, during which time women relied primarily on a black market of diaphragms and cervical caps. Then in the fifties, Sanger recruited a scientists at work on infertility problems to help her achieve her dream, the Pill.
When the Pill was finally approved in 1960, American women embraced it immediately. In the sixties, the high doses of estrogen in the original pills may have been responsible for a disturbing spate of blood clots and the size of many women’s bosoms—the sale of C-cup bras increased 50 percent during the decade, as many Joans and Peggys popped their medicine—but these days, there are few blood clots with most pills and rare side effects with the “mini-Pill,” made only of progesterone. It’s unfortunate that the Pill doesn’t protect against STDs, but as a matter of medicine, it’s a triumph, with very few serious drawbacks.
Some versions of the Pill even reduce acne, soften the experience of painful periods, and significantly decrease the chance of endometrial and ovarian cancer (when a woman ovulates less, her cells divide less). This October, Bayer, the biggest maker of contraceptives in the world, even came out with Beyaz, a Pill that includes the same folic acid that women who are trying to conceive are supposed to take every day to reduce the incidence of some birth defects—just in case the Pill doesn’t work. But forget a male Pill: With the high cost of clinical trials, the lack of interest in upending cultural norms, and the need to make a pill with zero side effects (after all, this Pill is being taken by a man), this formulation hasn’t gone much beyond forays in the mid-sixties, when a male Pill, tested in Oregon prisons, turned men’s eyeballs red when combined with alcohol.
With the pill’s relative safety today, it’s suprising that so many women still complain of side effects. Women’s blogs like Jezebel are swarming with women who attribute a whole host of side effects and medical problems to the Pill, most of which are most likely unrelated (though there may be some loss of libido with the Pill, which ties up the body’s free testosterone). Earlier this decade, when women were offered the chance to eliminate menstruation with extended-cycle pills like Seasonale and Seasonique, which promise the visit of “Aunt Flo” only four times a year, not many women chose to take it. (The period a woman gets on the Pill is artificial—it’s just the withdrawal of the Pill’s hormones—and there is no medical reason for it.) That’s amazing: Who would have ever imagined that women would turn down the chance to abolish periods?
The reason for this may be that women are half-consciously rebelling against the artificiality of the Pill’s regime. Removal from one’s true biological processes was more appealing in the Mad Men era, when machines were going to save the world and pills could fix everything, even the ennui of housewives. But for the wheatgrass-and-yoga generation, there’s something about taking a pill every day that’s insulting to one’s sense of self, as an accomplished, adult woman. “I feel like I’ve gotten a message over the years that the less I have to do with the nitty-gritty biological stuff of being a woman, the better, and that’s a weird message,” says Sophia, 35, who was on the Pill for fourteen years. “In my ninth-grade health class, I remember the teacher saying, ‘You can get pregnant any day of the month, so always use protection,’ and I kind of knew that wasn’t true, but because I was on the Pill, I never really cared about finding out the right answer. The Pill takes a certain knowledge away from you, and that knowledge is empowering.”
The Pill didn’t create the field of infertility medicine, but it turned it into an enormous industry.
Consequently, a cult market has cropped up catering to women in the process of rediscovering their bodies when they go off the Pill. There are ovulation kits, though they carry a hefty price tag ($30 for a pack of seven tests, while Viagra is covered by health insurance—how revolting), and Whole Foods carries a set of plastic beads with colors that indicate when a woman is fertile and when not, called CycleBeads, a collaboration between a private company and Georgetown’s Institute for Reproductive Health. CycleBeads use a twelve-day “fertile window,” because even though an egg is able to be fertilized for only 24 hours, sperm can last up to five days inside a woman’s reproductive tract—though a more realistic estimate of a woman’s true fertility window is more like three days, certainly for women whose fertility is declining because of age.
But the most popular new natural method is the Fertility Awareness Method (FAM)—a more sophisticated version of the rhythm method—which was popularized by fertility guru Toni Weschler, a mellow, soft-spoken 55-year-old from Seattle. “Oh, I’m not a guru,” she says, calling from the West Coast. “I’m just a regular Josephina.” Weschler doesn’t have any kids—“I am an unadulterated weenie,” she says, giggling, “I can’t deal with a splinter, so I don’t know how I would handle taking care of a kid who banged his head”—but she’s devoted herself to helping women start their families or just get in touch with their bodies. In some ways, her 400-page book Taking Charge of Your Fertility has become the Our Bodies, Ourselves for our time. Alternately silly, whimsical, and exhaustingly specific, the book was published fifteen years ago and is ranked higher by customers on Amazon than all other books except the third and fourth Harry Potters.
Weschler’s method is precise, though it requires some organization. Every day, women have to take their temperature first thing in the morning with a basal body thermometer and then monitor their “cervical mucus,” which, in addition to being a great name for a riot-grrrl group, is one of the best signals of impending ovulation (monitoring your “cervical position,” which Weschler advises doing in a squatting position, is optional). All this information is written down on “the chart,” a piece of paper with a series of boxes that looks like a primitive Excel document. Cervical mucus (or fluid, the word that Weschler prefers) means that estrogen has risen dramatically and ovulation is about to occur. A rise in temperature tells a woman that she has ovulated. A sudden drop means a period is about to begin.
“There’s no reason for girls to have to worry about getting their period in gym class at school, or for women to be worried about wearing their white pants,” says Weschler. “There is no mystery here. If you take your temperature, you will know when you’ve ovulated and when you get your period.” She sighs. “Think about a woman who gets pregnant accidentally when she’s on the Pill, because she missed a few pills: How come she doesn’t know that if she feels a lot of fluid, which I like to call ‘egg-white cervical fluid,’ her estrogen is rising, and one of the eggs hasn’t been suppressed? In fact, she’s about to release it. For no other reason, all women should know that, so they can say, ‘Oh, dear, my estrogen seems to be rising, something is wrong.’ ”
You’re not going to find anyone, male or female, who isn’t a little grossed out by the words egg-white cervical fluid, but it’s just basic biology. “The egg-white stuff is just my body preparing for ovulation, which is the time to hop into bed,” says Barrie, 35, a FAM enthusiast. “It’s the glue that transports the sperm into my uterus.”
To arrive at the stage when one stops taking the Pill and starts timing one’s ovulations is to enter a new and anxious universe. After that, if you’re unlucky, you may enter a kind of medical and bureaucratic purgatory of doctors’ waiting rooms and insurance companies and worries that’s very far indeed from the freedom you enjoyed before.
On the Pill, it’s easy to forget the truths about biology. Specifically, that as much as athleticism or taut cheekbones are, fertility is a gift of youth. The body that you wake up with after fifteen or more years on the Pill is, in significant ways, not the one you started out with. With age, body rhythms change. Cystic conditions, endometriosis, and a whole host of complicated ailments are more common. And whatever “irregularities” a woman may have experienced in her teenage years before going on the Pill will likely be around when she goes off it. “Some women who come off the Pill in their thirties are surprised that it takes a few cycles to get their periods back, or that they may have very long cycles, or cycles without ovulation,” says Jill Blakeway, founder of acupuncture center Yinova near Union Square and a co-author of the cult book Making Babies. “The Pill didn’t create these problems: In most cases, the problems were there all the time, but because they were on the Pill, these women were never motivated to deal with them. And now they have a time issue.”
But the biggest issue for aging women, of course, is that over time, their stockpile of eggs becomes depleted, and the ones they still have are not of top quality. Fifty percent of women over 35 will fail to get pregnant over the course of eight months, and after that the odds keep dropping.
And as it turns out, it’s difficult to predict how hard it will be for any given woman to conceive. “We don’t completely know what determines who is fertile and who is not,” says Dr. Jamie Grifo, the compassionate, plainspoken program director of NYU Langone’s Fertility Center. “The only test is trying to get pregnant and getting pregnant. That’s it.”
For women who have spent so much of their lives pressing the off button on their bodies while on the Pill, it’s upsetting to learn that there’s no magic pill that causes instant impregnation. (The same is not the case for men: With the advent, in the nineties, of a technology that can fertilize an egg with a single sperm, almost every man can be a father.) In fact, fertility doctors have a surprisingly small suite of options for women who are having trouble conceiving—and very few that don’t involve the risk of multiple births. There’s Clomid, a neurological drug that encourages ovulation and can trick a woman’s body into making more than one egg a month; a bioengineered follicle-stimulating hormone, originally synthesized from the urine of postmenopausal nuns, which also makes the body produce multiple eggs; and in vitro fertilization (IVF), or test-tube babies, which has been the gold standard of infertility treatments since 1978 (the British doctor who pioneered it received the Nobel Prize this year).
IVF has never been more effective than it is today, but cycle by cycle, it still fails more than it succeeds. NYU has one of the best IVF programs in New York—the other is the Weill Cornell Medical Center, part of New York–Presbyterian—and its success rates put it near the top in the country. But a look at these rates should give one pause. In a single cycle of IVF, about 64 percent of 30-year-old women wound up with a child. At 35, 47 percent were successful; at 40, only 28 percent; at 43, only 13 percent; and at 44 and over, it’s 2 percent.
Many women try IVF four or five times, hoping for a successful cycle; even when it is unlikely, getting pregnant becomes an obsession. Insurance companies rarely cover the costs, which run up to about $15,000 per cycle including medication—a shortsighted policy, as they are on the hook for covering any preterm costs for multiple births, which are much more likely when financially struggling patients transfer three or more embryos in hopes of finally achieving success. Patients also need to factor in possible costs for donor eggs, surrogates, or adoption, which usually runs into the tens of thousands. Adoption is also a more difficult prospect now than it has ever been in American history, with far fewer infants available to adopt these days, since China, Vietnam, and Guatemala are effectively closing their borders (like Angie and Brad, many parents are turning to Ethiopia).
All of these decisions involve heartbreak and stress, and it’s easier to pretend that the clock isn’t ticking. “I’ve got 44-year-olds who show up in my office after trying two months and say, ‘I don’t understand, my gynecologist told me I was fine,’ ” says Grifo. “Now, he didn’t say, ‘You’re going to be fertile forever.’ But they didn’t hear that part—they heard the part where he said they’re healthy. And for these women, if IVF doesn’t work, it’s very hard to recover. They have to grieve and mourn and make a life. These women, the 44-year-olds, are the ones that struggle the most, because they are so angry. And they’re angry at one person, but they won’t admit it. They’re angry at themselves.”
Sexual freedom is a fantastic thing, worth paying a lot for. But it’s not anti-feminist to want to be clearer about exactly what is being paid. Anger, regret, repeated miscarriages, the financial strain of assisted reproductive technologies, and the inevitable damage to careers and relationships in one’s thirties and forties that all this involve deserve to be weighed and discussed. The next stage in feminism, in fact, may be to come to terms, without guilt trips or defensiveness, with issues like this.
Choice is a more accurate word when the chooser—us—is aware of all the possible consequences of taking different possible paths. But reality has a hard time getting into these areas, let alone the Brave New World of infertility medicine. Women have certainly come a long way—and this, a sense of reality about these most fundamental of issues, may be the next stage. “The fear of reproductive-rights groups is that if you regulate or say no to procedures like reducing a twin to a singleton after IVF, or whether extra embryos should be thawed, it will chip away at the fundamental concept of choice when it comes to abortion,” says Liza Mundy, the author. “These groups might want to say no to some of these, like sex selection of embryos, because that might privilege boy babies or girl babies. But if they say no to sex selection, does that mean they’re not pro-choice?” She sighs. “The easiest thing for them to do is not engage with any of this.”
The Pill may seem to promise eternal youth, but doctors have only middling odds of recapturing fertility when a woman has crossed into early middle age. There’s an easy answer to this conundrum, even though it’s a little weird: freezing eggs in one’s twenties. The technology has come a long way in the past five years, and women with frozen eggs now have a very good shot at successfully thawing and implanting them later in life. In 2009, NYU had a baby born from a woman who froze her eggs at 38, and it’s now posting the same rates of success with frozen eggs as it does with embryos frozen during IVF.
That may be the world to which many are heading—even more medicalized and technologized, where all women freeze their eggs and submit to assisted reproductive technologies, and with it, more complicated choices and questions that bioethecists love to hash over. Even Carl Djerassi, one of the inventors of the Pill (before he became a Stanford professor, playwright, and sci-fi novelist), has suggested that all forms of birth control will eventually become obsolete and the Pill “will end up in a museum.” In his imaginings, girls and boys will deposit their eggs and sperm in a reproductive bank to be frozen at 20 or so and then get sterilized. They’ll want to do this because genetic diagnoses of embryos will become increasingly sophisticated, and no one will want to risk having a child with birth defects, let alone a child of an unpreferred gender or one predisposed to a hairy back. When these people want to have children, either one or six, at 30 or 60 years old, they’ll make a withdrawal from the bank.
But that’s a long-term vision, a place that few of us will ever see—even if we want to. In the shorter term, Djerassi once wrote, “many a woman in our affluent society may conclude that the determination of when and whether she is ovulating should be a routine matter of personal information to which she is entitled as a matter of course.”
Now he tells us.