The new Serial podcast, The Retrievals, tells the story of patients attending a Yale fertility clinic. All of them experience extreme pain during an egg retrieval procedure, and all of them see their pain trivialised and dismissed. It later transpires that a nurse at the clinic has been replacing the Fentanyl that should have been used for the procedure with saline. What comes through most powerfully in the first episode, which tells the patients’ stories, is these women’s impulse to blame themselves. Having been told they received the maximum dose of pain relief, they reach for stories to explain their responses: “I’m immune to Fentanyl. It’s my fault. It’s supposed to be painful”. “There’s nothing like feeling shame,” says one patient, describing her distress at hearing women who’d experienced egg retrieval at other clinics refer to their experiences as relatively painless. “I started shutting down after hearing those stories, like this was on me. Something wasn’t right with my tolerance and my ability to handle this.”

There has been a flurry of recent books, including Elinor Cleghorn’s Unwell Women and Pragya Agarwal’s Hysterical, which explore the way in which female experiences of pain are minimised and dismissed. This is true in general terms; as podcast presenter Sarah Burton comments, “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.” In this instance, however, there’s an additional level of judgement. The women attending the Yale clinic compare themselves, but not to men, and not just, as in the example above, to other women undergoing fertility treatment. They compare themselves to women who do not need to access the treatment at all.

One patient, Leah, is described as having “internalised the narrative that her body was to blame. Her body was inadequate, deficient. Her body had had miscarriages. Her body didn’t make enough eggs. Her body couldn’t cooperate long enough to get through a critical procedure”: “Oh God, my body was like, here it goes again. Not only can I not have a baby, I also can’t even just lay still with the right amount of Fentanyl.” This is not just about gendered perceptions of pain tolerance. It’s about the censure that surrounds the whole issue of female fertility: which women can get pregnant, which can’t, which women can stay pregnant, which can’t.

Much of the time, infertility and recurrent miscarriage are unexplained, but like the women who cannot understand why their maximum dose of opiates is not working, we invent reasons for then, and whatever reasons we invent tend to make women themselves the culprit. A toxic combination of ignorance and misplaced guilt then makes it easier for the fertility industry to mistreat women. Patients arrive in an already weakened state, weighed down by the fear that they have “let down” both themselves and those around them: their partners, potential grandparents, any future babies, maybe even feminism itself.

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Like cosmetics, fertility is a multi-billion pound industry that capitalises on female shame. It can be an intense, multi-levelled shame — particularly for the kind of liberated, professional woman who visit clinics such as that at Yale. On the one hand, you have failed to do what is, according to the traditionalist, a woman’s main purpose; on the other, you have failed to prove the traditionalist wrong by having a baby on your own terms, in your own time. In an era that prizes freedom and choice, you are subject to the restriction and unpredictability of your own body. Your “failure” is shameful, but so, too, is your desire, a desire that is so strong that you will throw yourself at the mercy of an industry whose success rates are shockingly low.

According to the NHS website, the percentage of IVF treatments that result in a live birth is 32% for women under 35. However, this goes down to 11% for women over 40, and 5% for those over 43. Statistics for egg freezing — now increasingly promoted as a workplace perk — are even more depressing. Data from 2016 puts the pregnancy rate from thawed eggs at a mere 1.8%. Women suffer a great deal of physical and emotional pain for outcomes that are in no way assured. In the Yale case, the patients do this repeatedly, even before the Fentanyl issue has been exposed, enduring the agony of retrieval multiple times. “The women gear up for second, third retrievals,” we are told. “They change their diets. They cut chemicals out of their home… Despite these efforts, some of the women miscarry… It’s the cycle of hope and loss. It just clobbers you, and the longer you stay in it, the more that drugs mess with your head.”

What happened at Yale was a scandal because of the specifics: a drug-addicted staff member, victims gaslighted and disbelieved. But it also describes, in heightened form, the patriarchal attitudes that underpin the medicalisation of the female reproductive system. “A man’s life proceeds in smooth continuity,” wrote the gynaecologist Robert Wilson in the Sixties pro-HRT manual Feminine Forever. “How different is the fate of woman. Though modern diets, cosmetics, and fashions make her outwardly look even younger than her husband, her body ultimately betrays her. It destroys her womanhood during her prime.” The alleviation of specifically female pain becomes indistinguishable from the drive to “correct” women who are not fulfilling their designated role. “For centuries”, writes Cleghorn, “many medical ‘cures’ for women’s apparent deviancy and defiance had been punishments masquerading as therapies.” Fertility treatment is not a punishment, but it sometimes mis-sells hope. It sometimes downplays costs.

In criticising any aspect of the process, I feel unpleasantly unsisterly and finger-wagging. After all, it’s easy for me to say: I already have children. My experience of the pain of being denied is very limited. My first pregnancy ended in miscarriage, which prompted panic that any subsequent pregnancies would end this way, plus a kind of bewilderment. I’d “followed the rules” — I was under 35! My career wasn’t high-powered! I’d even given up coffee! — yet still lost out. I pored over miscarriage statistics and compared myself constantly to women who’d “managed” to stay pregnant. At times, I experienced the fact that every single person who has ever lived is the result of a successful pregnancy as a personal insult. Beneath my anger, though, was guilt. I must have done something, otherwise it made no sense. Like the Yale patients, I knew this was irrational. It didn’t alter my need for a story.

Since then, I have had three healthy babies, my last being born when I was 40. There is no moral, just a randomness to it. It’s one of two things those of us who obsess over making the world fairer for women — the feminists, the progressives — do not like: limitation and chance. It feels politically uncomfortable, and also regressive.

This is particularly the case at a time when a feminist politics rooted in the realities of the female body is being pitted against claims that sex is as socially constructed as gender. The latter position, which insists we interpret our own bodies regardless of the sex they have been “assigned”, implies endless possibility – you are whoever you say you are! – while also insinuating that those who continue to politicise the female body create the very limits it imposes. As Catherine McKinnon recently wrote, “women are not, in fact, subordinated or oppressed by our bodies”: “It is core male-dominant ideology that attributes the source of women’s inequality to our nature, our biological sex, which for male dominance makes it inevitable, immutable, unchangeable, on us.”

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This is true in regard to socially constructed inequality — what men choose to do to women — but not in regard to what our bodies are in relation to us. They do not always do what we want them to do. It is cruel to make us feel we can think ourselves beyond our own flesh. Some things are unchangeable. Yet a feminist politics that points this out — that explores both the possibilities and the boundaries, to the point of admitting that not everyone can get pregnant — will inevitably sound mean. By contrast, the false promises of the fertility industry, like those of the cosmetic surgery industry, will sound kind.

Patriarchal narratives which situate fertility in relation to virtue and women’s “natural” role are set in opposition to social justice narratives which prize the right to be and do whatever you want, with neither side accommodating the reality of women’s bodies. Sex difference has so often been presented as the justification for restrictions that are cruel and arbitrary — and the threat of infertility so often used as a stick with which to beat women who might otherwise become too liberated — that it has become very difficult to speak the truth.

We forget that the morality tales we impose on our reproductive lives are just that. Overwriting supposedly conservative narratives with apparently progressive ones is meaningless when the supposedly guilty party is at all times the female body. The betrayal of the Yale patients is symptomatic of a culture that profits from women’s self-blame at the expense of allowing them the space to grieve. A compassionate, honest fertility industry would tell the truth, and spare women further pain.

Indeed, that I ought to have done it years ago; at 35, I was already over the hill, egg-quality wise. Their daughter, they said, had already frozen hers — aged 25, when the eggs are in prime health. In the UK, there is a 10-year storage limit on egg-freezing, which is why women here rarely consider it in their 20s; most aren’t ready to give up the ghost of finding a partner and conceiving naturally in their 30s. The US has no such limit.

The advice from my parents’ friends came at a time when I’d already considered egg-freezing or “oocyte cryopreservation”, in industry jargon. By the time 35 loomed, the message had reached me loud and clear that my fertility was about to hit a perilous cliff-edge. Should I act? I was just on the way out of a long-term relationship, was hungry for fun and freedom, and having children then held no appeal. I wasn’t sure I’d ever want kids. The only thing I knew for sure was that I didn’t want to think about it. After a brief bit of research, which showed that less than 1% of frozen eggs end up becoming babies, I put the whole thing aside as too remote for serious consideration.

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Now, in 2020, egg-freezing merits fresh thought. The pandemic has exacted revenge on those who planned to wait and see what unfolded. The clock has stopped — all the hurly burly of social life has been suspended — but bodies are still ageing. This has put particular pressure on single women in their late 30s, for whom in a stroke all possibilities of conception seemed to evaporate when in-person dating became lethally risky and fertility clinics had to be closed.

Clinics were able to apply to reopen in May, and I know a number of women who — feeling the dread and panic of a socially, professionally and quite possibly romantically aborted year or even two — are considering either egg-freezing or going ahead with sperm donor insemination. The option to “wait and see” has lost its air of promise.For those who don’t want to take the plunge of a pregnancy yet, the temptation to pay through the nose to freeze eggs — £8,000 per cycle, with three cycles recommended — is strong as the world becomes more uncertain.

In the past few years, the procedure has been glamorised by celebrities including Rita Ora and Sofía Vergara. American companies from Uber to Unilever now offer egg-freezing benefits to female staff. So far, so empowering. But despite the hype, egg-freezing remains a marginal practice in the UK. According to the fertility regulator, in 2017 there were just 1,463 egg freezing cycles (compared to 70,000 IVF treatment cycles) — up from 816 in 2014. Between 2010 and 2017, only 700 babies were born through frozen eggs in the UK — compared to 732,000 total live births per year. The number of “thaw cycles” of patients’ own eggs, rather than donor eggs, was only 178 in 2016. So this is still very far from being a mainstream salve for women unsure about the future, though that does appear to be changing.

For the many women who feel time is running out — fertility campaigns since the 1980s have ensured awareness of a number of cliff-edges, from 30 to 35 and now 37 and 40 — egg-freezing has been presented as a way to defer the plunge-taking (or not) that biology eventually demands of us, whether we have a partner and a good job or not. It therefore provides intense psychological relief, like any insurance policy. Marcia Inhorn, a sociologist of assisted reproduction at Yale, and the author of a large-scale study on the reasons American women freeze their eggs, told me: “The overwhelming majority of women who did freeze their eggs, and got a decent response, felt relief — they felt they could take the pressure of time off. People used ‘peace of mind’, the ‘pressure’s off a bit’. A lot of it was put into psychological terms.”

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Mental relief is clearly a payoff for those who choose to undergo the expensive, invasive ordeal of egg-freezing cycles. But most women still want to wait for a partner before defrosting and if no such person materialises, they leave the eggs untouched. Or they find partners and get pregnant naturally. But for those who do want to use their eggs, only 19% of IVF treatments using those eggs result in live births (according to 2017 figures), compared to 30% when donor eggs are used, though most women don’t envision using donor eggs to get pregnant. If egg-freezing is an insurance policy, it’s not good value: the chance it will pay out is small.

And the costs are staggering. Women have to pay for egg-collection and freezing (£3,350 per cycle), medication (£500-£1500), egg-storage cost (£125-£300 per year), thaw cycle and embryo transfer (£2,500). The procedure, which involves women making repeated trips for scans to the clinic, injecting themselves with hormones and then undergoing egg retrieval under general anaesthetic, can be gruelling. Some women are going public with regrets, particularly over the high costs and eventual abandonment of the eggs. Hannah Selinger, who froze her eggs in the US aged 34, wrote a piece in Glamour headlined: “I spent $17k freezing my eggs and regret every penny”.

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Beyond the nitty gritty of cost and outcomes, the egg-freezing phenomenon houses an unpleasant paradox: when women actually want to freeze their eggs, and do so, those eggs are far less worth freezing. Women over 35 who freeze their eggs have a considerably lower chance of being able to make viable embryos out of them than younger women. Over 37, the quality and viability plummets further. And yet 38 is the most common year for women to freeze their eggs — this is when women really want it, can afford it, and are ready. Yet it is also the moment the benefits of doing so shrink. At the best age for freezing viable eggs, under 30, few women want to even think about it. And why should they? Infertility is a future and uncertain problem. Still, they are told that this attitude may mean hell to pay later — even though there’s only a 30% chance that IVF cycles using eggs frozen at peak fertility will lead to pregnancy.

But the most insidious aspect of it all, perhaps, is that while egg-freezing promises empowerment to women, it also adds queasily to the pressure. Zeynep Gurtin, a sociologist of reproductive technologies at UCL, told me that “reproductive anxiety”, an idea she has developed with her colleague Charlotte Faircloth, is an increasingly pronounced part of women’s lives, with the onus on women to constantly engage in “responsible decision-making” to manage their fertility. “If you fail it’s your fault, you didn’t go to enough experts”; spend enough money, take enough steps.

Of course, women have long been hounded about the passage of time and the dangers of a laggardly approach to their fertility. A 1973 advert for Ivy Gibson, a London matchmaker, asked women: “Are you under 30? Are the years ticking off, NEVER to come back?!” In 1982, the New England Journal of Medicine reported that between the ages of 31 and 35 women stood a 40% chance of being infertile. It went from there.

As Susan Faludi wrote in her 1991 classic Backlash: The Undeclared War Against Women: “Like the children’s game of Chinese whispers, as the 40 per cent figure got passed along it kept getting larger. A self-help book was soon reporting that women in their thirties actually faced a ‘shocking 68 per cent’ chance of infertility — and promptly faulted the feminists, who had failed to advise women on the biological drawbacks which went with a successful career”.

The timescales have since lengthened — the fearful numbers are now 35 and 37 — and, thanks to the evolution of a more progressive gender politics, feminine milestones have diversified and the overtly anti-feminist agenda in terrorising women about fertility has been softened.

Still, the driving pressure remains. Egg-freezing may help free some women from the old harness of time. But it has also helped tighten the screw, at eye-watering cost, and with a low chance of ultimate success.

We may hold our nose when nativists like Viktor Orbán describe his nationalisation of IVF clinics as a “strategic investment”, but across Europe tax breaks and cash handouts are everywhere and growing. This month Greece became the latest with plans for a €2,000 baby bonus, joining a long list of European countries now providing strong incentives for its people to have more children.

Indeed many demographers view Britain as oddly unsupportive of natalism, and of 41 OECD countries, the UK comes in 34th in paid parental leave. While in France mothers receive extra-long maternity leave and a cash bonus after their third child, and there are travel perks and reduced income tax for large families, in Britain child benefit is means tested and capped at two children. Oh Mon Dieu!

Former Eastern Bloc countries, once the family’s enemy, are now resurrecting the idea that parents must somehow be allowed to capture the economic rents of child-rearing. An outflow of young workers to the West, empty cradles at home and a reluctance to embrace immigration have produced an existential crisis.

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From the Baltic to the Black Sea, governments are thinking long-term demographic thoughts. Hungary, which now spends four times more on pro-natalist measures than it does on defence, aims to get the birth rate up to replacement level — 2.1 babies per mother — by 2030.

Britain, too, has targets for the 2030s, but not for children. Indeed environmentalists behind our green carbon goals see population as a problem, even though — with the number of Britons living alone recently hitting 8 million for the first time — rising consumption per capita will be one consequence.

The green argument against children is popular, and it’s not just Harry and Meghan who fret about their minuscule contribution to population growth. A YouGov survey in January found that of under 35s who do not want children, one in seven cite fears for the planet’s future as their motivation. A fifth of British women are childless, the third highest proportion in the developed world.

Yet where this is a genuine sacrifice, it may also be unnecessary. Many demographers say global population is a lagging indicator and should top-out by mid-century, falling sharply thereafter. In many developed countries it’s already in free fall.

In Finland last month the Finnish equivalent of the CBI demanded that the government starts to think about managing fertility as it might inflation or growth. Whereas those traditional economic indices are cyclical, Finland’s fertility rate looks terminal. In just a decade it has crashed from 1.9 to 1.3 children per woman, creating a “doom loop” of ever older pensioners supported by fewer workers. The young pay more tax to sustain the welfare state, which means less disposable income for homes and babies.

Breaking that cycle is the work of decades, and governments rarely think that far ahead. As Ross Douthat wrote in the New York Times: “It’s very hard to find a way to effectively place value on things like the creation of new workers 30 years from now. It’s just too long-term.”

So could this be a job for a prime minister whose personal contribution to the British birth rate may be at least three times the national average? Someone who — by signing off on HS2 — understands that some projects are a generation in the making and that, though we’ve left the EU, we could still have much to learn from the continentals?

If he has at least two terms in office, Boris will serve to see other countries grapple with demographic challenges, and might be surprised by what he sees. When Vladimir Putin gave his annual state of the union address last month he spent 20 minutes on constitutional reforms and twice as long on the need to remedy Russia’s birth-dearth. Here, as elsewhere, religion is increasingly invoked; in neighbouring Georgia, the birth rate jumped after the Orthodox Patriarch took to personally baptising babies.

China, having ditched its wicked one-child policy, is now in a panic about becoming the first country to get old before it gets rich. For now it seems to be trying gentle persuasion – a recent stamp to mark the year of the pig showed three piglets, taken as a sign of government approbation for bigger families – but draconian measures may not be far off, with reports from some provinces suggesting that it is getting harder to secure abortions and divorces.

But could Boris launch a British pro-natalism agenda, while staying true to his liberal roots and new northern electoral powerhouse?

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For a policy so mired in memories of dictators ordering women to breed for the fatherland, a new wave of demographers is stressing the liberal case for pro-natalism. The Left-leaning IPPR think-tank has addressed the “baby gap” — the difference between the number of children wanted by women and those they actually had — which is running at about 100,000 a year.

A Guardian survey in 2014 found a third of couples would have more children were they not so expensive; indeed if British women had all the babies they wanted, our birth rate would be above replacement level. In the US, which has seen huge falls in fertility in the past decade, 40% of women do not have all the children they wish.

When I interviewed the demography writer Jonathan V Last for a BBC documentary last year, he stressed how reproductive rights once meant the ability to control fertility downwards, something still true in parts of sub-Saharan Africa. But in the developed world a woman’s ability to achieve her stated fertility ambitions can be seen as a form of social justice and source of empowerment.

Nuanced pro-natalism might also allow Boris to spike nativist guns (if that is, you believe that relying on ever increasing numbers of migrant workers stokes populism). Best of all, pro-natalism could allow him to forge a connection with his Leave heartlands and further undermine Labour’s territorial claims there.

In his book, The Road to Somewhere, David Goodhart argued that Somewhere women had been ignored by a highly-educated elite of Anywhere careerists, who obsess about things like boardroom representation.

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Somewheres, according to data from the British Social Attitudes Survey, are much keener on a work-life balance and feel pressured into going back to work after having a baby. “Thanks,” wrote Goodhart, “to those Anywhere assumptions, Britain has evolved into one of the most family-unfriendly tax and benefit regimes in the developed world.”

It may even be possible to mobilise the cultural arguments for bigger families. There’s strong evidence to show that children do better with siblings and, other things being equal, are less prone to mental health issues and obesity.

This is not an easy sell, because it can annoy the parents of only children (a segment of the parenting public which has now climbed to almost half of all couples), but that doesn’t invalidate the argument. It may be true that the growth in what the media calls “snowflake culture” owes something to the rapid rise of the singleton whose rough edges are not worn down by abrasive contact with brothers or sisters. It’s certainly true that a future Britain — and it’s coming — where a large proportion of marriages involve an only child marrying an only child, will consolidate wealth and militate against social mobility (something especially damaging to the prospects of children from bigger BAME families).

So go on Boris, do it for Britain. Do it for those patriotic hard-working northern Leave voters who want to see that you’re really serious about change. Roll out free IVF for the youngsters of tomorrow. Give young people a chance to start the sort of families their parents enjoyed. The cost will be dwarfed by the billions you’re about to spend on social care for the elderly — and in future decades we’ll all be reaping the rewards.