There was a moment in time, however fleeting, when I thought I had my fertility figured out. Married at 31, I’d had my first child at 33, a feat that in New York City had somehow managed to become worthy of praise. “You’re having a baby before 35!” my OB/GYN beamed at me, as if I’d mastered some complex puzzle. “Good for you!”
In fact, getting pregnant the first time around had been as simple as ordering takeout: “Oh, you think you want a baby? Boom! Here you go.” Having my son was so blessedly angst-free that I’d assumed the next pregnancy would follow suit, that in a couple of years — just a matter of months past the dreaded moment when doctors would scribble “advanced maternal age” on my chart — I’d give him a sibling, then bow out of the whole fertility guessing game once and for all. But, you know, raising a baby is hard. Thirty-four turned into 35, which turned into 36, and just when I felt ready to again tackle the tribulations of infanthood, a second pregnancy ended in a miscarriage so catastrophic that I was told it would be a year at the very least before I could even try to get pregnant again. Suddenly, I was staring down the barrel of 37, 38, maybe older.
At which point, I began to thoroughly freak myself out. At 3 a.m., my husband would stumble out of our room and drag me to bed, having found me still hunched over the computer, poring over statistics about waning fertility and information about the costs of IVF and adoption. I knew that 35 was not the fertility cliff the media and even some doctors made it out to be, that those alarmist statistics were based on French birth records from 1670 to 1830 — a time before birth control could mask more natural fertility patterns, but also a time before the advent of epidurals or electricity, when living past 35 was kind of a feat in and of itself. I knew that women in their late 30s who had had a previous successful pregnancy were only 10 percent less likely to get pregnant than their 20-something counterparts. I knew that a substantial portion of women who had trouble conceiving at my age would have probably had trouble a decade earlier, if they’d been trying. And I wasn’t even left to rely solely on generalities: Taking pity on me, my doctor had ordered a blood test that was meant to measure egg quality and quantity, coding it in such a way that I didn’t even have to pay. Those numbers had come back reassuring. If things didn’t change drastically in the next year or so, I shouldn’t have trouble conceiving again.
But would things change drastically? Due to lifestyle and genetics and sheer, dumb luck, people’s other organs — hearts, livers, skin, you name it — age at different rates. Why would our reproductive organs be any different? Outside of not smoking, not undergoing chemotherapy, and not getting chlamydia — all of which are known to damage eggs and/or suppress fertility — was there anything I could do to tip the scales in my favor? No one could tell me. No one seemed to know for sure.
It was somewhere in this dark night of the soul that I stumbled on Dr. Molly Maloof. “Welcome to the Future,” proclaimed her first (and only) blog post, on a website that prominently displayed a picture of a doe-eyed young woman in her physical prime, her silky brown hair tumbling over one shoulder in soft curls. “I optimize the health of my patients using precision medicine, genomics, microbiome” — “poop,” for us laypeople — “analysis, personalized custom compounded medicine and nutraceuticals, virtual coaching, quantified-self apps, wearable technology, and digital health tools,” the post went on to explain. “My apologies to all of the people in my waiting list.” For those lucky enough to not be on the waitlist and rich enough to pay a yearly sum of $40,000, give or take, Maloof has been doing all this as a “Scientific Wellness Pioneer,” bringing the biohacking mindset to bear on concierge medicine and running her mostly male clientele through an impressive battery of tests, with the end goal of not only achieving health, but attempting to perfect their physical apparatus. She was, obviously, based in San Francisco.
And naturally, I was skeptical. This was navel-gazing personified, medicine for the 0.1 percent; “I’m not a millionaire (yet),” Maloof had written in a Facebook post that took solace in the idea that “Your network is your net worth.” But here’s the thing: Maloof was about to embark on an experiment to try to answer exactly the questions I was asking, and it appeared that she not only had the personalized tools to actually do so, but also the type of desperation to which I could relate. “I didn’t really think about my fertility much in my 20s because I was busy creating my career,” she told me on one of our many calls over the next half a year. “Then my sister had a baby, and it was like this switch flipped, and I was like, ‘Whoa. I totally need to think about this. I need to think about how I want to plan my life, and I need to think about my dating in a more serious way.’”
Therein lay the rub. Maloof, 33, had fallen in love with a guy who seemed perfect in every way but one: he was 25 and had made it clear that he was in no way ready for children. Not that he was insensitive to Maloof’s predicament. He’d told her that he’d be game to have a family with her one day and, in the meantime, had offered to help pay to freeze her eggs. But rather than putting her body through that ordeal or simply breaking up with him, Maloof had decided to try to assess her situation fully: over the next six months, she was planning to biohack her own fertility in the same way one might hack a computer system, breaking down the component functions to understand (and, yes, optimize) how the machine is run.
“In a lot of ways, women are the original biohackers,” she explained. “Women have been following their menstrual rhythms for thousands of years, women have been doing things like lunaception and timing their hormones and fertility to the moon cycles. Now we have technology that is enabling us to get more data from our bodies and figure these things out.” Which, Maloof argued, is a good thing, because, “in my experience of regular, conventional doctors, they don’t really know that much about hormones and they kind of throw their hands up in the air when I ask them all these complex questions. The system isn’t set up to make us optimally well; the system is set to make us not sick.”
And when it comes to fertility, part of the problem is that, historically, only women who are “sick,” or have had trouble conceiving, have been studied. That blood test my doctor gave me, the results of which I clung to like an emotional life raft? Turns out that the numbers measuring ovarian reserve were reliable when it came to egg quantity, but not as reliable in assessing egg quality as I had been led to believe. In fact, the test was designed not to predict natural fertility, but rather the likelihood of IVF success — how well a woman’s body will respond to that treatment, how many eggs will ideally be retrieved. Naturally, the more eggs you harvest, the greater your chances are of getting a good batch of healthy ones. But for a woman who only releases one egg a month? Well, quantity doesn’t matter nearly as much as quality. A study released just this month in the Journal of the American Medical Association — notable in that it observed women between the ages of 30 and 44 without a history of infertility as they tried to get pregnant — found no correlation between diminished ovarian reserve and reduced fertility. “These tests are out there misleading people,” explained Anne Steiner, an author of the study and a professor of reproductive endocrinology at the University of North Carolina in Chapel Hill.
Which means that when it comes to natural, rather than assisted, fertility, we don’t really know how to assess the most important factor. “The biggest thing that decides whether conception is going to be successful is whether the egg is genetically normal,” says Dr. Thomas Price, president of the Society for Reproductive Endocrinology and Infertility, an affiliate of the American Society for Reproductive Medicine. “At age 38, half of your eggs are abnormal; by the time you hit 40, about 70 percent of them are abnormal; and by the time you get close to 44, 45, over 90 percent of them are.” But these, of course, are statistical averages. They don’t account for the fact that some women will struggle to get pregnant at 32; others will find it easy at 40. The average age of menopause in American women is 51, but don’t set your watch to that. As Dr. Jamie Grifo, the program director of the NYU Langone Fertility Center, puts it, “Everybody has a different curve.”
Maloof’s goals for biohacking were lofty. Along with other biomarkers, she wanted to monitor her hormones continually, rather than just doing a spot check every few years: “Apparently these numbers can change throughout the year depending on your health,” she told me. Using this data, she wanted to know if there were biomarkers that correspond to fertility patterns that might be better than the ones we use now. She wanted to chart trends, to see if the markers of her fertility were sloping down slowly and predictably, or whether they were dropping off more precipitously. She wanted to monitor how her lifestyle choices affected her hormones, to know if her fertility lifespan could be extended, her chances of conceiving optimized. “There’s a whole wide range of ‘normal,’ and maybe I’m not optimal,” she explained. “And if I’m not optimal, what can I do to become optimal?” More than anything, she wanted to know whether she should freeze her eggs now, and if she didn’t do that, she wanted to quantify the risk she was taking by waiting. She wanted, essentially, to predict the future. And so did I.
In early January, just after I got the green light to try to conceive again, Maloof and I kicked off our individual biohacking regimens. Mine was fairly analog: Every morning in the week or so after my period, I peed on a stick that would indicate whether or not I was about to ovulate, and then, when the color on the little tab changed, I had sex once (or, okay, maybe twice) that day. I noted the dates when my period started, and when it ended. I took a prenatal vitamin. I tried not to drink too much and to eat organic foods when it wasn’t too onerous to do so. And, basically, I crossed my fingers and prayed.
Maloof’s regimen, relayed to me in the breakneck clip of an entrepreneur, was far more intensive. In addition to the standard blood tests and basal body temperature readings, she was using a test from Genova Diagnostics called Rhythm Plus that pulled her hormone levels from saliva samples she sent in 11 times each month, providing a running tally of what she called her “hormone rhythm, the whole spectrum of [her] hormones through the course of a month” rather than simply a snapshot of a moment in time. That gave her a sense of whether her hormones were rising and falling as they should, and she was comparing those results against a blood hormone test from ZRT Laboratory. She was also testing her cortisol, “to see how much stress I’m under, because stress can affect your hormones.” Like me, she was checking the luteinizing hormone in her urine by peeing on strips. Through her Fitbit, she was using an app called Clue that tracked her heart-rate variability and helped her know when and if she was ovulating, and she was looking into research on the metabolites in her urine to see how well her body was detoxifying estrogen, because “there are certain supplements that you can take to improve the process.” Another app, MyFLO, helped track her period, which not only underscored its irregularity, but also made recommendations for getting it on track. Meanwhile, she was wearing a continuous glucose monitor — a plastic patch with a tiny needle lodged in her arm — that measured her blood sugar and insulin resistance, two data points that she felt might affect her hormone swings. And before doing any of this, she had gotten off all forms of hormonal birth control that would skew her numbers and mask the symptoms she wanted to track.
Every so often, we’d check in with each other. I got pregnant, but then had an early miscarriage (emotionally hard, but physically no more trying than a heavy period) — which reassured me that, at the very least, I wasn’t totally infertile. Maloof found that her progesterone was low, though possibly not so low as to signify a problem. As the months passed, her data sets grew, but she vacillated between a scientist’s optimism in the value of data and the realistic difficulties of what she was trying to accomplish. “I am freaking out about my fertility when really I haven’t been asking myself, ‘Am I as ready as I think? Can I actually do this?’” she told me at one point, a frame of mind that came across a cop-out despite its obvious sincerity. Certainly, the stress of trying to answer those questions while also trying to figure out how their answers might affect her life long-term was taking its toll on her relationship. “I don’t know. Part of me just feels like I don’t want to leave him,” she sighed. “Life is more than just our children, right?” Anyway, more tests were needed. We kept at it.
Meanwhile, so did Silicon Valley. Maloof was quick to point out that what she was doing was time-consuming and costly — in other words, not scalable. But Silicon Valley was suddenly copping to the fact that women’s health was a massive market, and that milliennial women in particular — moving into their 30s, focused on their careers, used to individualization, and wary of conventions of all sorts, including conventional medicine — were a new, untapped frontier. It’s a sign of the times and no coincidence that biohacking has become to San Francisco what the wellness movement is to L.A. There are fewer New Age vibes, more wearables and data, maybe, but all to the same end: constant attention paid to the tiniest vicissitudes of one’s moods, sleep patterns, food consumption, and general state of being. If this was self-absorption as science, it was also a form of empowerment, putting women “in the driver’s seat of their health,” as Maloof put it. And it could be commodified. Which means that it was only a matter of time before the Silicon Valley mindset would be brought to bear on possibly the oldest human endeavor, and that women delaying childbirth to launch businesses would use those businesses to tackle the risks of delayed childbirth.
“You see all these crazy start-ups that are invented, like on-demand valet parking or whatever else, that aren’t solving real, actual problems,” says Lauren Schulte, founder of the period-cup start-up Flex. “Millennial women are looking around like, ‘What are all these start-ups that aren’t addressing our needs? What are our needs?’”
Flex, a potential competitor to period-panties company Thinx, is one of the start-ups that’s attempting to tackle those needs head-on. Meanwhile, there’s a start-up that’s trying to codify all the clinical data from women who have gone to fertility clinics to see which ones have the highest success rates, a start-up that advises other start-ups and tech firms about offering fertility benefits like egg-freezing (which more established tech companies like Google, Apple, and Facebook already do), and a start-up that’s working on making personalized prenatal vitamins. Last winter, Maloof hosted an info session for women who might be interested in banding together to get a group rate on egg freezing, inviting women who had gone through the process to talk about their experience, and streaming the event live.
But the most potentially revolutionary start-ups are the ones that mean to take health practitioners out of the equation and give women direct access to their medical data for a fraction of the cost. “I ended up doing fertility testing and got a bill in the mail for $1,500,” says Afton Vechery, explaining why she left 23andMe to become a co-founder of Modern Fertility. The company, as of mid-November, will offer a $149 mail-in fertility test that purports to provide the same information about ovarian reserve that you would get at a clinic, at a cost that’s achievable exactly because of potential scale. “You can think of our cost as a group rate,” Vechery tells me. Meanwhile, bluDiagnostics is developing a saliva-based test that the company says will be able to tell a woman if she’s pregnant, ovulating, or has a hormone imbalance. Y Combinator-funded Qurasense is poised to offer a smart pad that can test the hormones in your menstrual blood. And while you’re changing that pad, you may soon be able to have Bisu’s smart toilet check your urine for signs of ovulation, too. Lest you think the future has not already arrived, in 2016, Eve Medical started offering at-home pap smears (you order the test online, swab, and then mail the sample back to the company for analysis).
These tests would make biohacking one’s fertility more scalable, allowing women to chart their fertility continuously, in real time, and look out for trends. Which means potentially finding ways to manipulate hormone levels and protect their balance. “We haven’t found too many things that affect the reproductive organs,” Anne Steiner said when I asked her about lifestyle changes that might prolong fertility. Then she paused. “I mean, honestly, we don’t know.”
So far, none of these tools have purported to yield the holy grail of fertility testing, the thing Maloof and I both sought: a way to plot one’s individual fertility decline along a curve that’s predictable enough to help dictate life plans. “I’ve been having this conversation for 30 years of practice,” says Jamie Grifo. “And we still don’t have answers to the question we all want: Predict my future.” But Grifo doesn’t think it’s impossible that we could one day identify a biomarker, or a number of biomarkers, that would be predictive. “I’m sure there is a gene, or a host of genes, that affect ovarian reserve and aging,” he tells me. “But we haven’t found it yet.”
In part, that’s because there’s no good control group. Says Grifo, “Women who get pregnant easily aren’t going to be motivated to be giving blood samples.” But it’s also because it’s difficult to tie data to outcomes. Assuming other variables are equal, how long does it take a woman with one set of hormones to get pregnant versus a woman with a different set? That’s where the new tech data could one day come into play. If enough women — and enough different demographics of women — signed up to not just use biohacking equipment, but to also entrust their (very personal) ongoing stats and eventual pregnancy outcomes with a tech company (which, to be fair, current trends show that we’re surprisingly willing to do), eventually a correlation might emerge. “Somebody’s going to realize that they can just cut the costs, and the value of the data will be more valuable than charging the person,” Maloof points out.
But right now, the advantage of biohacked data — that it’s completely individualized — is also its drawback. Biohackers remain a small, self-selecting, privileged group. And so while hacking can tell a woman if her biomarkers, at that moment, are within what is considered a normal range, they can’t help her project out a given number of years, because there’s no far-ranging basis for comparison. As Maloof had told me about interpreting her own labs, “Data is great, but data without context is useless.” Nor can you control the other factors that account for the majority of infertility: physical abnormalities (such as blocked tubes, endometriosis scars, or a missing ovary) and the quality of sperm. For many women, then, biohacking would be an exercise in futility — and a potentially heartbreaking one at that.
Sometimes, though, you take what you can get. However fallible, it soon became clear that for both Maloof and me, biohacking was a coping mechanism, a way to deal with the anxiety of not being in control, using numbers and data to try to harness a future that remained unknowable. As Maloof’s experiment wore on, I took some comfort in the fact that, at least as science now stands, I hadn’t been remiss in trying to analyze my fertility — or protect it — there may yet come a day when, having banded together, women can do, and know, a whole lot more. And Maloof herself learned enough to feel confident that nothing clearly ruled out her chances of bearing a child in the future, even as some of the same markers she had once scoffed at became the ones she pointed to as encouraging when test after test came back within the normal range. “Basically, my fertility is great right now,” she told me the last time we talked. “And I know how to monitor it over time to address if it’s changing, or if I need to do something more drastic like freeze my eggs.”
She also took control in the ways that she could. In the end, the solution to her fertility problem was decidedly low-tech: She ended things with the younger guy and started dating someone new, someone who wanted kids in the next few years. “He wants all the kids — he wants as many as possible,” Maloof told me, happily. “I’m giving myself until January to decide [about freezing my eggs] because you never know how things are going to work out with someone, but I’m feeling really happy about this decision.” She was now using biohacking as a hormone-free way to avoid getting pregnant.
As for me, I write this, my daughter — conceived the month immediately after that second miscarriage — is due one week from today. All the anxiety, the fretting, the number crunching, and the late, late nights proved to be completely unnecessary. If only there had been a way to know that then.