Inequity

Today I paid what I hope will be the last of the bills associated with my third miscarriage.  And, it was the hardest of them all to pay because of the situations that gave rise to it.  Perhaps I’m numb, perhaps my spirit is just broken, but these days my emotional pain doesn’t center around the fact that we lost another potential child in February.  Instead, I just grimace at the general unfairness of it all, and the realization that this process has been made so much harder thanks to the American medical and insurance systems.

Our most recent pregnancy lasted to 9 weeks, but for only a week of that time did we actually have cause to hope.  Like both my prior pregnancies, my beta HCG values throughout the pregnancy were problematically low.  In the majority of normal, healthy pregnancies one’s HCG value will approximately double every 48 hours for the first few weeks of pregnancy.  But, like so much else in infertility and early pregnancy, beta doubling times are just an odds game.  Healthy pregnancies result from abnormal rises, normally rising HCGs can result in miscarriages.  But, when your in the thick of beta hell, it’s hard to believe you’ll come out on the right side of those odds.  And, at least so far, I never have.

The betas for my last pregnancy went as follows:

• 3w5d: 41
• 4w:     97 (doubling time 38.64 hours)
• 5w:     1113 (doubling time 47.72 hours)
• 5w6d: 1479 (doubling time 351.08 hours)
• 6w5d: 2038 (doubling time 363.22 hours)

At 5w6d we were told to expect a miscarriage, then three days later, at the appointment scheduled for the purposes of confirming the loss, I saw the heartbeat on ultrasound for the first time.  That little heartbeat hung around for 3 more weeks despite extremely poor bloodwork results.  On Valentine’s Day we found out that the heart had finally stopped.  We weren’t destined to be one of those lucky couples who beat the odds and succeeded despite bad lab results.

The heart stopped on a Thursday, and we decided straight away that we wanted to have this embryo tested for genetic abnormalities.  The best way to obtain a sample capable of being testing was to have a procedure called a dilation and curettage (D&C) performed.  Essentially, the cervix is dilated and the “products of conception” (POC) and some of the uterine lining are scraped out and sent off to pathology.  (If there’s one thing you learn pretty quickly in this repeat loss/infertility game, its that so much of this “medicine” is just about as low tech as you can get.  And, as a result, hasn’t actually changed all that much over the years.  During my first miscarriage, my husband’s 85 year old grandmother (who had suffered losses of her own as a young woman, including the heartbreaking loss of a new born) asked why we weren’t just having a D&C.)

So, heart stops on Thursday, we ask for a D&C on Thursday, we get scheduled for the following Wednesday.  Absolutely astonished doesn’t even come close to explaining my state of mind at the time.  Aside from the fact that I was basically getting sent home (yet again) with a dead baby inside me, I was irate that I was being made to wait nearly a week during which time I was certain I would either miscarry on my own or, if not fully miscarry, at least lose the opportunity to perform the testing that we needed to have performed as the products decomposed.  “Sorry, that’s the best we can do,” said one of the revolving door of smug nurses.  So, we waited.

On Friday afternoon I started to spot.  I called right in.  “We can move you to Monday, but that’s the best we can do.”  Tears and screaming and a lot of, “I’m not going to fucking make it ’til Monday”s went unheeded.  It was, after all, the best they could do.

On Saturday morning the contractions started and the bleeding picked up.  My clinic has Saturday hours, so I called first thing and reported that the process was well and fully started.  The response, “Well, I don’t know what you want us to do for you, I’ve already rescheduled you for Monday!”  Being no stranger to this IF game, I asked if I could collect the products at home and drop them off for testing at least, to which she replied that their clinic won’t test products passed naturally.  She strongly insinuated I was bat-shit crazy, actually, to even think that naturally passed products could be tested.  Through my tears and hysteria I told her of my friend, C, who did just that for m/c #2.  This bravest of mothers who wandered the empty halls of her local hospital on Christmas Eve carrying yet more lost hopes and joy in a Tupperware container, kept cool with a bag of frozen peas.  I told her of the other women, whose stories I’m less familiar with, but who still got test results from products passed naturally.  She remained completely unfazed.

So, Saturday morning I called the on-call nursing line for our local rural hospital.  Without mincing words I explained the situation, I asked if they had a pathology lab in their large hospital network, and I inquired whether they had doctors on call at the emergency room that could perform a D&C.  She was the first faceless voice on the phone throughout this entire process to give me any sympathy.  I was actually completely taken aback when she offered her condolences and genuinely asked me how I was holding up emotionally.  Her care and concern actually reminded me that, wait, there was some heavy shit going on right now and I wasn’t just calling in to make an appointment for a mild medical inconvenience.  She promised to get in contact with the OB/GYN unit at our nearest mid-sized hospital (about 30 minutes from home), and call us back.  When a representative from that unit called back about 15 minutes later, I was in the bathroom bearing down and passing small clots.  My husband answered and was informed that, yes, the staff could perform a D&C and that, yes, the products could be sent off for testing.  In the middle of a snow storm we bundled ourselves up and headed for the emergency room.

An hour of waiting and intake and vitals later, the general ER doc came in to do a pelvic exam.  He noted I wasn’t yet bleeding heavily (something we had repeatedly told them on the phone and during intake) and informed us he doubted they’d be able to help us.  Next in the room was the OB on call.  He reiterated that I wasn’t bleeding heavily enough or in enough distress to merit an emergency D&C.  I’ll never forget the next words out of his mouth.  “You aren’t an emergency and it’s a Saturday.  My team doesn’t work on Saturdays, and I won’t pull them in for this.”

Abandoned by the clinic that helped get me pregnant and whom I’d already paid hundreds of dollars and abandoned by the nearest OB/GYN unit, we walked out of the hospital with the two sterile specimen collection jars they gave us to collect the embryo once I passed it at home.  Today, I paid that ER bill.

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By my best estimates, my miscarriage cost us about $600 out-of-pocket (and, of course, much more before insurance).  It would have been more, but I had already met my individual deductible for the calendar year on January 9 after my second round of pregnancy bloodwork.  Included in that $600 is Mr. But IF’s deductible for chromosomal testing performed on him during my D&C, the D&C we did ultimately do (for who knows what reason, I’d already passed the products), and my $75 visit to the ER where I received no testing and underwent no procedures.  Those are some expensive specimen jars.

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Earlier in the week I needed to look up eyewear coverage through our new insurance since Mr. But IF and I are both sorely overdue for new glasses.  I don’t know why I do it to myself, but every time I log in to my insurers site and bring up the detailed policy description I still find myself scrolling down to the infertility section.  It’s always a punch in the ovaires to read:

IVF: No coverage

but, this time, I opted to read further.  It continues:

Elective sterilization: 100% covered (no co-pay or co-insurance)

Abortion: 100% covered (no co-pay or co-insurance)

And, that’s the moment I realized what I had done wrong two months ago.  Instead of placing my fate in the hands of my rural podunk hospital, I should have found the nearest abortion provider.  I’m absolutely not being facetious, either.  The services they perform are the services I needed, and I don’t expect they would have sent me away with a collection jar.

I’m no idiot when it comes to the whys and the hows of the medical insurance industry, and, though I find it morally abhorrent  I also understand it is in their financial best interest to ensure I don’t procreate.  That said, my situation underscores the flaw in this supposedly unemotional, bottom-line only approach.  I paid for my miscarriage, but would have had no financial obligation for an abortion.  Medically, nothing separates an abortion from a miscarriage.  Indeed, miscarriage is not a medical term, the appropriate nomenclature is either fetal demise or missed abortion.  It is hard to take a step back from this situation and not feel like I am being punished for the mere act of wanting a child, because it is only that aspect of wanting and trying that separates my medical history from that of a woman wanting an abortion.  Indeed, the contrast is even more stark when I recall that my ectopic was, in fact, medically terminated.  I’ve had an abortion, yet my insurer didn’t view it as such.  And the only reason I can fathom?  Because these unemotional bottom-liners do, in fact, care that my motivation was to become pregnant.

These are always difficult discussions to have with myself, because if there is one thing infertility has done to me it is that it has strengthened my resolve to support a woman’s right to choose.  Years of giving everything I have to trying to become a mother, has made me willing to fight tooth and nail for other women to have the choice to not become a mother.  Part of it is motivated by self-interest – it’s hard to live in this era of personhood hysteria and not see the slippery slope that leads from anti-abortion activism straight to my broken ovaries – but, another part of it is also my growing belief in the importance of choice.  My infertility has stolen choice from my family-building decisions, and it’s been exceptionally hard for me to accept that my busted body, lack of access to quality medical care, and an insurance system that views my infertility as akin to breast augmentation, has removed my ability to choose when and how to grow my family.  Therefore, I can’t in good faith put countless other women and men through the same loss of control, the same hell, purely because their politicians won’t get out of their bedrooms.