Age-related infertility: a tale of two technologies

Authors


Address for correspondence: Elizabeth Szewczuk, Department of Sociology, University of Essex, Wivenhoe, Colchester C04 3SQ
e-mail: shewchuk@btinternet.com

Abstract

The reproductive body has become the site of intensive medical intervention, yet, paradoxically, women have never been more at risk of suffering the distress of infertility. Drawing on in-depth interviews with 22 infertile women, this article explores their reproductive experience from fertility postponement to assisted conception. All had used both modern contraception and in vitro fertilisation, yet none achieved the fertility they desired, when they desired it. All had structured their use of these technologies around the social practice of postponement. Modern contraception, however, while removing the sexual costs of postponement, did not resolve its reproductive dilemmas. Rather it appeared to collapse the experience of this traditionally difficult process, sustaining an illusion of reproductive control in which fertility decisions were ‘put on the back burner’, undiscussed and sometimes unimagined. For these women this delay then revealed the hidden cost of postponement – infertility – which, in turn, led to their pursuit of assisted conception after the age of 35, at precisely the point when its already limited efficacy begins to fail sharply. In these accounts age-related infertility emerged as a tale of two technologies: two technologies linked to each woman, and each other, through the social practice of postponement.

Introduction

Over the past 40 years advances in medical science, in particular modern contraception and in vitro fertilisation (IVF), have revolutionised women’s reproductive lives from menarche to menopause and beyond. While agreeing that reproductive technologies have transformed women’s reproductive experience, sociologists tend to disagree on the significance of this transformation. The technologies can be viewed as freeing women from the constraints and vagaries of biology and conferring upon them reproductive choice and control (Benagiano et al. 2007, Hakim 2003, Harraway 1991) and conversely, they can be viewed as emblems of an ongoing project to medicalise the female body, perhaps in preparation for further patriarchal oppression (Corea 1988). However, in the long view provided by demographers an altogether different version of events emerges. Across Europe the greatest reductions in fertility occurred during the period 1850 to 1930, many decades before the advent of reliable contraception (Kirk 1996, Leridon 2006). By 1930 British fertility rates were so low that fears of depopulation prompted parliamentary debates (Solway 1982). Moreover, British fertility has been shaped by the social practice of late marriage and fertility postponement since the sixteenth century (Hajnal 1965). This indicates that in Britain fertility has been subject to conscious control for over 450 years, many centuries before the advent of reproductive technologies. From this demographic point of view the role of reproductive technologies in the incidence of fertility can seem almost irrelevant (Leridon 2006). The picture becomes even more confusing when we examine the historical evidence on one particular fertility hazard, age-related infertility. Women in late-marrying societies have always faced the risk of postponing marriage, and thus fertility, for too long (Wrigley et al. 1997). Yet over recent decades there appears to have been a steady increase in age-related infertility, as manifested in the ever greater numbers of women over the age of 35 seeking an assisted conception, many of whom will be unsuccessful. It seems, paradoxically, that despite the female body now being the site of intensive bio-medical intervention, women in the western world have never been more at risk of suffering the distress of infertility. And what is most disturbing and revealing in this is not just the fact that a woman might use IVF to remedy this fertility hazard but that she appears to have used modern contraception to recreate it. In age-related infertility the intersection between reproductive technologies and reproductive experience, and incidence, becomes complex and confusing. Reproductive experiences may be transformed, but not necessarily in ways that are assumed or that are beneficial, and the notion that they automatically act to extend reproductive choice appears rather suspect.

Age-related infertility: facts, figures and history

Infertility is an elusive concept; it is an outcome that has not happened, an absence. Age-related infertility is a conundrum; as an involuntary infertility that arises out of a previous practice of voluntary infertility; an involuntary infertility that has, apparently voluntarily, been socially constructed over the reproductive life course. In 2007 women over 35 years old accounted for 53 per cent of all assisted conception cycles in the UK, and it is in the Human Fertilisation and Embryology Authority (HFEA)’s long-term data that age-related infertility in the UK today comes most clearly into focus. Table 1, drawn from this data, illustrates three underlying factors driving the growth of the fertility industry in the UK. Firstly, there is the underlying relationship between maternal age and successful conception. Assisted conception, like natural conception, is age-related and so, as maternal age rises, success rates fall. This correlation is so consistent that it represents one of the most solid pieces of scientific knowledge to emerge from all medical research on infertility. Maternal age, above and beyond any other factor including male infertility, tubal disease and endometriosis, acts as the best predictor of assisted conception outcomes (Baird et al. 2005, Pal and Santoro 2003). Khanapure and Bewley (2007) estimate that 34–46 per cent of women over the age of 35 will be unable to conceive naturally.

Table 1. Live birth rate for all in vitro fertilisation (IVF) and intracytoplasmic sperm injection by age of patient in selected years 1994–2005
 27 years30 years36 years42 years
  1. Source: Table 8, p. 23 HFEA long-term data (2007) (with permission).

1994
 IVF cycles (N)70615991814396
 Live births (N)13726725021
 Birth rate (%)19.416.713.85.3
1998
 IVF cycles (N)98221142585539
 Live births (N)21343746427
 Birth rate (%)21.720.718.35
2002
 IVF cycles (N)73218812880764
 Live births (N)18649055457
 Birth rate (%)25.42519.27.5
2005
 IVF cycles (N)799179135071110
 Live births (N)29950580473
 Birth rate (%)28.72822.96.6

Secondly, there is the overall increase in numbers of women seeking assisted conception. In some part this trend reflects an overall rise in treatment-seeking. However, over this period the demand for IVF from women aged 30 remains quite stable, while the demand among women over 35 doubles. This disproportionate rise in the numbers of women over 35, corresponding with the rising age of mothers at first birth, indicates an increase in age-related fertility problems. What makes these figures even more disturbing is the apparent tendency of women to access this technology at precisely the point its already limited efficacy begins to fail sharply, revealing the paradox in which the longer a woman postpones her fertility the more likely she is to need assisted conception but the less likely she is to be successful.

The challenge of situating age-related infertility

Greenhalgh (1995) warns that fertility is too important to be left to demographers and calls for its analysis to be situated in its historical, social and cultural context. However, as Greil et al.’s (2010) review of the literature on infertility acknowledges, most theorising on the sociocultural context of infertility and childlessness still tends to rely on notions of pro-natalism (Ireland 1993, Parry 2005, Throbsy 2004) or variants of coercive patriarchal relations (Becker 2000, Corea 1988, Natchigall et al. 1992). Thus, women experience infertility and childlessness as a form of stigma (Gillespie 2003, Lisle 1999, Morrell 1994) because they live in pro-natal or patriarchal societies. Clearly, age-related infertility that is an outcome of fertility postponement cannot also be a product of pro-natalism or, indeed, patriarchy as we know it, but the problem goes deeper. Measuring the infertile woman’s distress and monitoring her progress through the clinic are valuable projects, but women also deserve a sociology that is prepared to interrogate the relationship between the voluntary process of postponement and infertility; not least because most women will experience infertility only after a long phase of postponement, and will do so having used a technology that purports to offer reproductive choice and control. This is the challenge of age-related infertility. Within the context in which many women delay first childbirth beyond the age of 30, the concept of pro-natalism appears to be both limited and misleading, obscuring the fact that childlessness, rather than being stigmatised, is an entirely normative phase in western women’s reproductive lives. Moreover, when we engage with demographic history, postponement emerges as a practice with a long and distinctive history that has been shaping the incidence and experience of both voluntary and involuntary infertility, for many centuries. In short, thanks to the demographic record, reproductive experience in the UK can be situated, precisely and solidly, within the historical and sociocultural context of a pattern of delayed marriage. In exploring the particular reproductive constraints and dilemmas of this historical fertility pattern not only can we situate age-related infertility but we can begin to explore just how a woman today might use a modern reproductive technology to recreate a very old fertility hazard.

Historical perspective on postponement and age-related infertility

It is hard to over-estimate the importance of postponement in the reproductive lives of English women. Since the sixteenth century English women, as with other north-west European women, maintained a distinctive pattern of late marriage at around the age of 25, with significant proportions of women never marrying at all (Hajnal 1965, Laslett 1983, Wrigley et al. 1997). This was in contrast to non-western, early marrying societies, where female marriage was both universal and early, generally prompted by puberty. The late-marrying society is, in effect, the postponement of fertility writ large as postponement is the reproductive practice that underwrites late marriage and represents its most distinctive reproductive practice.

That postponement has long shaped English fertility levels is an undisputed fact of demography. Demography, however, tends to be blunt instrument that views postponement as a mechanism for limiting fertility. The purpose here is to read between the demographic lines and explicate a sociological view of postponement as a social practice; a practice at once so large that it has shaped and still shapes demographic structures, yet at the same time so intimate that it shapes and structures female bodies and experience.

The systematic practice of postponement divides the reproductive life course into two phases; a long phase of unmarried childlessness followed by marriage and fertility. In the late-marrying society unmarried childlessness becomes an entirely normative stage in the female life course. In this it writes complexity into female lives as, over the reproductive life course, the reproductive norm changes from childlessness to fertility. In the late-marrying society, as opposed to an early-marrying one, the reproductive life course and the social interpretation of childlessness become distinctly age-related. Hartman (2004) and Froide (2005) have argued that this long non-reproductive phase opened up new non-maternal opportunities for unmarried women. But late marriage also exposed women to two new fertility hazards: the danger of achieving fertility before marriage (Laslett and Oosterveen 1973), and the danger of delaying marriage for so long that fertility is compromised and the marriage remains childless (Kreager 2004, Wrigley et al. 1997). Arising directly out the wider social practice of postponement, age-related infertility represents the most quintessential fertility hazard of this late marriage pattern, which systematically writes childlessness into women’s lives (Kreager 2004). Postponement, therefore, not only opens up a social space with new social and economic opportunities for women but at the same time it opens up a social space that is fraught with reproductive dilemmas and dangers.

Managing postponement

Traditionally fertility postponement largely depended upon a regime of sexual abstinence, especially among young unmarried women (Cook 2004). Szreter notes:

For generations sexual self-denial had been the institutionalised norm for young unmarried adults in Britain’s culture, necessarily associated with the ‘peculiar institution’ of late marriage. This, then, was a population that had been thoroughly schooled over centuries in the attitudes and expectations required for this form of self-restraint.

(Szreter 1996: 393)

Certainly, the postponing woman faced a series of particular sexual and reproductive dilemmas. Charged with maintaining a long regime of sexual abstinence before marriage, she must attract and yet at the same time repel her would-be husband’s attention. Too much intimacy may lead to an unmarried conception but not necessarily to marriage; conversely, failing to attract a partner may lead to the physical, emotional and social isolation of spinsterhood. Postponement opened up a childless space that the young unmarried woman must negotiate with caution. This regime of sexual abstinence, however, was often undermined by the need for sexual and emotional intimacy. That this long regime of abstinence was often difficult to maintain is evident from the fact that it was women in their mid-twenties and not naive teenagers who appeared to be most at risk of conceiving outside marriage (Laslett and Oosterveen 1973).

For most women this failure to continue postponing precipitated their marriage, such that an estimated 30–40 per cent of brides during the late eighteenth and nineteenth centuries were pregnant at the time of their wedding (Hair 1970). It appears that it was only as courtship intensified and the prospects of marriage came closer that unmarried women were prepared or pressurised into taking greater sexual risks. Postponement through sexual abstinence appears to have been a process that was often in danger of breaking down, leading to the social and moral hazard of an unwedded conception. As such, relations between courting couples often revolved around a series of delicate and sometimes difficult negotiations in which sexual boundaries were continually reappraised and often breached (Cook 2004, Hartman 2004, Laslett 1983, Secombe 1992, Szreter 1996).

While sexual abstinence is a useful term for academics the popular term for sexual abstinence was chastity; a term that more fully reflects the nuances of the traditional experience of postponement. Infusing and conflating sexual abstinence with spiritual virtues, chastity denoted far more than just a prudent reproductive strategy; it was also a token of virtue, especially female virtue. The practice of chastity ensured the virtue of the unmarried woman, whatever her social or economic situation; as long as she remained chaste she remained virtuous, a fact rehearsed by the unmarried heroines of countless English novels. So while other postponing methods may have been available, for the unmarried woman abstinence represented the only socially and morally acceptable method. This is more than adequately reflected in English literature, with the subject of chastity and perils of the unchaste, dominating women’s popular literature throughout the nineteenth century (Mitchell 1981); indicating that postponement was a practice that greatly occupied the English imagination.

It certainly occupied Thomas Hardy’s imagination, with Tess of the D’Urbervilles (1894) and Jude the Obscure (1896), both charting the inexorable tensions that bounded English sexual and reproductive relations. His own parents’ rather reluctant marriage had been precipitated by his own conception, when his mother, Jemima, found herself at the age of 26 to be three months pregnant (Tomalin 2006, Pite 2006). Jemima clearly resented her hasty descent into marriage and maternity, admonishing all her children to remain single. However, after a protracted engagement, Thomas married Emma Gifford, aged 34. To Emma’s distress she remained childless; his brother and two sisters remained unmarried. By the time of Jemima’s death in 1904 the Hardy family consisted of a middle-aged childless couple, one childless bachelor and two childless spinsters. Even in this rudimentary overview of English reproductive history two important points emerge. Between these demographic lines we glimpse reproductive lives shaped not by reproductive biology, or pro-natalism, but by the social practice of postponement. Jemima Hardy married reluctantly at 26 because she was unable to continue postponing, while Emma Hardy’s marriage was postponed for so long that she then failed to conceive.

This article is concerned with the contemporary experience of the postponement and over-postponement of fertility. However, viewed from this historical perspective we see that what has changed over time is not so much the desire or ability of Englishwomen to postpone or over-postpone but, with the advent of modern contraception, a radical change in the postponing method.

Revelations and revaluations: the decision to stop postponing

The remainder of this article is drawn from a qualitative study on the contemporary construction and experience of age-related infertility. In all 22 women who had sought assisted conception for a first or second child after the age of 35 were interviewed in their own homes. All had been in full employment when they had initially tried to conceive and they included a pub landlady, nurses, teachers, shop and clerical workers, a research scientist and solicitor. The purpose of the study was to explore the series of fertility experiences that began with fertility postponement and culminated in assisted conception. The in-depth interview is ideally suited to charting changing perceptions and experiences over time. Infertility, however, is an intimate and emotive subject and care was taken in the initial design of the study to reduce any potential confusion over the aims of the research and any potential harm to participants.

To avoid confusion over its social, rather than medical, aims, and to emphasise the independence of this research, participants were recruited through notices in local newspapers and magazines rather than through a fertility clinic. Information sheets detailing the academic aims of the research and assurances of confidentiality and anonymity were then sent on request to potential participants. Women who had suffered any serious reproductive trauma in the previous three months were considered too vulnerable to be interviewed and were politely redirected to appropriate infertility organisations. Each interview was preceded by discussion of the aims of the research and the storage and dissemination of the data, and then a consent form was signed. It was anticipated that some women would find the interviews distressing. It was considered important to allow women to express their distress as long as they were also aware that they could stop the interview at any time they chose. It was also considered important to ensure that each interview would close by moving away from personal experience and end with a general discussion on funding and service provision, allowing participants time to regain their equilibrium. In that these women had all opted for fertility treatment they are a small self-selected sample. However, in both their desire to extend postponement and their subsequent desire to achieve fertility they reflect wider reproductive trends, but whereas for most women extended postponement leads only to a late conception, for these women it appears to have led to non-conception.

The 22 women in this study underwent 79 IVF cycles at a total estimated overall cost of £225,000. Yet at the time of the interviews only four women had achieved a live birth. This sample is not representative yet this low success rate does reflect the low overall success rate per cycle for women over the age of 35. Their experience provides us with a new and very different perspective from which to view the role of reproductive technologies in women’s lives. Over their reproductive life course they had used two reproductive technologies yet none could be said to have achieved the fertility they desired when they desired it. And what makes their stories so revealing and disturbing is that they appear, albeit unwittingly, to have used a reproductive technology that purports to extend reproductive choice and control only to recreate a traditional fertility hazard. As such in this article it is modern contraception which becomes the prime focus of analysis, with IVF appearing, both literally and figuratively, as a secondary technology. For, rather than resolving reproductive dilemmas, the evidence from this study indicates that modern contraception simply appears to have made postponing easier, fostering an illusion of reproductive control in which fertility decisions could be put on the back burner, undiscussed and even unimagined. This delay, however, then revealed the hidden cost of postponement – infertility – and thus begins the pursuit of assisted conception.

Postponing but not thinking about fertility

At the centre of this article is the reproductive mystery, as narrated by Kitty, of how she came to know that she wanted a baby. As we unravel this mystery it becomes clear that while these contemporary reproductive lives are still structured around the old social practice of postponement, their experience of postponement has been radically transformed by modern contraception. Kitty was 34 years old when she had her first child. At 37 she began trying for her second child; after 18 months of non-conception she sought assisted conception. At the time of the interview she was 41 years old and had undergone four unsuccessful IVF cycles, which she estimated to have cost over £16,000. On her use of contraception Kitty said: ‘I took the pill till I was about 32, 33. I don’t think I thought much about it. It suited me; it worked’ (Kitty, 14 March 2007).

Kitty’s answer was typical of responses on contraception. None of the women could give any meaningful account of their experience of contraception, except that it had worked. Generally it was seen as ‘no problem’ (Heather, 1 May 2007) or:

Oh no, I never really thought about it. I just took the pill and never really thought about it.

(Susan, 6 March 2007)

No, never really thought about it.

(Leanne, 2 April 2007)

I never thought about it that much, really. As I said, the pill suited me and so that side of things was always OK. I mean, I never worried about accidental pregnancy so I don’t recall ever worrying about that sort of thing, really.

(Harriet, 8 November 2006)

Err, I mean I never really thought about it. It’s a habit, like brushing your teeth; it just gets integrated into the day. So for me that was never a big problem.

(Karen, 15 October 2006)

Contraceptive use here appears something of a non-issue, something that was not thought about in any detail. If during this postponing phase the use of contraception was not given much thought, it also became clear that fertility desires and intentions were also something of a non-issue. Most women claimed to have always wanted a family with at least two children but further probing revealed that fertility intentions had rarely, if ever, been talked about:

Well, we never talked about it; no. But I always knew he did want children. He loved children and I love children so there was never any need to ask him if he wanted them or anything. I didn’t feel I had to talk to him about it.

(Susan, 6 March 2007)

I don’t actually remember sitting down and discussing it, but then I don’t remember Matt ever saying, ‘I don’t ever want children’. I guess in my mind, with rosy glasses, I thought that at some point I would have children.

(Vita, 1 March 2007)

Umm, well, I mean we didn’t have a family plan as such, or we didn’t really talk about it back then. It was more of an unspoken kind of thing, if you know what I mean.

(Beth, 10 June 2007)

Well, I can’t say we talked about it a lot. It was kind of assumed in a way if I think about it. But I can’t say we had any definite plans … no.

(Ruth, 17 August 2007)

One particular phrase occurred in three interviews: Cathy (14 October 2006), Lucy (11 May 2007) and Beth (10 June 2007) all explained that discussions about fertility were ‘put on the back burner’. Fertility intentions seemed vague and unformed, remaining unspoken or assumed and rarely discussed. This lack of detail at first appeared disappointing, especially when compared to the volume and richness of all the other data. The decision to conceive was narrated at length and with precision; most women recalling in rich and vivid detail the date, time and place of the intended conception. The experience of infertility and assisted conception prompted long and detailed soliloquies, sometimes running to over a thousand words. However, below is Kitty’s account of the moment she decided to start her family. Here it becomes apparent that it is precisely her ability to not think about contraception or discuss fertility that is the most significant feature of her postponing experience:

I wasn’t broody or maternal or anything like that. I just got to a point – it must have been when I was about 32, 33 and I don’t know … I’d got everything but I didn’t feel happy somehow. I’d got everything I wanted in life; I’d got a good job, Mark and I were happy. I was working as a teacher in [town L] We’d just moved here because Mark had got a job in [town C] and here was half way between [town L] and [town C] and I didn’t know why I was unhappy. I had every reason to be happy but I wasn’t. And then we had an ‘accident’ and I thought I was pregnant and then, suddenly, I was happy. As it turned out I wasn’t pregnant but I thought ‘Ah! That’s what’s wrong with me: I’m broody’. But it didn’t come in that, sort of, looking in prams and wishing for a baby way. I wanted a baby but I didn’t even realise it. Strange!

(Kitty, 14 March 2007)

Before we examine what Kitty does say about how she came to know that she wanted a baby, it is equally important to discuss what she does not say. Delayed childbirth is often associated with the instability of modern relationships (van de Kaa 2001, Sobotka 2004). But Kitty’s late fertility decision, like most of the women in this study, occurred within a stable relationship; she had been married for eight years. It is also associated with social or economic impediments to fertility, such as the desire to avoid gender inequity (MacDonald 1997) or the need or desire to balance working life with fertility (Hakim 2003). It is also often associated with a desire to avoid the inherent economic risks and uncertainties of fertility (Becker 1960, 1991, Easterlin 1985).

Yet although Kitty has every incentive to locate her over-postponement in social or economic circumstances beyond her control, she does not do this. She could appear to fall into Berrinton’s (2004) typology as a ‘perpetual postponer’ who has simply over-estimated her fertility, with her late first birth leading to her inability to conceive her second child. Yet even perpetual postponement implies some form of fertility desire or strategy but the nub of Kitty’s puzzle is that she claims that she did not even realise that she wanted a baby. Moreover, just how does a woman who has continuously used modern contraception since her late teens begin to estimate her fertility? A live birth is the only meaningful measure of fertility and if she has been using contraception correctly that is the one experience she will not encounter.

Kitty continues to use contraception into her early thirties but not because she definitely knows that she does not want a baby. Neither is this an account of a woman who thinks she does not want a baby but then changes her mind: to change your mind you must first know your own mind and the point of Kitty’s mystery is that she claims that, until that contraceptive accident, she did not know she wanted a baby. She does not present us with a fertility decision by calculation or miscalculation; she presents us with a fertility decision by revelation – a truth suddenly revealed, a process completely outside of rational thought. Her desire for a child is not filtered and weighed in a process of considered calculation on the costs and benefits of fertility but seems to appear suddenly, unbidden and yet fully formed. And with that concluding ‘Strange!’ we, too, are invited to ponder this mystery. She implies that the inspiration for this fertility decision arose outside of her conscious, rational mind and from within her body; a body that appears to know things about Kitty and what she does or does not want that her mind seems to have overlooked.

Kitty has already given two clues to this mystery. She did not think very much about her use of contraception and it is clear that before the accident the subject of children remained, not just undiscussed but unimagined. She makes no mention of children in that review of her marriage, job and home. Presumably, if she and her husband had discussed children she would have realised that she wanted a baby. And it is this lack of thought or discussion on the subject of childbearing that provides a rational explanation of her mystery. The accident prompted a situation in which, for the first time for perhaps a long time, she engaged her mind, consciously and intellectually, with the subject of her own fertility. Thus, her desire for a child appears like a bodily revelation simply because before the accident she did not really think about her fertility and after the accident she did.

This is an account given by a woman who was using contraception until the age of 32 but who did not think very clearly about why she was continuing to use it. Fertility limitation is understood to be a rational process in which agents make calculations about their fertility with forethought. It is, or should be, an inherently thoughtful, mindful process. Theoretically, to limit fertility is to think about fertility, therefore it should be impossible for any woman to reach the age of 32 limiting yet not thinking about her fertility. Yet in Kitty’s account her continued use of contraception appears to have become an almost entirely unconscious, unthought-of process, part of an unquestioned routine. Karen (15 October 2006) had described her use of contraception as a habit like brushing teeth, and Kitty’s continued use of contraception does now appear somewhat routine or habitual; the accident marks the moment this routine is disturbed and openly questioned. Kitty appears to be not so much a perpetual postponer as a habitual user of contraception.

Kitty’s account may appear extreme yet she was not alone in narrating a story of fertility by revelation. Miriam (3 August 2007) claimed that she was not the maternal type yet she also had a contraceptive mishap which then revealed fertility desires she had been previously unaware of. Karen (15 October 2006), who likened taking the pill to the habit of brushing teeth, had no family plans but then at 34, after the sudden death of a close relative, she felt that:

suddenly the generations started to look a bit thin … It was like, ‘Well, do we want to be doing this same rut forever?’ You know, lots of exciting holidays in exciting places but that’s not what’s life’s made of. It was about wanting something more in life, something with more purpose.

(Karen, 15 October 2006)

This unexpected life event appears to shake Karen out of her postponing rut or habit, and suddenly she begins to think about the purposes and value of fertility. McAllister and Clarke (1998) argued that some women simply drift into childlessness. Before that contraceptive accident Kitty could be said to be drifting, unthinking, into childlessness, except that the women in this study cannot have been drifting into childlessness as they were already childless. They were drifting on with childlessness. And this change in preposition is hugely important as it alerts us to something which is so obvious we tend to overlook it.

For these women childlessness was not a new phenomenon; there had been no change in their reproductive status, they had been childless all their lives and were as childless at the age of 20 as they were at the age of 35. What had changed over time was not the fact of their childlessness but how it was perceived and experienced. Indeed, there is a sense in these accounts that these women had become somewhat habituated to postponement and childlessness until some other life event prompted them to think consciously and seriously about whether they wished to remain childless.

This is made more than transparent in their language. At first reading we assume that Kitty and Karen are talking about their desire for a child but if we make a literal re-reading of these data it is clear that they are not talking about children at all; they are talking about childlessness. Both women narrate their fertility decisions by reviewing and then rejecting their childless lives. Inhorn (2002) remarks on the dialectical relationship between fertility and infertility but what was striking in these accounts was how, when women discussed their decision to start childbearing, they did not draw on discourses concerning the qualities or values of children or motherhood but on the relative benefits or costs of postponement. As with Kitty and Karen, it was the postponing life that got reviewed and in this their fertility decisions appear not so much as an affirmation of motherhood but as a rejection of ongoing childlessness.

Epstein argues that the stronger a prevailing social norm the less the agent actually thinks about it or subjects it to any critical or calculating analysis. Thus, through the action of social norms we ‘learn to be thoughtless’ (Epstein 2001: 9). In late-marrying societies postponing fertility is a very strong reproductive norm; however, achieving fertility before the age of 35 is also a strong reproductive norm. These women in their early to mid- thirties are on the cusp of these two strong, yet contrasting, reproductive norms and it here we find them beginning to seriously think about their fertility. This is why these accounts appear as tales of revelation and revaluation; indicating that it was the changing perception and experience of childlessness, and the value of ongoing postponement, which prompted their fertility decisions. Kitty postponed her fertility until the age of 33, apparently without worrying about or discussing childbearing. There is nothing new about her desire to postpone but the ability of a sexually active woman to postpone her fertility and not have to think about or discuss it is, historically speaking, quite remarkable and without doubt a gift of modern contraception.

A tale of two technologies

For the women in this study postponement through modern contraception was ‘no problem’; it appeared that once a suitable contraceptive regime was established it could be continued without having to think very much about it. But what of the assumption that the widespread use of this reproductive technology has facilitated a reproductive revolution. Writing of the tension between sexuality and fertility inherent to late-marrying societies Cook writes:

It is shown that women’s reproductive careers continued to be governed by the constraints that made up the north-west European marriage system right up until the late 1960s.

(Cook 2004: 318)

That modern contraception has resolved the sexual dilemmas inherent to postponement is undeniable but it is classified and legitimised as a reproductive technology, not as an aid to sexuality. Cook appears to be making the assumption that in resolving sexual dilemmas modern contraception automatically acts to resolve reproductive dilemmas as well. Hakim’s (2003) influential preference theory is also largely based on the assumption that modern contraception enables women to construct the fertility and employment balance they prefer. Yet the demand for assisted conception among women over the age of 35 indicates that it is not necessarily the case that in resolving the old sexual dilemmas of postponement, modern contraception automatically acts to resolve its reproductive dilemmas or remove its reproductive constraints.

Indeed, if late-marrying societies made a problem of female sexuality this was largely because they made an even bigger problem of fertility, with sexuality becoming a casualty of the larger ongoing war on fertility. These contemporary accounts are distinguished by the presence of reproductive technologies; however, the fact remains that their use is still structured around the old practice of postponement. The first is used to effect and extend postponement, the second is used to remedy an inadvertent over-postponement of fertility.

Sexual experiences may have changed but it is still fertility postponement that appears to be underwriting these reproductive lives, just as it was for Jemima and Emma Hardy. Bledsoe (2002) provides us with a pertinent example of how, rather than revolutionise, modern contraception can act to reinforce a traditional reproductive regime. Women in rural Gambia used the pill, not to reduce their fertility but to achieve high fertility with clearly defined birth intervals. Bledsoe challenges the view that this represents an ignorant misapplication of contraception. Instead, she argues that in many non-western societies high fertility is not a product of unrationalised biology, as assumed in western discourses, but is actually a highly desired and valued social product. Turning her Africanist eye on western reproductive culture, Bledsoe (1996) also comments that there is an almost complete dissociation of contraceptive technologies from fertility levels in western societies.

With reference to this study this remark seems strikingly apt. On one level the use of contraception in Gambia and that found in these accounts appear to be very different. Gambian women appear to have used contraception very purposefully in order to achieve a clearly defined fertility outcome, while the women in this study appeared to have had no clearly defined fertility intentions; just vague and unspoken assumptions. Kitty’s disassociation between her use of contraception and her fertility is so complete that her desire for a baby takes her by surprise.

But there are also striking similarities. Both groups of women appear to have used modern contraception to re-enact and reinforce their respective traditional fertility patterns. In a traditionally early-marrying culture that places a high value on female fertility and no value on childlessness we find women using this technology to achieve higher fertility, while in the traditionally postponing society that values the childlessness of young women, we find women using it to extend postponement.

Indeed, across Europe the most widespread and consistent use of modern contraception has been the extension of postponement (Sobotka 2004). So modern contraception, rather than overturning traditional western reproductive patterns, appears to have acted to confirm and consolidate postponement, with all its inherent fertility hazards, as the most significant reproductive practice in western women’s lives. But if it has not changed the underlying culture of postponement modern contraception does represent a radical change in postponing method, which in turn appears to have profoundly changed the postponing experience. Before its advent English minds and imaginations were intensely interested in the relationship between sexuality and fertility. A woman relying on any unreliable contraceptive practice to limit her fertility is highly unlikely to disassociate sexual activity and fertility. Understanding how reproductive technologies intersect, not with female biology or pro-natalism, but with the traditional practice of postponement is the first step in understanding how a woman might use two reproductive technologies yet not achieve the fertility she desires.

The hidden costs of postponement

Over the past 30 years assisted conception technologies have provoked much popular and academic interest. They have been credited with being key symbols of our times (Inhorn and Birenbaum-Carmelli 2008) and collapsing the nature-culture divide (Rabinow 1996, Strathern 1992). However, within the context of this study the most significant feature of IVF was simply that four times out of five it failed to work. For women aged 35 the success rate is around 22 per cent and only around 11 per cent by the age of 40 (HFEA, 2007). Ultimately, it is this very low success rate that propels women on successive, and often unsuccessful, cycles. Yet, even as it fails IVF is expensive, invasive and time-consuming and women rearrange their entire lives around the demands of the technology.

Some respondents left the workplace altogether while others cut their working hours. Most women changed their diets and took up alternative therapies. In contrast to their silence on modern contraception they narrated in thousands of words details of times, dates, places, sensations, techniques, discussions, frustrations and expectations of their IVF experience. They also, most tellingly, spoke of miracles, prayers offered, fingers crossed, wood touched, of destiny and fate and the need to stay positive. This contrasted sharply with the everyday experience of modern contraception.

Women do not touch wood, cross their fingers, change their diets or feel the need to stay positive, when using modern contraception: they use it in the knowledge that it works, easily and efficiently. Not only does it have an over 90 per cent success rate; it fits almost seamlessly into everyday life, requiring only the occasional visit to the doctor or clinic. The pill sits easily in a bedside drawer or handbag; an intrauterine device, once fitted, can be conveniently forgotten about for up to five years and neither requires discussion nor the approval of any sexual partners. In this modern contraception acts to reduce the experience of postponement to a kind of non-experience about which there was little to say, while IVF acted to open up and amplify the experience of infertility, creating an experience that the women struggled to manage and contain.

But it is this silence surrounding modern contraception that is deceptive and disturbing, making modern contraception, and not IVF, the most significant technology in these stories of age-related infertility. For this silence is not empty. It is filled with unspoken discussions and hidden assumptions on childbearing; assumptions that intertwine and fuse to create an illusory notion of reproductive control, which then subsumes and silences discussions of fertility. As modern contraception removes the sexual costs of postponement so it appears to resolve that most intractable problem of late-marrying societies – an inherent contradiction between sexuality and fertility. Thus, reproductive biology appears rationalised; fertility can be postponed without sexual denial, sexuality can be expressed without paying the penalty of fertility. The traditionally unreliable and difficult process of postponement that occupied English imaginations for centuries appears to be transformed into the effortless and costless process of popping a pill. Fertility can be safely put on the back burner, undiscussed and even unimagined. Kitty’s thoughtless use of contraception occurred in a culture that appears to have conflated the sexual and reproductive dilemmas of postponement. She assumed that because modern contraception resolved her sexual dilemmas it automatically resolved her reproductive ones as well. However, the moment the postponing woman desires but fails to conceive is the moment this illusion of effortless and costless reproductive control is shattered. Modern contraception does not automatically resolve the reproductive dilemmas of postponement, it just makes postponing easier. Modern contraception does not resolve the inherent dilemma of when and why to start childbearing, a process that still involves couples in a series of risks, disruptions and discussions; it simply delays it. And surely, it is precisely because modern contraception has made postponement easier, while the disruptions of childbearing remain unchanged, that its most consistent use has been to further delay fertility. However, for the women in this study it is this delay that then reveals the hidden cost of postponement – age-related infertility. For these women, rather than removing its costs, modern contraception appears to have transferred the costs of postponement from their sexuality to their fertility.

Conclusion

In the western world the female reproductive body, from menarche to menopause, has become a site of bio-medical intervention as never before, yet at the same time western women have never been more at risk of not achieving the fertility they desire. This article is drawn from qualitative research on the lived experience of age-related infertility. Its purpose has been to unpick the puzzle of how a woman was unable to realise that she wanted a baby. It differs from other qualitative research on infertility in that it draws on historical demographic data to place the social practice of postponement at the centre of analysis. The justification for this is that it has proved surprisingly fruitful.

This practice not only underwrites a historical pattern of late marriage and contemporary fertility patterns, it also shapes the use of reproductive technologies found in the accounts. In this the childless woman of 35 who stands at the door of a fertility clinic is the living embodiment of a historical pattern of postponement that has long shaped western fertility outcomes and experience. However, the relationship between the two technologies, as found in these accounts, remains disturbing. Modern contraception appears to have created a disassociation between sexual activity and fertility, allowing fertility to be put on the back burner, undiscussed; this delay leading in turn to age-related fertility problems and consequently to assisted conception. The fact that a modern reproductive technology is used to reproduce a very old fertility hazard reveals just how profoundly this historic pattern of delayed fertility not only shapes reproductive lives but also the way in which we use reproductive technologies. Thus, in these accounts the contemporary experience of age-related infertility emerged as a tale of two technologies linked to each woman, and to each other, through a traditional practice of postponement.

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