Reviewing 'The Retrievals': The Compounding Pain of Reproductive Injustice

Biopolitical Times
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The New York Times and Serial Productions recently released a five-part podcast series, The Retrievals, which has topped podcast charts and sparked conversation––even Hillary Duff is listening to it. The podcast is produced with the typical “true crime” hallmarks––suspenseful music, powerful dialogue, and cliffhangers punctuated by jarringly cheery advertisements. But its exploration of the intersections between cultural dismissals of women’s pain and unjust structures in the fertility industry directs our focus toward the systemic rather than the salacious.

The podcast covers a nurse’s monthslong theft of fentanyl, used for pain control in egg retrieval procedures, at the Yale Fertility Center in 2020. The nurse, Donna, whose descent into opioid addiction is covered in the podcast’s second episode, admitted to taking fentanyl from clinic vials and replacing it with saline (salt water). The switch left patients undergoing egg retrievals at the clinic to endure the procedure “stone cold sober and awake,” as one woman put it.

Donna was eventually sentenced to four weekends of incarceration, three months of home confinement, and three years of supervised release. She also had her nurse’s license suspended, although the final episode traces deliberations in response to her appeal to have it reinstated.

The central question of the podcast is not necessarily Donna’s conduct and the consequences she faced, but rather, how skepticism of patients’ reports of severe pain during and after the procedure allowed Donna’s deception to continue for months. According to a federal investigation of the incident, as many as 200 patients were affected by Donna’s thefts. The podcast presents evidence that suggests even more patients may have been harmed. There is no way to definitively know which patients did not receive pain medication, in part because the women’s reports of pains were dismissed, minimized, or ignored. The podcast’s host, Susan Burton, interviewed 12 women who experienced painful egg retrievals––some more than one painful procedure––in the five months of 2020 that Donna admitted to stealing fentanyl.

Although contested by many who have undergone the procedure, clinics present egg retrieval procedures as not painful––typical anesthesia protocol is supposed to leave patients feeling only “mild discomfort.” Women interviewed for the podcast described the pain they experienced as “horrific,” “nightmarish,” “excruciating,” “extreme,” and “inexplicable.” They recalled that their evident suffering or their frank communication that they were in pain was either ignored or met with the response that they had been given the maximum amount of fentanyl already. For instance, one patient, Laura, explains how she tried to communicate her pain to no avail: “I’m thrusting my hips and telling these — like, wide awake speaking to them. And I was just like, I feel everything you’re doing. And that was when I — I remember actually saying to them, I could drive myself home right now. I’m that alert.”

As Burton explains, reports of pain from women, especially women of color, are often dismissed in healthcare settings: “There’s a balance you have to strike as a woman patient. You have to complain just the right amount to be taken seriously, but not so much that you seem shrill. Still, your pain is more likely to be underestimated than men’s. Black women are more likely to have their pain ignored no matter what they do.”

Katie, a patient who underwent egg retrieval with what turned out to be no pain medication, was herself a researcher in addiction, and had the thought that the nurse might be stealing fentanyl: “I came out of that procedure, and I immediately — I remember immediately texting my friends who are also colleagues in addiction research at Yale, like the nurse is stealing the fentanyl. It just seemed so obvious.” But the nurse in the recovery room suggested that the pain was due to the number of eggs they retrieved, which made Katie doubt her own read on the situation. Eventually she, like other patients, concluded that she must not be very sensitive to fentanyl.

Why would the medical staff not notice or intervene when patients expressed severe discomfort or intense pain? One explanation was supplied by clinic staffers who spoke with Burton––all anonymously. They described the combination of fentanyl and midazolam as a form of “moderate sedation” that would not always fully control patients’ pain during the egg retrieval procedures. Some experts from other clinics were surprised to learn that Yale was still using this drug combination for pain control; deeper sedation by a nurse anesthetist or anesthesiologist is now more typical. But because Yale used this lighter form of sedation, it was not unheard of for patients to experience pain during egg retrievals, even before Donna was stealing the fentanyl.

Burton surmises that this shaped staffers’ expectations and interpretations of patient experience. Reports of pain were not surprising enough to prompt an investigation; instead, they were within the range of normal experiences for women undergoing egg retrieval. Partway through Donna’s months of theft, the clinic did begin using stronger forms of sedation, which seemed to reduce pain during the procedure, but not after it. Some staffers speculated that the deeper sedation may have made the lack of fentanyl less apparent because patients only became aware of the extreme pain that they were in once the sedation wore off.

The podcast’s fourth episode focuses on the policies and practices at the Yale Fertility Center that allowed Donna’s theft to continue for months undetected––even as many patients were reporting severe pain during and after egg retrievals. While concerning in their own right, increasing reports of pain are also a known indicator of “drug diversion,” or theft, across medical contexts. Burton reviews missteps in how drugs were procured, tracked, and stored at the clinic, emphasizing how the lack of oversight during the early stages of the Covid-19 pandemic made the environment “ripe for abuse.”

Burton continues to zoom out in identifying who is responsible for causing patient suffering: clearly, Donna’s theft is most evidently the culprit, but clinic structures play a role as well. Yale’s policies and practices of lackluster pain control and limited oversight are what made Donna’s crime possible.

Two additional factors are crucial but more difficult to pin down because they are cultural currents that affect how others interpret and respond to women’s reports of pain. One is the historical and ongoing tendency to dismiss and discount the pain of vulnerable people, especially women of color and women with disabilities. The second is the cultural emphasis on women as mothers, as reproductive vessels and childbearers, which contributes to what Burton calls “the pain of longing.” While the first explains why patients’ reports of pain were not sufficient to trigger an investigation, the second offers some insight into why patients may have been willing to endure such extreme pain, as most did, rather than attempting to stop the procedure. Burton explains: “The patient puts up with the pain because she longs to have a child. The doctor knows the depth of that longing. Getting the eggs causes one kind of pain but relieves another.”

The podcast focuses on egg retrieval experiences of mostly white, well-educated women hoping to have children, but the underlying cultural and structural issues that contributed to their painful experiences have an impact far beyond these particular women and the Yale Fertility Center. The lack of regulations in the fertility industry and the tendency to minimize and dismiss women’s pain make egg donors and surrogates more vulnerable, as initiatives including We Are Egg Donors and Surrogacy360 have made clear. In the case of egg donation, clinics hoping to recruit donors are incentivized to downplay risks and pain associated with egg retrievals, and physicians focused on intended parents may not prioritize attending to donors’ pain in egg retrieval procedures. Women of color and women with disabilities face additional barriers in reproduction, as the legacies of eugenic projects of forced sterilization, experimentation, and discrimination make it more difficult for women of color and women with disabilities to exercise reproductive autonomy.

The storytelling of The Retrievals has captivated many listeners, providing a compelling story that illuminates one horrific instance where the fertility industry and cultural dismissals of women’s pain intersect. The conversation can’t stop there: the power of these women’s voices should encourage us to listen to others who make clear the disproportionate impact of reproductive injustice on marginalized populations.