Paging Dr. Internet, we need a diagnosis. In this series, Mashable examines the online world's influence on our health and prescribes new ways forward.
On Instagram, I scroll past a blonde toddler's second birthday, a senior dog that's up for adoption, a pair of daytime pajamas, and then, a post with a question: "Want kids one day?"
It's an ad from Modern Fertility, a company that is one of an expanding group of contemporary tech-oriented companies offering fertility services to people with uteruses before they are trying, and having trouble, getting pregnant. Typically, testing for markers associated with fertility only happens after a person does not successfully conceive after one year of trying. But in the last half decade, "proactive" fertility testing and care has become a big business for individuals and employers who offer the services of these companies as a benefit to employees.
The Instagram ad offers a quiz that will help "get information about your body to help you plan." My mind races: What information? Should my doctor have told me something? Yes, I do want kids. Is my lunch break on a Tuesday the time to start planning, and what does "planning" even mean?
These Instagram ads putting my reproductive future right up in my face are jarring and have made me feel some potentially unwarranted anxiety about having kids. But the companies, and their ads, also expose a gap in the healthcare system that has only widened as people wait longer to have children. Health professionals say planning for how many kids you want, and when you would like to have them, is probably a good idea if you are waiting into and beyond your mid-30s to have children. But doctors aren't necessarily making that known to patients, or giving them tools to help plan.
"The more that people are informed and thinking about it, the better," Andrea Braverman, an obstetrics and gynecology psychologist at Thomas Jefferson University, said of family planning for those considering having children.
Strangely, these ads, and the companies behind them, are on the forefront of making that happen. The question is whether the companies elevating the issue — with products for sale — are the right voices to fill that gap.
Your view of the glass
Venture capital funding for fertility tech companies jumped to $176 million in 2021 — an 89 percent increase over 2020, after an already steady rise beginning in 2017. It's easy to see why: The value proposition of these companies makes a lot of sense.
Dr. Fahimeh Sason, the founding physician at millennial-focused fertility clinic Kindbody, explained that preventative care is popular right now in healthcare circles. For example, doctors screen for heart disease before waiting for people to have a heart attack. Why shouldn't infertility care be "preventative," too? Modern Fertility's co-founder, Carly Leahy, described the current "wait and see" approach to fertility as backwards, especially for millennials who are "planners." Why wait a year to discover something's off, when you could have known information earlier and saved yourself a year of pain?
Sounds incredibly reasonable, right? But the answers to those questions are more complicated than they may seem.
For one, infertility isn't as common as our imaginations make it out to be.
"When it's more difficult, you hear more about it," Emily Oster, a Brown University economist and author of Expecting Better, a book that debunks pregnancy myths, said. "I think that makes it salient to people."
Through interviews with medical experts and researching government-collected statistics, I learned that, if you get your period regularly, age is the best information doctors and patients have about fertility.
About 85 percent to 88 percent of couples between the ages of 20 and 44 get pregnant within a year of trying, according to the National Institutes of Health. In general, your chances improve if you're under 35 and decrease over 40.
This is the same data — presented in the opposite way — that Kindbody and Modern Fertility cited to me: that one in eight couples will have difficulty getting pregnant. Is that a lot? Or isn't it?
The answer is personal. Maybe you're someone who focuses on the fact that 88 percent is a high success rate! So there's little to worry about. Or maybe you see that 12 percent of people who have trouble, and think, hey, that's not insignificant. That could be me.
Perhaps, even if fertility problems are rare, the pain of what you might experience if you are in that 12 percent warrants giving that chance more weight. That's something doctors don't usually make space for, and is a way some people — maybe you — may feel. It's where fertility companies are stepping in to offer a lifeline to a group that's anxious and feels underserved.
But it's also worth remembering that this space of fear and uncertainty is where ads for fertility startups selling their services come in.
"Getting pregnant isn't always easy," reads one Kindbody ad.
The results are in, but the jury's out
If you do decide you want to take action, there's another reason choosing to do so with a fertility tech company is not so clear cut. Doctors and fertility companies (and their doctors) don't agree about what you can actually do to prevent or foresee infertility problems.
Modern Fertility offers a hormone test that it says screens for levels of the same hormones that a reproductive endocrinologist would test for after a person has trouble getting pregnant for a year. Hormones play a role in getting your body to ovulate every month, and they can be indicators for certain conditions that can impact pregnancy. While a hormone test a person takes after struggling to become pregnant might help identify or eliminate problems, the proactive hormone tests are intended to help you understand how your hormone levels compare to the general population, and may empower you to go speak with a doctor if there is any irregularity.
The issue is that, for a person who has not struggled to become pregnant, the tests are not predictive, because they are just one part of a person's unique biology. That's why doctors I spoke with were both skeptical that these tests can offer any useful information, and warned that the test results could actually be harmful.
"I just don't know how it's going to help them," Dr. Anne Steiner, an OB-GYN at Duke University who studies AMH, one of the most important hormones associated with the amount of eggs in a person's ovaries. "I recommend they use their age to make this decision [regarding family planning]. That's going to be what's most helpful."
Both Steiner and Dr. Sigal Klipstein, a reproductive endocrinologist and ethics expert with the American College of Obstetricians and Gynecologists, stressed that the tests could be misleading in multiple ways. Explaining why is a bit wonky, but essentially, if you get an "all clear," you could get a false sense of security about your fertility, since there are many other factors beyond hormone level that impact your ability to conceive. On the other hand, getting abnormal levels might make you think there is something wrong, when actually, there is not a clear-cut connection between any of these hormone levels and getting pregnant.
"Knowing your hormone levels does not predict your fertility," Klipstein said. "The association between increasing [hormones associated with ovulating] and decreasing fertility is not linear. It is also not very predictive of how fertile a woman might be."
Modern Fertility says hormone levels are meant to be educational, and that physicians' objections to its test usually dissipate when they see the way the company's product presents this data and information to clients. It also makes it very clear on the company's website that its tests do not predict future fertility — as both Klipstein and Steiner said, there are no current tests that can do that.
"The information will not tell you, you know, 'go, or no go,'" Modern Fertility's co-founder, Leahy, said. "It's the first step to understanding how all of this stuff works."
But you'd be forgiven for getting the opposite impression if the only interaction you've had with a company offering at-home fertility tests like Modern Fertility, Everlywell, Thorne, and others, are their ads. It takes a lot of digging into the nuances of fertility to understand the role hormones play. But the nebulous "getting more information" about your fertility, which is how most of the companies describe their tests in advertisements and on their websites, can easily be interpreted as a way to get a glimpse into the future.
"There's still debate about what this stuff means, and new research is coming all the time," Braverman, the gynecological psychologist, said. "When we do this commercialization and commodification of fertility, it’s at the expense of oversimplifying what is a very complex picture."
Leahy said that Modern Fertility focuses on the stories of customers in its advertising, and never uses anything like a clock. But Leahy also acknowledged that "In 15 seconds or in one square, it's very difficult to explain the conversation that you and I are having right now," Leahy said.
While companies offering fertility hormone testing abound, others, like Kindbody, are actually building brick-and-mortar clinics that aim to make fertility planning and preventative care a part of what's known as "whole women's healthcare," which includes an annual gynecology visit, screening for conditions that affect people with uteruses, and more. Sason wants to make talking to patients about whether or when they want to have kids, thinking about how many kids a person wants, and educating patients about the role age plays in fertility, a routine part of healthcare. A fertility assessment in a Kindbody clinic includes hormone testing, as well as an ovarian ultrasound and an intake of family history.
"Fertility assessments are important if done comprehensively," Sason said. "Nothing works if you give just one piece. We need the whole puzzle for it to be meaningful."
Of course, those fertility assessments come at $300 per session, plus the additional cost of bloodwork, for which Kindbody does not list the price. So while education and potentially proactive testing sounds like a good idea, it is also a way to commodify worry.
"I think you can be knowledgeable about the age related to decline in fertility, protect yourself against STDs, and see your physician if you have irregular menstrual cycles," Steiner said. "We can take control, and knowledge is power. But I'm just not certain that tests really are the knowledge we need right now."
What's the harm in 'information'?
In 2016, tech industry entrepreneur Joan (who asked to use a pseudonym for privacy and career reasons), paid $16,000 to freeze her eggs. She was in her mid-30s, and had been hearing about the egg freezing benefits Facebook and other tech companies were offering employees.
Egg freezing is just one piece of the fertility startup economy, but it is the ultimate expression of what these companies are trying to sell you: The idea that you can and should proactively take control of your fertility. While that journey may begin with learning more about your body, it can also manifest into fear, driving you towards complicated and painful medical interventions.
"It felt like, this is what a responsible woman does, along those lines, like, oh I should get health insurance, I should have a college degree, I should freeze my eggs," Joan said. "lt was really like that."
Meeting the needs of those who want to take a more active role in planning for children may be valuable, especially for people who might be anxious about getting pregnant. The fertility startups are also certainly raising awareness about having a plan for having kids based on your age and life circumstances, which might help people avoid surprise and anguish if they try, or think they might try, to conceive later in life.
"This is a high stress thing to think about, it generates a lot of uncertainty and anxiety, and if this is something that would make them feel better to do, I can see the value in that, and I think we probably underweight the value of that," Oster said.
But offering some reassurance through "proactive" fertility testing also glazes over the fact that there is still a lot doctors don't know about why some people can become pregnant, and some can't. That's partly because every person's body is different, and fertility is a process with a lot of moving parts. But it's also because there just isn't that much data on the topic, thanks to a gender gap in medical research and the shameful, taboo space that problems with fertility have occupied in the past.
Ironically, the fact that we don't know that much — which makes people want to buy products out of anxiety over their lack of control — could actually help us learn more. Some of these companies, including Modern Fertility, are doing studies about fertility based on customers that opt-in to having their data collected.
"By bringing attention to this, they are going to prompt better data," Oster said. "We're only going to understand [infertility] better with more data, and companies like this are going to have that better data because they're more motivated to collect it than others. So I think in that sense, it's kind of a value."
But until those studies do materialize, papering over the truth of biological mystery and chance surrounding pregnancy — a truth that is admittedly hard to swallow for career-oriented millennials, like me — can have some unintended consequences.
Joan's experience freezing her eggs ended up being painful and isolating, leaving her feeling inadequate and alone. With regard to fertility testing, or even targeted fertility testing advertising, the information may be educational and empowering — or it might be stressful, inconsequential, misleading, and potentially harmful.
"It’s unfortunate, because it might be planting something that the person wasn’t even thinking about, creating anxiety where there hadn’t been any previously," Deanna Pledge, a clinical psychologist specializing in women's healthcare for the American Psychological Association, said. "It might cause people to make medical decisions that they wouldn’t have approached prior to that, and that could be necessary or unnecessary."
At first I hated seeing that "Want Kids One Day?" ad, when all I wanted out of Instagram in that moment was to ooh and ahh over other people's kids, not ponder the potential existence of my own. But I'm actually grateful that it prompted me to sit down and think, to do research, even to speak to my doctor. Yes, when it comes to fertility, knowledge is power — and not necessarily something you have to buy.
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