It all looks so good, it's hard to know where to start

If you can't find something in this story to be cranky about, even if only the hot-button misuse of "implanted," I will be forced to conclude you're simply not trying:

Mom, you're too old to have twins!
Giving birth at 60 sets U.S. record, but newborns' sis, 29, thinks it's a bad idea

Frieda Birnbaum's new bouncing baby boys may be bundles of joy for the 60-year-old mom who gave birth yesterday, but they've got her grownup children hopping mad.

The New Jersey mom earned a place in the record books and the debate over fertility treatment by becoming the oldest American woman to give birth to twins.  [...]

New dad Ken, 63, a grandfatherly type with receding white hair, was thrilled. "He sort of pushed me in this direction," said his wife.

But her two grown kids — Jason, 33, and Alana, 29 — are appalled.

"My mother is too old, for health reasons and for lifestyle," Alana said last night. "I don't think she's thinking about the future — being 80 or 90 and having a kid." She said her brother is worried they will end up taking care of the babies. "He's against it even more than I am," she said.  [...]

Married for 38 years, the Birnbaums had their first two kids when they were relatively young.

But when Frieda was in her mid-50s, she decided she wanted another baby and underwent in vitro fertilization to conceive her son Ari, who is now almost 7. It was Ari's arrival that convinced Birnbaum that she should have at least one more child.  [...]

They considered adopting, but had heard too many horror stories.  [...]

Over the next few years, they went through two IVF cycles — in which eggs are fertilized with sperm in a petri dish and implanted in the womb — at a U.S. clinic.

The new mom played coy on whether she used her own eggs, which had been frozen years before, or eggs from a donor.  [...]

At any rate, the first two procedures failed.

"Now her age was getting to the point where [the American clinics] didn't accept her any longer," her husband said.

So the couple decided to go to a clinic in South Africa that specialized in treating older women. This time, Birnbaum beat the odds and got pregnant.

The pregnancy was high-risk by any definition. Older mothers are more likely to have complications, and Birnbaum was the oldest ever treated at Hackensack.

But the gestation and birth went smoothly, and Birnbaum said her obstetrician, Dr. Abdulla Al-Khan, thinks she's an inspiration for other soon-to-be seniors.

Fertility news niblets

Stop the presses!  Desperate women make risky choices.  A British research team has found a significant association between an IVF patient's mood and her willingness to take risks.  "Women estimated their chance of having a multiple pregnancy as lower when they were experiencing more negative moods," said the lead researcher.  In other words, women who were pessimistic about their chance of a multiple pregnancy (or indeed any pregnancy at all) tended to do what the study called "engage in greater risk-taking behavior," i.e., opting to transfer more embryos.  Yeah, uh, doctor?  Next time you have a question like that, don't spend millions in grant money.  Just ask a veteran of multiple failed cycles.  She'd have told you that for free.

PGD reduces older women's chances of pregnancy.  A multicenter, randomized, double-blind, controlled trial has found that PGD sucks.  Okay, the wording of the study itself is a bit more scholarly — "Preimplantation genetic screening did not increase but instead significantly reduced the rates of ongoing pregnancies and live births after IVF in women of advanced maternal age" — but it boils down to the same conclusion.  The subjects of the study, 408 women aged 35 to 41, had had no previous failed IVF cycles and agreed to a program of three cycles.  Patients in the PGD group had  "the two chromosomally normal embryos with the best morphologic features" transferred on day 4; known abnormals were not transferred.  An ongoing pregnancy rate of 37% was achieved in the control group; for the PGD patients, it was only 25%.  The cause of PGD's detrimental effect on the pregnancy rate in older women is unknown, and the jury is still out as to PGD's efficacy when used for reasons outside advanced maternal age, such as for recurrent pregnancy loss or repeated IVF failure.  "No other medical procedure with such profound medical and ethical consequences has been so poorly studied," said the director of the Genetics and Public Policy Center at Johns Hopkins.

Those presses?  Yeah, stop 'em again.  Women still desperate.  Women who used complementary or alternative therapies [CAT] such as reflexology, acupuncture, and nutritional supplements to improve their fertility had a 20% lower pregnancy success rate over a 12-month period.  The study, initially intended to examine patients' reasons for undergoing CATs, found that women who did seek out these treatments were more distressed and emotionally affected by infertility than women who did not.  It also found the aforementioned lower pregnancy rate — intriguing, but in no way conclusive, since the design of the study did not distinguish between therapies, especially between those that have some documented value behind them, such as acupuncture, and those that do not, such as regular infusions of vodka and Cheez-Its.  (Shut up.  I can call those nutritional supplements if I want.)  The lead researcher is aware of the study's limitations: "Our findings do not allow us to make a direct causal link between CAT use and pregnancy rate.  It may be that complementary therapies diminish the effectiveness of medical interventions.  Or it may simply be that persistent treatment failure encourages women to seek out CATs because they are more willing to try anything to get pregnant."

Immature egg retrieved, matured in vitro, frozen, thawed, fertilized, transferred, implanted.  Et voilà!  Practically instant baby!  The first baby has been born from a frozen, lab-matured egg.  The baby is doing well, with no apparent signs of freezer burn, and another three women are currently pregnant via the same method.  The most exciting application for this new technique, researchers say, is for women diagnosed with cancer, whose treatment might make them sterile; women's eggs can be retrieved without hormonal stimulation before their cancer therapy begins and frozen for later use.  Eggs have been retrieved and subsequently matured from girls as young as age five, a breakthrough that could allow survivors of childhood cancer to use their own eggs if they later wish to have children.

Infertile?  Hey, maybe your bully of a sister-in-law is to blame.  A British biologist has suggested that the patterns of the impressively ugly naked mole rat may shed light on stress-related infertility in humans.  Although mole rats live in colonies numbering between 100 and 300 animals, only one female, the "queen," reproduces.  "The queen exerts her dominance over the colony by literally pushing the other members of the colony around" — causing stress to the other animals by shoving them.  This bullying suppresses the other animals' fertility, causing the sperm count of the males to decline and halting ovulation in the colony's other females.  "By making careful comparisons with model species like mole-rats, we may be able to tease apart the relative contribution of genes, environment, upbringing and culture to complex social behavior in our own species," the researcher speculated.  Now if only we could get those naked mole rats to just relax.

Hey, those presses we were talking about?  You didn't by any chance start them again, did you?  Yes?  Oh.  Huh.  Well...Patient stress during ovarian stimulation is greater than appreciated by doctors, who are apparently blind, deaf, totally devoid of any powers of observation, human compassion.  Investigators have found that clinicians "underestimate the burden [the daily regimen of injections] places on patients and the high levels of stress associated."  Further, doctors "underestimated how many of the women believed they had made mistakes with dosages, taken the wrong medications and/or used incorrect self-injection techniques."  That the press release for this study comes from Organon, makers of the Follistim pen, which "provides women with a discreet, convenient method to self-administer FSH with ease and confidence," and Ganirelix (formerly Antagon), which eliminates the need for a long period of downregulation prior to ovarian stimulation, is, I am certain, no more than incredible coincidence.

Thanks to urszula for the PGD link.

I'll just be a minute

I'm writing about our consultation earlier this week.  I want to get it just right so it's taking a while.  While you wait, please enjoy these tidbits of pregnancy- and fertility-related news:

1. Eat, eat — it's good for you.
2. Thousands of human eggs may be missing.
3. "Customer service, tech support...these days we outsource everything to India. So why not pregnancy?"

Deeeear kindly social worker

Hey, I owe you a story, don't I?  About our meeting with the social worker at the new clinic?  Yes.  But first a few links you might find intriguing:

• Lesbian sues crappy doctors for being totally crappy and crappily refusing to perform an IUI due to their religious beliefs.  Guadalupe Benitez, who brought the suit in 2001, charges that the doctors violated California's anti-discrimination law, claiming she was turned down due to her sexual orientation.  (The doctors say they refused to treat her because she's single.  Yes, that's muuuuuch better, Doctors Crappy and Also-Crappy, especially since in California lesbians can't marry.)  Benitez is now a mother of three, having sought treatment with other, not-crappy doctors.
• The Duggars now number 19, and say they hope for more.  Michelle Duggar has now been pregnant for at least 153 months of her life (not counting the miscarriage that caused her to cast away her pill pack as if it contained Satan's own abortifacients).  I know women who've been trying that long to have one.
• Martha Stewart's daughter Alexis, age 41, discusses her infertility in the current issue of People.  "My mom's just desperate. She has wanted grandchildren forever. Forever! She's always like, 'For my birthday, I would like you to be pregnant.' And I'm like, 'Me too!"'
• Baby Einsteins: Not So Smart After All.  Well, float me a tampon, who knew?

But enough about not-me.  I've been wanting to tell you about our talk with the social worker, which had been the source of a great deal of anticipatory anxiety for me.  I spent a lot of time imagining it: I'd be sitting there with all the wrong answers blithely coming out of my mouth, not even realizing they were wrong, while she sat there with a clipboard, held, of course, at a secretive angle, writing, "Patient bugfuck crazy.  Decline treatment, notify authorities, present as shocking case study at next ASRM conference."

(I guess I couldn't blame her if she wrote, "Patient has exaggerated sense of own importance," huh?)

My fears were entirely unfounded, which in the reproductive sphere is unusual for me.  As it turned out, the meeting's main purpose was for the social worker to discuss their donor pool — how the clinic recruits donors, who the donors are, and how they're screened prior to acceptance.  I'll talk about this in greater detail later, because I also want to write about what's important to Paul and me as we consider donors, but for now I will simply say that I approve of their stringent policy that all potential donors must possess two ovaries and an ass for that all-important hCG shot.

We also talked about the question of disclosure.  It is commonly accepted that if anyone is told, the child should be told as well.  And apparently the order of things is important: She suggested very strongly that if we choose to tell anyone, we need to tell the child himself before telling Charlie, to minimize the potential for sibling conflict.  That seemed like sound advice.  Can you imagine it otherwise?  "You're stupid."  "Oh, yeah?  Well, you're a big doodoo."  "Well, you're a big doodoo who likes to eat doodoo."  "Well, you're the greatly desired much loved hard-won product of an anonymous egg donation!"  "[Sobbing]  Moooooom!"

We talked about how to go about telling a child of donor gametes how he came to be.  The social worker reassured us that although there's not much in the way of guidance available now, since the first wave of donor egg children are only 12 or so, by the time we're facing the more complicated questions, those children will have discussed their experiences in print (and certainly in pixels), providing a useful blueprint for our own approach.  Thank you in advance, designer genetic cybersupertechnochildren!  Now get blogging.

"But then this is something you can discuss in the simplest, most everyday way," she finished.  "It doesn't have to be a surprising revelation.  You'll have pictures of your embryos, and if you show those to your child along with all his other baby photos, he can know from the earliest age.  You already do that with Charlie, I'm sure."  Since this blog is the closest thing I've compiled to a baby book, the answer to that is a disbelieving cackle and a loud, rude no, but of course she's right.  So here goes: Charlie, look, here's a picture of you with the one that, uh, went to live on a farm so it could romp in the sun-kissed fields of everlasting daisies.

"You're a writer," said the social worker to Paul as we gathered our things to leave.  He confirmed that he is, and said that he's a science journalist.  I expected her to ask what his beat is — computers, privacy, and technology — or even to ask about my work, but no.  Instead, her face lit up and she said, "Oh!  That's wonderful!  Then you should consider documenting your whole infertility experience."

So, Paul, get on that, would you?  I wouldn't want the last four years of our lives to go completely unrecorded.

I will also be boycotting my own advertisers forthwith

Several of you have pointed me towards the story of an Australian woman, now a mother of twins via IVF, who is suing her doctor for transferring two embryos when she asked for only one, and asked me what I think.  Given how well such essays of mine have gone over in the past, I am forced to conclude that you enjoy watching me expose myself as the judgmental ass I can occasionally be.

Well, who am I to say no to such an irresistible invitation?

Here's what happened — just the facts, which are undisputed.  The woman, whose name has not been published, had been pursuing parenthood with her female partner for some time.  After three unsuccessful IUIs, they turned to IVF.  According to their testimony, they told their doctor they only wanted one child.  Just before the mother was sedated for embryo transfer, she asked that only one be transferred.  The doctor warned her that even with a single-embryo transfer, there was still the risk of conceiving twins.  "Do not even joke about it," she said.  "I only want one."

Hilarity ensued when the doctor — Oops! Fuck! — transferred two.

The doctor doesn't dispute the couple's testimony and admits to the mistake, which occurred when he failed to communicate the couple's wishes to the embryologist who loaded the catheter.  He is being sued for almost A$400,000 — the couple's estimated cost to raise one of their daughters to the age of 21.

Now, having opinions is a dangerous hobby, not for the faint of keyboard.  Normally when I post my reactions to news item pertaining to fertility treatment, I manage to offend, oh, let's say about a third of you.  This time I'm shooting for a healthy 85, maybe 90%, somewhere in that neighborhood.  You might want to stand back while I do my thing, because almost everything about this case makes me fucking crazy.

First off, do you know what?  I'd sue, too, if I woke up pregnant with dizygotic twins after explicitly asking that only a single embryo be transferred.  In my case, I'd be suing not for the cost of raising a second child but rather the cost of a fetal reduction, because, uh, I wasn't kidding, Doctor: I really only want one.  So I'm with them as far as that goes, whether their reason for requesting a single-embryo transfer was related to matters of health, as my own would be, or of convenience.

However, I am uncomfortable expressing any understanding for the parents' position because, lordy, do they seem like a couple of assholes.  They claim that the mother who carried the twins has — get this — lost some of her ability to love — wait, lemme look and see how many twin moms are nodding in rueful agreement — and that they can no longer function as a couple because their everyday lives have been taken over by the day-to-day demands of child-rearing, a fate from which I suppose we carefree parents of singletons are exempt.  They claim they were traumatized by the act of purchasing a double stroller, for God's sake.  How can I not think they're hateful?

And yet.  I've seen the suggestion that if they'd really only wanted one — see above, Doctor, I mean it — they'd have reduced.  Or they'd have placed one of their daughters with an adoptive family (a path the women considered but rejected as being unfair to both children).  Or they'd have adopted a child themselves, that being the only way to be absolutely certain of having a singleton.  I read these statements and it makes me want to defend them again, because what a shitty, shitty choice to have to make, all because someone else was careless.

But that little surge of compassion doesn't last long, because I keep coming back to the inevitable: Someday these girls, the daughters, are going to know that their parents were so offended by the mistake of their very existence that they felt someone should be made to pay.  That their parents were eager to face the court and say not "We are requesting that the doctor face professional censure," but "Here's what we're owed for experiencing the terrible disappointment of becoming our daughter's mother."  See?  Assholes.

And then I have to feel sickened and sorry that this case will surely be used as ammunition by those who would bar same-sex couples from trying to become parents.  That the case involves a lesbian couple is, to my mind, irrelevant.  (All that fact proves is that lesbians can be assholes, too.  Those of us concerned with establishing real equality must gracefully concede that we have, after all, gained some ground.)

So when I think about this case, I basically end up het up and pissed off at everyone involved: the doctor who was so unthinkably careless; the couple who are so grossly unsympathetic; the people who say — yes, really — that the couple should shut up and be grateful they got pregnant at all; and the small-minded bigots who would use this as proof that gay people are unfit to be parents.  I'm even pissed off at myself, if you want to know the truth, for being so goddamned judgmental.

I guess that means I have to count myself in that lucky 90%.  Will the tiny unoffended remainder, you gentle 10-to-15-ers, please turn off the lights when you leave?  As irritated as I am, I may never read this blog again.

Et tu, TiVo?

Oprah's gotten it wrong before — bad wrong, quite wrong, really, really wrong — so it was with great trepidation that I set my DVR to record Tuesday's show.  I halfway expected the TiVo to tell me, "I'm sorry, Julie, I'm afraid I can't do that," and then vengefully fill its hard drive with back to back episodes of Deal or No Deal.  And then, since I simply can't have 18 pounds of hyperintelligent plastic trying to kill me like that, I'd have to unplug it, and then some other stuff would happen with big flying monoliths and whatnot, and I'd hurtle unchecked through time and space, and some other stuff would happen — I'd fast-forward through this part if I hadn't already disconnected the TiVo, but you're my witness: it was him or me — and then I'd be all old and wrinkly, and then I would mysteriously become a fetus, orbiting the earth, bathed in light, mellowing out to Also sprach Zarathustra.  Or maybe watching Oprah.  (I've kind of lost control of this metaphor.)

But, yes, I did watch Oprah, because she was doing a show on infertility.  Since her last foray was so disappointing, I fully expected this one to be just as bad: a carnival of finger-wagging.  A festival of sanctimony.  A 44-minute-long make-your-peace-a-ganza.  A veritable let-go-and-let-God-a-go-go.  (I've kind of lost control of this one, too.)

Anyway, you know what?  It...wasn't...all...that...bad.

Wait, wait, this is even worse.  It was almost...kind of...good?

Great.  Now y'all are going to try to kill me, too, just like my treacherous DVR.

I began my viewing with great trepidation, especially since Oprah opened the hour by promising to reveal "why they will stop at nothing to have a baby," and asking her viewers in an ominous voiceover, "How far would you go?"  This didn't bode well, especially when she revealed that the answer for one couple, Jennifer and Kendall, was "Innnndiaaaa," in a tone one might normally reserve for "halfway up the ass of Satan himself."

Lisa Ling, as it turned out, would travel there with Jennifer — to India, I mean, not the Devil's Duodenum, which is, I believe, a breathtaking rock formation somewhere in the American desert — to report on one clinic's surrogacy program, where poor Indian women carry babies for women from the U.S. and elsewhere.  And to witness, according to Oprah, "her...dessssperate...pursuit of motherhood."  (At this point I decided to count how many times "desperate" was used during the broadcast.  I can call myself desperate, but you, Ms. Winfrey, may not.  That's one.)  And to figure out "why Jennifer and Kendall chose a developing country like this" — wrinkled nose from Lisa Ling, as if assaulted by the unholy vapors of Beelzebub's bunghole even within the soothing beige confines of Oprah's stateside studio — "to try and have a child of their own."

So this was not, in my opinion, beginning well.

But it got better fast.  Jennifer, age 34, told us a bit about their struggles thus far.  She and Kendall have been married for five years and trying to conceive for three.  "On all the infertility procedures over the three years," she estimated, "we've probably spent about $25 or 30 thousand — basically, everything we had saved up."  (Hearing this I tried not to compare the total unfavorably to my own tab at Schraft's, or to calculate the cost of the cycles endured by my friends inside the computer, because however you look at it, Jesus, that's a lot of money.)  "How does it feel not to be able to get pregnant?" Oprah asked.  To her credit, Jennifer did not roll her eyes and tell her it was a sunny stroll down motherfucking Fifth at the goddamned Easter Parade — how does Oprah think it feels?  No, she was sincere, and said it exactly right.  She talked about having believed that she could do anything she put her mind to, that if she put in enough effort and time and heart, she would eventually be successful.  Infertility, she said, gives the lie to that belief.  Simply, "it's the worst kind of failure."

So as soon as she started to talk, I knew I liked Jennifer.  I liked her even more when she ignored Oprah's inevitable "Why didn't you adopt?"

Unable to afford surrogacy in the U.S. — which can run up to $70 to 80 thousand, according to Lisa Ling, whose numbers I cannot vouch for — Jennifer and Kendall turned to a program in India, where "healthy embryos could be implaaaanted into a surrogate."  (Here I paused the recording to titter, imagining the heads of countless infertiles simultaneously exploding at Oprah's clumsy choice of words.  One.)

The program they chose was Dr. Nayna Patel's Akanksha Infertility Clinic, which was profiled in Marie Claire a few months ago.  Shots of Jennifer and Lisa's arrival in the small city of Anand were heavy on the shantytown poverty, editorial cinematography if ever I saw it, with Dr. Patel explaining that Indian women choose to become surrogates to provide better lives for their children.  Seeing the footage, I was moved, and could only hope they'd succeed.  (Then Lisa threw out another "implanted," so I was back to being amused.  Two.  And not a moment later, again!  Great Lucifer's vent, that's three.)

Amid all the abject poverty, Lisa explained that the surrogates stay at the clinic after transfer — get it, Lisa?  Transfer? — at least until a positive pregnancy test.  This is a big investment, she pointed out, and the stakes are high, not only for the foreigners who hope to have a baby, but for the surrogates, whose hopes for improving the lives of their own families hang on whether they're successful.  With the total cost of a surrogate cycle at Patel's clinic running approximately $12,000, the surrogates themselves make between $3,500 and $6,000, an amount it would take a lifetime for these women to amass otherwise.

Then Oprah asked whether this constitutes exploitation.  It's the most important question she would ask all day, one Lisa would later repeat.  Jennifer's answer spoke volumes.  She pointed out that the critics who'd charge exploitation haven't walked in her shoes — unable to have children — or the shoes of her Indian surrogate — unable to pay for her children to be educated, or to provide them a decent home — and therefore shouldn't judge.  "We are able to give each other a life that neither of us could achieve on our own."  Lisa added that couples from other countries commonly employ surrogates in the U.S., and claimed that no one says that American women are being exploited.  (This is, of course, not necessarily so, but that is the subject for another day, and thousands more cranial explosions.)

And then Oprah misused "implanted" again.  Four.

But back to the question of exploitation.  I found that my earlier inclination — how could it not be? — was not an easy position to maintain when watching Jennifer's emotions as she described receiving news of the positive pregnancy test.  Her husband was just as visibly moved.  And when I saw Jennifer present for her surrogate's first ultrasound, and watched her hold up the cell phone so that her husband back in California could hear the embryonic heartbeat?  Well, in the moment it was easy to agree with Jennifer's stance on the deal Dr. Patel has brokered, which benefits two families enormously: "I don't see what's wrong with that."

Even more incredibly, so did Oprah.  In her habitual holy tone.  Right before she cut to commercial.

But the issue isn't nearly as clear-cut as that, and I confess I was pleasantly surprised that their coverage acknowledged it.  In the final part of the report, Lisa visited a home for surrogates provided by Dr. Patel.  Many surrogates stay in seclusion during their pregnancies because of the enormous stigma attached to surrogacy.  Lisa asked the women whether they miss their homes during their long absence.  Many of the women cried because they miss their own young children.  They worry about surrendering the child after the birth, and the sense of loss they may feel: "It is [the parents'] choice to remember us or not but we will be remembering the child to the end of our life."  And they are well aware that their decision to carry another woman's baby could have enormous social consequences, so they plan their stories carefully: "If someone sees them pregnant, they'll say it's their own child."  Upon returning to their villages without a child after the birth, they'll say the baby died.

A sobering note, and one they chose not to end on.  After this, the focus swung again, back to the positive changes in the surrogates' lives made possible by the fees they collect.  Lisa visited one former surrogate in the new house she and her husband have built, an ugly concrete edifice that seems like a palace next to the rickety tarp-roofed shacks that surround it.  And then a cut back to Jennifer and Kendall, whose surrogate was 10 weeks at taping, and then the segment ended.

Despite my wanting to grab Oprah by her shoulders and give her a good firm shake, and despite how vapid Lisa sounded when she described couples like Jennifer and Kendall as "cultural ambassadors" instead of "people who only want what the rest of us get to have easily," and despite the repeated disgusting jokes about how the 4'6" surrogate would surely need a C-section to deliver the child of 6'5" Kendall, because, people, it's surgery, and we don't take that shit lightly, okay?...I thought it...wasn't...that bad.  I appreciated the window into the surrogates' lives; and I really related to Jennifer, enough to question my own convictions; and I was glad for the discussion of the ethics of the situation, as far as it went.

Frankly, I'm surprised.  I was...not overly offended..., when I'd expected to be enraged, particularly since I started Lupron this morning.  Lupron, as you'll know if you watched the remainder of the broadcast with Alexis Stewart, is a drug given during IVF cycles "to make sure you don't develop endometriosis."  Wait, what?  You didn't know that?  You didn't know that's what it's used for in IVF?  You've done umpteen cycles yourself and you never heard that?

Well, in that case, come back tomorrow morning and I'll clue you in on what else Stewart had to say.  That is, if my TiVo doesn't kill me in my sleep.

Final score: "desperate" 4, "implant" 4, Oprah 0, Alexis kind of a lot

So after our long journey out of the muddy hole of Satan, I found myself safely back in Oprah's studio being introduced to Alexis Stewart.  "She's 42, she's single, and desperately" — that's two — "also wants a child of her own."  Stewart, we'd already been told, spends $28,000 a month trying to have a baby.

It's the first thing Oprah said at the very top of the broadcast, and I think it was supposed to shock us.  But to a repeat IVFer, a fellow poor responder, it's truly not so shocking.  I've checked the numbers myself.  Here is what I came up with, based on my own experience:

• Medication, maximum dose for a poor responder from a discount mail order pharmacy: $6,000, plus or minus
• IVF, including monitoring, retrieval, anesthesia, fresh transfer, and hospital fees (Cornell as of 2004): $9,619
• Assisted hatching (Cornell): $1,500
• ICSI (Cornell): $2,500
• PGD (Minnesota clinic): $5,000
• Donor sperm (half-assed Googling): $200-500

...for a total of something upwards of $25,000.  Assuming that Alexis, daughter of media mogul Martha Stewart, goes to a clinic even slightly more expensive than Cornell, it is not at all difficult to believe that a single cycle could cost so much.  So, Oprah, I'm not shocked yet.

Oh.  Wait.  I'm supposed to be shocked that she does it, given the cost, and not that it costs so much?

Well.  Er.  How embarrassing.  Because I'm not.  In fact, the only thing that really shocks me is that I...kind of...almost...well, I liked Alexis Stewart, despite her giant diamond earrings, incongruous given the previous segment, and her utterly flat affect.  (So robotic did she seem that I think my TiVo might have developed a teensy crush on her.)

She began by declaring she'd waited too long to decide she wanted children.  "The aura around the whole thing is that you can wait," she said.  "You get distracted.  We have jobs, we have other things to do, medicine seems miraculous, you can do what you want..."  She pointed out that movie stars have babies late, and charged the media with perpetuating the myth of endless fertility for older women.  "You don't hear the stories of the people who can't have babies."  Stewart thought she had time.

"But very few people can have their own baby at 45," she warned.  "They might have surrogate eggs [sic]."  I found this misuse richly amusing, as if Stewart herself had never been given the donor egg speech. ("I think they're called something like donut eggs, but I certainly wouldn't know.")  But I appreciate anyone, anywhere telling the truth about declining fertility, so I restricted myself to a kindly chuckle.

Throughout this part of the conversation, Stewart was straightforward and matter-of-fact, quite a contrast to Jennifer West's visible emotions in the earlier segment.  "I'm a very calm, steady person," she explained, "so I treat [infertility treatment] as a job.  If I get too emotional about it, I'll be unhappy all the time, or freaked out all the time.  You have to look at it whatever way you can handle."  Curiously, this made me like her more, her unapologetic focus on the goal instead of the process.  And perhaps just a little bit envious of her ability to compartmentalize.  "You're on a mission," Oprah summed.  "Correct," agreed Alexis.

Still desperate, though, Oprah hastily pointed out at 46 minutes in.  (Three.)

They talked a bit about the cost of cycling.  "I am very lucky that I can afford this," Stewart said, confirming that her mother's contributions have helped.  Since Stewart's eggs are, as she described them, "hard and crusty," her protocol involves all of the extras above: AH, ICSI, and PGD.  It was never explicitly stated how many cycles Stewart has done, although she did say she'd had three implantations (aaand that's four "implant"s) of 3-5 "eggs" each, with none of them actually implanting.  She also revealed that on her last cycle, she had no embryos available to transfer, which makes at least four cycles so far.

Alexis walked us through her drug regimen, showing the various vials and needles.  Here is where she almost lost me, describing Lupron as a drug that's given during IVF "to make sure you don't get endometriosis."  Yes, and birth control pills are given to make sure you don't get pregnant.  And those ooky progesterone suppositories are given to make sure you allow no one within twenty feet of your vagina.  Jesus gay, Alexis, don't put this shit in your body if you don't know what it's for.  But I was immediately back to loving her when Oprah asked her whether the injections were easier if you did them where you had some fat.  "Maybe," said the wraithlike Alexis.  "I don't know."

Given the cost and the slim chance of success, Oprah asked whether Stewart had considered other options — measurably less bold than she'd been with the Wests earlier, stopping far short of "Why don't you adopt?"  (Draw your own conclusions about what the relative clout of her guests has to do with that.)  Stewart said she hadn't.  "I'm doing this now."  When it's time to do something else, she might, she said, but for now she is focusing on this.  Which is a really nice way to tell some nosy talk show host to step off, if you ask me.

So even while finding her a little bit loopy, I was already kind of liking Alexis Stewart for her candor, her determination, and her willingness to talk about a subject far too many public figures avoid.  That kind-of-liking turned to full-on love when Oprah introduced her next guests, a young couple sitting in the audience.

Tracey and Jaime Hanson are about to embark on their first IVF, and have taken out a home equity loan to finance their attempt.  Tracey admitted to being concerned about all that the cycle would entail, but said she was counting on the support of her husband to see her through it.  And, Tracey continued, her doctors had told her she's young, she's healthy, she'll have no problem.

And this is where Alexis jumped in.  Being healthy has nothing to do with it, she told the audience.  And "you can be 28 and be almost at menopause."  Though I cringed for poor nervous Tracey, because it seemed Stewart was speaking directly to her, eager to dash those newbie notions most of us once held dear, Stewart's overall point is vitally important: that infertility affects people of all ages, in all walks of life, even the young and otherwise healthy.  And who else on the national stage is saying such things so candidly?

And damned if I don't like her fatless robotic ass for it.  Even if her mother is yearning "desssperately" (four) for grandchildren.

Day late, dollar short

I was all set yesterday for a nice juicy post about two timely items of interest — coffee at my elbow, mind clear and focused, preschooler off at a job interview — and then a cheerful brace of workmen arrived to destroy my bedroom.  (Leaky roof, bubbly drywall, mildewy insulation, recalcitrant insurer, bitter homeowner.)  They are in there again today, banging and swearing and, for all I know, merrily buggering each other with the Sawzall; I am hiding in Charlie's room where the sound is somewhat muffled.

So, a day late, item one.  Yesterday was Blog for Choice Day.  I have always been pro-choice, and my own experience with infertility has made me more so.  The difficulty we've had conceiving has made it necessary for us to reaffirm our decision at every turn: yes, we really want this.  It makes it so easy for me to imagine the other side, to be exactly as certain that you don't want it.  I ache for those who want it and can't have it, and I ache for those who have it and don't want it.  How could I go to such lengths to pursue the kind of family I want if I didn't also support someone else's right to do the same?

A few years ago I followed the story of a woman who'd conceived a daughter via IVF, and discovered that the baby had Down Syndrome.  She was clearly devastated by the news she and her family had received, and had made the decision to terminate the pregnancy.

The reactions surprised me, though they shouldn't have.  Just like with anything else — any issue, any group — there's no homogeneity of opinion among infertiles.  Everyone offered support, but the support they offered took varying forms.  Some simply shared her sorrow and said they were there to listen.  Some told their own stories, from "I faced the same situation and terminated my pregnancy, too" to "I have a beautiful son with Down Syndrome and our life is rich and rewarding."  And some expressed hope that she'd change her mind, going so far as to try to persuade her not to have an abortion, even offering to adopt the baby if she would carry her daughter to term.

This story has stayed with me, in part because, my God, the presumption, but also because it reminded me never to assume anything about infertiles' position on choice.  To many, many infertile people, a baby is such a longed-for gift that they can't fathom not welcoming one, whatever the circumstances.  But I can imagine otherwise.  I am still hung up on the conviction that there can be right and wrong times in our lives for children, even for infertiles, and that the only people who deserve to decide when those times are, and what they're equipped to handle, are the ones who'll live with the repercussions.  They must be honored.  We must be.

...But, you know, brave words from a woman whose Ultrascreen — a screening for Down Syndrome, trisomy 18, and congenital heart defects — is on Friday.

...

Item two that was of timely interest earlier this week: A new study suggests that caffeine during pregnancy may increase the risk of miscarriage: "The new study finds that pregnant women who consume 200 milligrams or more of caffeine a day — the amount in 10 ounces of coffee or 25 ounces of tea — may double their risk of miscarriage."

I wish I'd gotten to this earlier because if ever there were a study that needed some holes poked in it, this appears to be one.  But Catherine Price of Salon.com's Broadsheet got there first, and gave it such a poking that any lunges I might make with my own pointy stick would seem feeble indeed.  So I'll just say that my strongest reservation about the study is that there appears to be a big causation vs. correlation problem here.  Maybe, as Price and the Times article point out, the women in the study who'd sworn off coffee did so as a result of morning sickness, which is associated with healthier pregnancies to begin with.  Maybe the increased caffeine consumption went hand in hand with other health-related risks that went unanalyzed in the study; the study's lead author says that they ruled out known risk factors like maternal age and smoking, but if a woman is consuming large amounts of caffeine, which is known to be mood-altering drug, who's to say she's not also, I don't know, living on unsteamed cold cuts and raw-milk raclette, or maybe mainlining toro?  Or maybe the women who consumed more caffeine did so to contend with high levels of stress — and we all know stress contributes to miscarriage, right?

Oh.  Wait.

I haven't seen the study itself (and if anyone can lay hands on a copy to send me, I'd love to read it).  But given the reservations I already have about it based on what I've read, and on another study that seems to suggest that at lower levels — say, a cup of coffee a day — caffeine has no apparent effect on one's risk of miscarriage, I will probably peruse it with my morning latte in hand.  And that's the way I see it.

...

Oh, but no sugar in that latte, as I flunked the three-hour glucose tolerance test, as expected.  Hey, so far everything's going exactly according to plan! 

12 weeks today.

Coffee, no sugar, dollop of low-fat milt

Back to the caffeine for just a moment.  What?  Only half a cup?  They always used to like my coffee...

I spent most of yesterday morning crafting a masterly summation of the study I mentioned last week.  Then I belatedly read the link kindly provided in my comments by Sandy.  I found this to be the most piquant part:

The public understandably believed that this new study must, indeed, be important since almost no medical professionals were heard contradicting the news reports.

But, there is a reason why:

Because the study had not yet been published in the medical journal or been made available to medical professionals. Anyone who might critique the study hadn’t seen it. It was released to the media before doctors and medical professionals with paid subscriptions had even had a chance to read it!

Gosh, no wonder so many of you wrote to say you couldn't track down the article.

That post raised enough questions in my mind that I crumpled up my own masterly summation and added it to the compost with the morning's clumpy grounds.  Look, I'm not a scientist.  In fact, I am so not a scientist that I am too embarrassed to ask Paul, who is, whether I drain my iPod's battery faster by listening to it loud.  (I was not too embarrassed to ask him why radio reception is worse when it rains, and that should tell you something right there.)  So you would probably do better to read the study (PDF) yourself, talk to a real live doctor about it, and form your own conclusions.  Because at this point I'm not touching this one with a ten-foot one tablespoon scoop.

I am, however, currently enjoying my customary morning latte, but a single instead of a double.  Make of that what you will.

A tip of the portafilter to Sandy at Junkfood Science; another Sandy who pointed me there; and Jen, Cindy, Jeanette, Maureen, and PRC, who went on a helpful paper chase.

...

Yesterday I had the opportunity to ask a real live doctor myself about caffeine, but I didn't take it.  I was too busy learning how to dose myself with insulin.  ("So you take one of these teeny syringes..."  "Yeah, I think I have this part covered."  "Then you take the alcohol swab..."  "Wait, you take the what, now?")

I knew it was likely that I'd end up on insulin sooner or later, as insulin resistance tends to increase in gestational diabetics as a pregnancy advances.  I did not expect that it would be so soon, but after ten days on the standard diet, my doctor took one look at my postprandial blood glucose numbers and said, "Wow!  You failed these good," then reached for her prescription pad.  I am mildly concerned, because I know from our experience with Charlie that infant RDS, which can be exacerbated by diabetes in pregnancy, is no trivial matter.  But of all my past complications that may recur, this was the most likely, and is happily the most manageable.  So I am perfectly comfortable managing it.

That said, it was not without alarm that I read up on the kind of insulin I've been prescribed, a long-acting variety called NPH.  Now, it used to be that insulin came solely from animal sources — to be precise, cow or pig pancreas.  (What a selfless, noble animal, that medically minded pig.)  But apparently there have since been advances.  Through the use of recombinant DNA, insulin can now be synthesized to be virtually indistinguishable in effect from human insulin.  As I mentioned above, I'm no scientist, so I'm not sure exactly how this is done — genetic engineering, nanobots, or big pharma's secret shame: enormous slave colonies of leaf-cutter ants — but it turns out that the brand I was given is made using Escherichia coli.

Wait, it gets better.  What makes NPH long-acting?  Why, it's "the addition of protamine obtained from the milt or semen of river trout."

Pig juice, E. coli, and fish spunk.  Strange, all of a sudden I'm not so hungry for my mandatory mid-morning snack.

...

Being somewhat securely with child, I have posted my last at REDBOOK's Infertility Diaries.  If you know of a blogger whose story you'd like to read there, why not go on over and throw her name into the ballot box?  Thanks.  I'll buy you a cup of coffee next time I see you.  (And then lunge across the table to knock that steaming cup of certain fetal death out of your trembling hand.  God, what are you, crazy?)

Monday morning omnibus

Needles in the news

Short version: Acupuncture at embryo transfer seems to dramatically increase pregnancy and live birth rates among women undergoing IVF.

Longer, pointier version: This study contradicts a 2007 finding that women who had acupuncture were less likely to get pregnant.  The researcher who presented that finding suggested that women undergoing IVF should not be advised to have acupuncture, but stopped short of saying the acupuncture itself had harmed the patients' chances of conceiving; instead she "said she believed the stress of having to drive to and from the acupuncture sessions was more likely to have reduced pregnancy rates than the acupuncture itself." 

Yeah, I don't know quite what to say about that, either.

The current study, appearing in the British Medical Journal, examines seven trials including 1,366 women undergoing IVF.  In some of those trials, a group of patients received fake treatments so that they thought they were getting the real deal.  In other trials the control groups received no treatment at all.  Although the researchers say the placebo effect is unlikely to be in play here since the outcome measures are so objective — either you get pregnant and deliver a live baby or you don't — other researchers disagree.  "IVF may not seem to be 'placebo-prone' but it probably is," says Edzard Ernst, a professor of complementary medicine.  "If women expect it to be helpful, they are more relaxed which, in turn, would affect pregnancy rates."  ("GAAAAAAH," says Julie.)

As reported in the Telegraph, the paper itself makes short work of that objection: "The research paper said if the results were largely down to a placebo effect then there would have been increased pregnancy rates among the women who thought they were receiving real acupuncture, but were actually receiving a sham therapy, where the needles were placed at random. However, this was not the case."

The idea that acupuncture could increase your chances of pregnancy with IVF might not be new to you if you're an infertility old-timer.  A 2002 paper fondly known as "the German study" found an increased pregnancy rate among IVF patients who had acupunture before and after embryo transfer.  That was what sent me to an acupuncturist during ill-starred IVF #2, chanting, "Can't hurt, might help."  To date, that remains my most turbulent, heartbreaking cycle — dominant follicle, retrieval cancelled, Hail Mary IUI, pregnancy, miscarriage — and I'll never know exactly what effect those needles had. 

I never went back, but perhaps the only conclusion to be drawn from that is that I worried that the driving might stress me out.

...

Low, blood sugar

Diabetes is getting me down.  I'm on insulin twice a day now, long-acting in the morning and regular right at dinner, and I am still occasionally failing my postprandial testing.  Every time I get a high reading, I think, Birth defects.  Was that the 2/3 cup of whole-wheat pasta that'll do it?

I recognize this as a morbid imagining, and moreover a tardy one, since most malformations occur during the first trimester.  I know the chances, even elevated by diabetes, are still small.  But imagine I do, and certainly will, until at least 20 weeks, when my congenital anomalies scan takes place.  Because unlike other complications, this one is at least partially, at least in some small way, under my control, and I am terrified I'm handling it badly.

...

Dispatch from Davy Jones' cubby

I'm glad y'all enjoyed Charlie's pillow.  I heard nothing specific about it from his teachers, but there have been two intriguing little clues since the pillow's maiden voyage:

First, Charlie's rest period has been no more restful since the introduction of Cap'n Scurvy's Rum-Soaked Sleepy-Time Sandbag.

Second, on Friday his teacher sent home a note that said, "Can you please send an additional comfort item for Charlie to help him settle down at nap time?"

I am not one to leap to conclusions, so I'll stop short of blaming the pillow, but just to be safe I won't be sending his favorite rusty cutlass, I can tell you that right now.