The Early Birds

What advice would you pass on to mothers concerned about premature birth or IVF? 
Infertility, pregnancy, and prematurity are all complex medical conditions. No two cases of infertility are the same, women all experience pregnancy differently, and problems related to prematurity can vary. So it is difficult to offer uniform advice. But there are many things that I learned while researching my book that should be helpful to women who are considering medical treatment for infertility.

Advanced maternal age is not, as I had believed, a factor for the majority of women pursuing infertility treatments. Presently, infertility treatments often result in multiple gestations, and there is a 50% chance of delivering twins prematurely and a 90% chance with triplets. Considering this, it makes sense for infertile women in their twenties and thirties to initially consider treatments that do not involve significant ovarian stimulation to produce multiple eggs, and with IVF, transferring a single embryo. Studies from the Netherlands found virtually no difference in pregnancy rates for women 37 years old and younger who transferred a single embryo instead of two or three.

If you could go back, what would you have done differently knowing what you know now?
My reproductive endocrinologist never raised the possibility of a single embryo transfer—possibly because we did not know yet whether or not I would be a good candidate for IVF (I was), or whether I had a tendency to deliver prematurely (I did). In retrospect, I should have transferred a single embryo on our first. As single embryo transfers become the norm, infertility clinics may start to freeze extra embryos separately so that at later dates each extra embryo could be thawed and transferred on its own.

I took my own advice and when, two years after Sam and Gus were born, we decided to transfer our frozen embryos, we used only one. Given my history, this was the right decision for us, and it resulted in the joyous birth of our third son. And yet, although I am still sometimes haunted by Gus and Sam’s premature birth, if I were offered the chance tomorrow to go back and do it all differently I know I could not. Sam and Gus are now three years old, and inseparable at preschool, always clowning around and looking out for each other, and so in love with their baby brother, Leo. If anything had gone differently, we might not have ended up with our exact three boys.
 
Any advice to offer those supporting friends, sisters, daughters going through this?  What did you find was the best comfort to you during this ordeal?
Prematurity is one of the last remaining medical mysteries. I have talked with obstetricians and neonatologists who don’t believe we will ever understand why it happens. But, if the friend, sister, daughter is anything like me she will relive her pregnancy and premature labor over and over in her mind, blaming herself. So my first piece of advice is this: tell her again and again that her child’s premature birth was not her fault. All mothers seem to feel guilt, to some degree, in their relationships with their children. Inevitably, if anything goes wrong, a mother will believe it is her fault. Somehow, it is scarier to think we have no control over our children’s lives than to hold ourselves wholly responsible for their wellbeing.

Knowing that today the vast majority of premature babies come through in good shape encouraged me while the boys were in the hospital. During Gus and Sam’s first year I was reassured by my friend, Lindsay, a pediatrician, that their development, though delayed, was progressing. I also found comfort in caring for our babies after I had gotten past my fear of the medical equipment attached to them.

Do you think there is ample support and information out there for families grappling with this?
We had two meetings with our reproductive endocrinologist before we did IVF and were shown a video about the procedure, and still I was not well-informed about the serious risks of a twin pregnancy. Of course I had seen countless double strollers on the sidewalks of New York, but I had no idea about the medical traumas some of the twins inside them had endured at birth. My friend, Lindsay, believes that infertility clinics should have a pediatrician attached to them to help inform couples about which treatment plan offered the best chance for a healthy baby.

As with most medical conditions, I found the portrait of preemies one gets from poring through material on the internet distorted and frightening. In lieu of that, Dana Wechsler Linden, Emma Trenti Paroli, and Mia Wechsler Doron M.D. have written a book called The Essential Guide for Parents of Premature Babies that I found very useful. The March of Dimes is also a good place for families of preemies to find information and support, and they have started a Share Your Story website where mothers can go to chronicle the births and early years in their preemies’ lives.

Having gone through IVF and the premature birth of your sons, what federal regulations do you wish the government would move to enact?  In what ways is our nation’s hesitance to delve into these issues causing problems for parents today?
Presently, fifteen states require that benefit plans include infertility coverage. Insurance companies are moving toward infertility coverage, largely because the cost of neonatal care for the babies of women who make their choices about infertility treatments based on affordability exceeds the cost of providing infertility coverage in the first place.

Along with this trend, private corporations and insurance companies have begun to establish their own regulations, limiting ovarian stimulation and the number of embryos transferred, so as to avoid exorbitant NICU costs on the other end. Corporations may increasingly become involved in their employee’s family planning, if they are covering the costs.

With neonatal costs in the U.S. skyrocketing and our infant mortality rate, ranking us twenty-fifth amongst nations, a substantial portion of which is due to premature births, I do think that there could be more political discussions about and government funded research into how best to protect our babies.

What brought you to write this book? 
I did not intend to write The Early Birds. The entire time we were in the NICU, my plan was to get the boys home and forget their birth experience entirely. Right before the boys’ first birthday I sat down to review a book for the Hartford Courant. I left Sam and Gus with their babysitter and locked myself into our office. I finished the review in an hour, and couldn’t bear to go back downstairs where I could hear both boys crying. So I started writing what I thought was a story about a girl at boarding school. And I had completed a few scenes when all of this stuff from the NICU started pouring out, conversations with doctors and nurses and Dan that I could record verbatim. I have since learned that in a crisis, it is common for a person to commit to memory, things you can not process at the time due to shock. I turned the story into an essay and sent it to Jordan Pavlin (my editor at Knopf) asking for her opinion, and she wrote back and told me I was writing a book. But I didn’t think I could bear to write a book about a painful experience I had wanted to bury, and I did not look at the essay again for three months. When I finally opened it up I wrote another fifty pages in about two weeks which I sent to Jordan, and she gave me a book contract. It took me another year to write the rest of the book, but the initial scenes that it grew out of came very quickly.

When did you start writing this—as things were unfolding or when you stopped to look back?  Did it help you process all that happened over the first year of Gus and Sam’s lives?
Although I did not realize it at the time, I don’t think it was a coincidence that I started writing The Early Birds as the boys’ first birthday approached. As Joan Didion wrote in The Year of Magical Thinking, grief involves a lot of repetition revolving around the moment that changed everything. I think from the start I was grieving for the happy, if still overwhelming, birthing experience we had not had. When I started putting everything down on paper, my editor and I both noticed that while I often expressed shock and anger at my doctors and myself, and fear about the unknown, my descriptions of the boys were full of love. The realization that my negativity about our boys’ birth had not seeped into my love for them was instrumental in helping me see that nothing had truly been lost. Sam and Gus are now smart, healthy three year old boys with distinct senses of humor. They are no longer preemies.

The worst aspect of publishing this book is that I suddenly feel terribly exposed having revealed my struggle with infertility, the fabric of my marriage, and certain things I thought and said during that first year about which I am not proud. The best thing that has come out of publishing the book is that I am donating half of the royalties from it (should there be any!) to the March of Dimes, whose organization now focuses on finding solutions to the silent crisis of prematurity in America.

You write about your own childhood in the book. Why?
I’ve talked with friends about how during the early years of motherhood we have vivid flashbacks to our own youths. I was a very guarded, fearful, and intense child. At a certain point I remember deciding that if I was going to have fun and fit in I had to mellow out. So I did. My teenage and young adult years were relatively carefree. During Gus and Sam’s first year, my young identity started coming back, in fragments, and I found I felt a stronger connection to my girlhood than to remembrances from my more recent past.

During their first year, my concern about whether Gus and Sam’s childhoods would be compromised by disabilities related to prematurity made me nostalgic for my own youth, for the learning experiences and memories I desperately hoped they, too, could create.
 
Talk a bit about this conflict you struggle with in the book between science and God, technology and timing. 
There’s a line of thinking that holds that if you undergo medical treatments in order to conceive, you reject the plan God designed for you and take fate into your own hands. At first, when the boys were in grave danger and we thought Sam would die, it was hard not to feel that God was punishing me for turning to medical help and not waiting to see if we would conceive “naturally” over time. But I don’t see it that way anymore. Besides, using birth control, many couples today determine when the timing is right for them to start a family rather than leaving it up to providence.

I find it interesting that God and science are often viewed as being at odds with each other. Who has the right to say God opposes technology that can help a woman conceive or save a baby’s life? Does thinking that the will of God could be compromised by science underestimate His power? I want to be able to explain to Sam, Gus, and Leo that just because they were conceived with the help of science does not mean they aren’t also God’s children. I have never felt God’s presence more strongly than I did on the operating table as our embryos were being transferred, the instant my babies were delivered by C-section, and later sitting beside Gus and Sam’s incubator.

How many of your worries do you connect to Gus and Sam’s prematurity, and how many do you chalk up to being a new mother?  How different have things been with Leo in his first year–and how were they the same?
All emotions, including anxiety, seem to be felt strongly during the first year of motherhood. All of a sudden you have this baby and, although you were prepared to care for her, you had not realized that once she arrived you would never again be able to survive without her. This new understanding can make mothers very anxious. On top of which the lack of sleep puts us on edge. My friends have all felt intense fear, fatigue, stress, joy, hilarity, and love during their first year as mothers. That said, I think that having seen Gus and Sam terribly sick, unable to breathe without the help of enormous machines, my own worries were mostly related to their prematurity, which I considered my fault. In addition to their delayed development, which was a definite cause for concern, much of my anxiety stemmed from post traumatic stress. I literally could not step into a pediatrician’s office, or onto a physical therapist’s mat, or enter a preemie clinic without breaking into a sweat and becoming teary eyed. If any little problem was detected, I imagined the worst case scenario. I’m not sure how much of my reaction had to do with the fact that Gus and Sam were my first children. One of my cousins recently gave birth to a baby girl prematurely and she carried her everywhere, worrying about whether she was eating enough, afraid to leave her with a sitter, and all of our other relatives kept asking what was wrong with this cousin. She was so calm with her first baby, but her first baby was born at eight lbs, and her second weighed four.

Things have been entirely different with Leo. He was born at thirty-six weeks, was not low birth weight, and did not have the painful reflux that contributed to Gus and Sam’s fussiness that first year. Leo is low-key. I am low-key. Personality as defined by birth order definitely makes sense to me now. And caring for one baby is less stressful than caring for two. Ironically, Leo has been diagnosed with persistent asthma. He has a nebulizer and receives medication every day, and I’m not alarmed. I feel sweet sadness at each milestone he meets.


What did this experience teach you?
Patience. Before Sam and Gus were born, I rushed through life. After their birth I had to wait nine weeks to take them home from the hospital, months before I saw them smile or laugh. They did not crawl until they were ten months old, walk until fifteen, or say their first words until they were nearly two years old. Time progressed at a slower pace for us; in comparison I find Leo is racing through his infancy. Although I am eager and a little anxious to see what the future holds, for the first time I am not hurrying towards it. I hope the boys will take their time growing up.

Nothing so far in my experience of motherhood has changed what I have always hoped to foster in my children—a love of learning, curiosity, creativity, hard work, character. You might think that having seen Sam and Gus in critical condition, I would be so happy just to have my children healthy and alive that nothing else would concern me. And I don’t care whether my boys will be the quickest learners or the top students in school, which perhaps does signal a slight shift in priorities. But it is insanely important to me that all three of my boys have the opportunity to be intellectually curious and articulate, to cultivate friendships, and to have the ability to build their memories of the past and dreams of the future into rewarding lives. Given that Sam and Gus came close to death, and now with Dan’s father dying, it seems crazy to me that I am still so concerned about the quality of my boys’ childhood experiences when we are all on borrowed time. And after everything we went through that was beyond our control, it is the fact that I still fret about each decision I make and that we all care so much about whom our children will become that seems most remarkable.