Lauren Rosenberg faced the heartbreaking reality of her babies being born too early to survive, and she struggled to hold herself together.

In November 2019, she was moved from Greenwich Hospital to Yale New Haven Hospital due to a serious pregnancy complication.

“My liver was failing. It was a very serious situation,” Rosenberg recounted.

While mourning her twins, she felt an overwhelming sense of despair. One of the doctors who helped her was an expert in fertility issues. At 40, she expressed to him: “I need a plan. This can’t be the end of my journey. I just want to be a mother.”

She was informed of a 40-60% risk of facing a dangerous complication called HELLP syndrome during another pregnancy, but was given the option of in vitro fertilization (IVF) with a gestational carrier. She was referred to the Yale Fertility Center.

She began her first round of IVF injections in January 2020.

Patients believed the high reputation of Yale guaranteed excellent care

After her life-threatening ordeal, Rosenberg was determined to choose a well-regarded clinic.

“I thought that being associated with Yale meant they would provide exceptional care for me,” she shared. “I never doubted that they wouldn’t be knowledgeable about my treatment or that they wouldn’t care about my well-being.”

However, her first egg retrieval left her in shock.

“During an egg retrieval, you find yourself in stirrups, feeling very exposed,” Rosenberg explained. “They also strap you down, which restricts your movement.”

Suddenly, she felt intense pain and her body started to convulse. She was instructed to stop moving.

“I was convulsing on the table, and I clearly remember the annoyed expression on the doctor’s face,” Rosenberg recalled. “He raised his hands and told me, ‘Stop moving or I can’t proceed with this.’”

In that moment, she chastised herself, thinking, “I need to control myself,” believing her discomfort was causing the doctor’s irritation. The nurse suggested she breathe deeply and give it another try.

“It happened again, and I told them, ‘I’m feeling everything.’”

Eventually, she received more medication, but it failed to relieve her pain.

“I asked the nurse, ‘That was extremely painful. Is that typical?’” Rosenberg remembered. “And she responded something like, ‘It’s not like you’re getting a manicure.’”

Due to the lack of urgency or empathy from the medical staff, Rosenberg started to wonder if her pain was part of the process.

“Perhaps this is just how bad it gets. Maybe this is what I must endure to become a mother,” she recalled thinking. “Honestly, I was prepared to go through anything for motherhood.”

She was taken aback by how different her experience was from others she had talked to beforehand. Generally viewing herself as resilient, after the procedure, she felt embarrassed about her struggle with the pain.

“I was almost ashamed to admit how painful it was,” Rosenberg shared.

‘It was 45 minutes of living hell and just absolute torture’

For Angela Cortese, the issues started even before her first retrieval.

In 2017, she and her partner began exploring fertility options. During her initial consultations, doctors informed her that she had only one fallopian tube and a “unicorn uterus,” indicating that her right ovary was not positioned normally.

She underwent her first egg retrieval at Yale Fertility Center in December 2019, with plans for IVF where her partner would carry the child.

In the lead-up to the procedure, Cortese faced numerous awkward encounters where medical staff struggled to locate her right ovary.

“They kept saying, ‘You can stop whenever you like,’ but that’s not true, because you have limited time during your appointment. You want to know how your follicles are progressing,” Cortese reflected.

On the day of her egg retrieval, everything appeared normal at first. However, during the procedure, Cortese described it as “45 minutes of living hell and just absolute torture.”

Despite the discomfort, the female nurses tried to keep Cortese calm as she struggled on the table. Cortese recalled, “But it’s the male doctor at the end saying, ‘Well, do you think you could hold on a little bit longer?’”

She was informed that she had reached the maximum dosage of medication but the doctor insisted he could retrieve three more follicles. He urged her to push through for better odds of success.

Aware during the entire process, Cortese was never offered a break and felt like a burden, enduring the pain without complaint.

“I was just trying to survive,” Cortese explained. “I had to convince my body to endure the pain knowing that if I couldn’t, I’d endanger my family’s future. It was a struggle between immense pain and the guilt of feeling it was my fault.”

When the procedure concluded, the pain remained, causing her to worry that her suffering had affected the success of the retrieval. Although the doctor prescribed pain relievers, he didn’t follow up to see how she was doing.

Cortese’s initial egg retrieval led to her wife’s pregnancy, but sadly that ended in a miscarriage, prompting them to decide on a second retrieval.

While preparing for the second retrieval, Cortese finally processed the intense emotions linked to her first experience.

“One of the nurses eventually said, ‘Yeah, that wasn’t a normal amount of pain you were feeling,’” Cortese shared. “But they would find ways to justify my experience.”

‘I was literally crying. There were tears coming out.’

Rosenberg’s first egg retrieval produced the embryo that resulted in her twin boys. However, it was the only viable embryo from that procedure. Concerned about the potential success rate of transfers, she opted for a second retrieval despite fearing the pain it involved.

During her second retrieval in June 2020, she was sedated but found herself alone due to COVID protocols, which heightened her feelings of isolation and anxiety. This time, while she experienced no pain during the procedure, she was left with intense pain afterward and had to be taken out in a wheelchair.

For her third retrieval in August 2020, she was groggy and often lost consciousness.

After these procedures, Rosenberg felt unheard when she tried to express her pain to the doctors.

“I think my desperation for a family allowed me to withstand it,” Rosenberg mentioned. “As I lay there with the needle going in and out, I was literally crying, tears streaming down my face. The dismissal of my experience speaks volumes.”

Cortese’s second retrieval in June 2020 was also deeply traumatic. Being without her wife during the procedure heightened her anxiety.

“There was no acknowledgment of my trauma,” Cortese reflected. “It was simply a matter of ‘suck it up’ or the procedure wouldn’t happen.”

This time, she was sedated; however, she woke up midway through as medical staff alerted her that she was in distress and had reached the limit for pain medication. After realizing she was awake, they ceased the procedure without retrieving any eggs from both ovaries.

No follow-up care occurred after the procedure. Instead, she only received pretzels and ginger ale before being told she could leave once she ate.

As her wife arrived to pick her up, a nurse informed Cortese of complications during the procedure, stating, “They went through your bladder, so you might experience some bleeding.” This nurse had not been present during the actual procedure and could not offer further insights.

Cortese continued to feel like she was imposing on the doctor, taking up too much of their time.

The retrieval was successful, but due to financial constraints, she opted for a third retrieval immediately—she couldn’t afford to wait in case this pregnancy ended in another miscarriage.

At this stage, she was frustrated with the substandard care she received at the clinic. She informed the team that they could proceed with an abdominal procedure to circumvent the ongoing trouble of locating her right ovary. “I just wanted to stop experiencing this. It’s clear my body can’t take it. Just get them out,” Cortese expressed.

As she was taken into the procedure room, she suffered a severe panic attack.

“I hadn’t truly grasped the extent of the damage that the first two retrievals had caused,” Cortese shared.

Her second retrieval led to the birth of her son.

Unwelcome news arrives by mail

A letter arrived in December 2021, sent to each woman, stating that Yale had “learned of an event that may have impacted (their) care.”

The center revealed that a nurse at Yale Fertility Center had been substituting fentanyl with saline in “some medication vials,” which “may have” resulted in patients receiving saline instead of the intended narcotic during their procedures.

“Although there’s no evidence suggesting that this incident has adversely affected your health or the results of your care,” the letter explained. “We feel you have the right to be informed.”

In that moment, everything clicked. The convulsions, sweats, tears; it was all real.

The pain they felt could have been prevented if the medical staff had simply believed the women in stirrups, crying out in agony.

Research indicates that healthcare providers are less likely to take women’s pain seriously

Certain behavioral traits considered to be “female,” such as being vulnerable, dramatic, or emotional, may lead medical providers to think women have a lower tolerance for pain and exaggerate their conditions. As a result, healthcare providers are more inclined to suggest psychological assessments for women who report pain, while they often readily prescribe pain relief medications to men.

A 2019 study revealed that one in five women felt their symptoms were dismissed by healthcare professionals, and 17 percent thought they were treated differently due to their gender—compared to just 6 percent of men.

During the retrievals, Cortese wished desperately for someone to recognize her suffering and help alleviate it. Her trust in doctors has since vanished. Despite finding a supportive experience at a different fertility clinic after leaving Yale, she remains apprehensive.

“You never imagine that doctors would overlook such matters or fail to address them,” she remarked. “I never suspected a nurse would be stealing fentanyl and exposing me to so much pain.”

Rosenberg, who sought treatment at Yale after a near-death experience, felt both relieved and horrified upon learning she “wasn’t losing her mind.”

“The moment I read the letter, I knew it was about me,” she said. “It felt like a betrayal.”

The letter included a contact number for inquiries, but Rosenberg was too angry to make the call herself. Her husband ended up calling, but no one picked up since the clinic had sent out the letters just before winter recess. They finally received a response a week later. When her husband requested information on which fentanyl vials Rosenberg had been given, he was dismayed to hear that they “don’t keep track of those.”

“I just felt so furious that there were no protocols in place to safeguard their patients,” Rosenberg recalled.

Her confidence in medical professionals has significantly declined since this incident, impacting her experiences even in settings unrelated to reproductive or maternal health.

Now, she monitors her own medical care more closely, verifying prescriptions with photos of the medication online to ensure the pharmacy dispenses what she needs.

“I found myself in a situation where I had to plead for medication, pleading to not endure unbearable pain,” Rosenberg stated. “Now, I approach every appointment wondering if I will be listened to.”

While she is thankful for her twin boys, she is frustrated that the pain she endured casts a shadow over her experience. “It’s disheartening to realize that I could have had them without all that suffering,” she lamented.

Lawsuit against Yale Fertility Center for drug diversion and medical negligence

Later reports revealed that Donna Monitcone, a former nurse tasked with overseeing controlled substances at the Yale Fertility Center, had been pilfering at least 75 percent of the fentanyl kept at the clinic and replacing those vials with saline over a span of no less than five months. In November 2020, she brought in about 175 vials of stolen fentanyl, discarding them in waste containers at the REI clinic.

Monitcone, who battled opioid addiction, pleaded guilty to a federal charge for tampering with a consumer product and relinquished her nursing license in October 2021. She had been self-injecting the fentanyl both at work and at home. In October 2022, Yale reached a $308,250 settlement with the Department of Justice to address accusations of violating the Controlled Substances Act.

“Yale deeply regrets the distress faced by some of its patients due to a former nurse at the Yale Fertility Center diverting pain management medications intended for patients,” Yale University stated. “Upon discovering the nurse’s misconduct, she was removed, law enforcement was alerted, and patients potentially affected were notified. The Center has reviewed and significantly overhauled its procedures to enhance oversight of pain management and controlled substances.”

Together with Rosenberg and Cortese, numerous patients who suffered extreme pain during fertility treatments are suing Yale for drug diversion and medical negligence.

“This represents a profound level of neglect and betrayal on Yale University’s part,” attorney Josh Koskoff stated in a press release in 2023.

The women believe this could have been easily prevented. There were warnings along the way—yet no one listened.