How to Make a Family: The Blog

Never Mind The Menopause. There's A Tsunami of Children.

I ran across this synopsis of fun facts about reproductive stuff via the headline "6,000 Women A Day Hit Menopause" -- and believe me, that's definitely not the most entertaining tidbit in the piece by Leslie Mann on the Baltimore Sun. In fact, I'm not sure why they chose to pull that one data point from the American Congress of Obstetricians and Gynecologists' "2011Women's Health Stats and Facts" to highlight, except that the editors might think it's alarming. 

Why do we think menopause is alarming?? Tons of reasons. Don't get me started. But for the record, I don't think the absolutely natural and normal cessation of menstruation and fertility warrants headlines. If it were up to me, I'd have pulled this fact to head up the article:

"Assisted-reproductive therapy, or ART, an infertility treatment, is on the increase, catering to women with an average age of 36, and resulting in more than 600,000 babies a year."

600,000 babies a year. From ART. 

Y'all know me. An earlier sentence in the piece ("Only 12 percent of women suffer from infertility.") had me grumbling and mumbling about how 12% isn't nearly as high as the industry likes you to think and how it all depends on your definition of the terms. I'm up to here with other headlines that shriek about infertility being "on the rise", while The Roommate (a much real-er scientist than I) says 12% is indeed pretty impressive.

When I got to the paragraph about offspring and read that aloud to The Roommate, he exclaimed, "600,000?!"

Me: "Yep. Crazy, huh?"

Roomie: "Yeah! That's like, like, like a..."

Me: "A tsunami?"

Roomie: "Yeah! A tsunami of wanted children!"

And I smiled. 

And that, my friends, is how perspective adds up to everything. And, fortunately, how quickly mine can change on a good day.

 

And Always Let Your Conscience Be Your Guide

You grew up thinking all doctors were devoted altruists, right? That they go into the medical profession to devote their energy to helping people -- not to make money. Okay, maybe if you grew up in the 80's or later, not so much, but a whole lot of us had those crazy thoughts, which explains the fussing and fretting when docs became legally allowed to market their services.

You didn't know there was a time when that was illegal, huh? (You know, it kinda sucks when I can no longer refer to myself as prematurely gray...)

But yes: Prior to a 1977 U.S. Supreme Court case (Bates v State Bar of Arizona), it was illegal for certain professionals (like doctors) to advertise or market their services or fees. Ah, those were the days.

Granted, most docs were slow on the uptake of selling themselves. That might be a little proof that, indeed, most physicians consider the practice of medicine to be a privilege bound by an ethical oath. But I don't know.

Today I learned that the Association of Reproductive Managers who attend the annual ASRM gathering will be taught the secrets that Disney knows for making happy customers. 

Reproductive Managers go by a few other similar names, too -- for example, Practice Manager or even Executive Director -- but they all share in common the tasks of running the business end of medical practices. RMs are all about keeping the lights on so your fertility specialist can see during exams, and about keeping those nurses paid. 

They're also about managing the creation of more business. After all, even though some of us unlucky infertile souls spend years and years cycling in and out of the clinic doors, most of us are only there for a year or so before moving on, one way or another. And let's face it: reproductive medicine is elective medicine. (You may want to die if you can't have a baby, but you won't really meet your Maker just because you're infertile.) So no matter how many people are struggling to get pregnant, there's always going to be a need to replenish the supply of patients. Kind of hard to believe, isn't it?

Speaking of make-believe: Who better than Disney, American marketing royalty, to impart inspired techniques for bringing both a dreamily hopeful smile and a poignant tear to the faces of millions?

Personally, I'm glad RMs exist. I like the thought that physicians can go about their healing activities without having to worry about (at least on a day-to-day basis) whether the janitorial staff was paid. And now they'll come back from ASRM whistling, "When you wish upon a star..."

Peeling the Baby-Making Onion Ring

So far, I'm still mostly unshocked. Call me an irritating devil's advocate, but my position has always been and will remain that if regulations, even just trace amounts, are nowhere to be found and there's money to be made, money will be made. Ethics and morals be damned. The most surprising thing of all to me in the whole thing is that an attorney with such a prominent reputation would risk her career and color the rest of life for herself and her family... for what? But shocked that "such a thing" has occurred? No way. 

Here's my dire prediction in black-and-white: Virtually any horrendous activity that you can imagine might happen within the reproductive medicine arena has happened (with or without everyone's knowledge) or will eventually, at least once. Life is long, folks.

You can call me cynical. I'm used to it.
But there's a point that I think is missing in some of the telling of this most recent Repro Med Gone Awry story. 

I'm reading the LA Times' account that unfolds details of the surrogates' points of view in the baby-ring scam headed by Theresa Erickson. 

[The prospective surrogate] found a couple nearby, but two attempts to get pregnant failed. That made her even more determined as she searched surrogacy want ads.

"I was responding to anything and everything," she said. "That's how desperate I was."

First, here's my bias, for those who don't already know: I'm on the kids' side. That's not to imply that every case of baby-making can be or even should be viewed as though it's a triangular and adversarial arrangement. But my professional experience with families tells me it's likely some percentage of family-building activities entailing third-party A.R.T. involves folks whose motivations are skewed toward uber-self-centeredness under the guise of self-sacrifice. 

"Well, sure," I can hear most readers thinking, "isn't that the point of living -- to meet my own needs, go after what I desire and, well, win?"

I guess. Bottom line, sure. Survival of the fittest and all that. But if there's any place in the repro med arena where The Point really should be centered around the needs of that possible kid at the end of it all, it's third-party ART. 

There was a "type" of foster parent that used to give me goosebumps: The Collectors, we called them. They never seemed to "have enough" children in their home, and often, hackles would raise when they wanted more than their sponsoring agency would allow. The line we social workers had to tread was thin and tenuous with these foster parents, because the need for more housing for more abandoned, neglected, and abused kids was always growing, never shrinking. Weighing the choice of which kid to place in which home was always huge, and The Collectors, with their -- yes, I'll say it -- pathological level of need to nurture children added yet another burden to our decisions.
 
I'll say it again. Pathological level of need to nurture children. And that's a clinically polite way of putting it. These weren't people who were scamming the system and trying to make "a quick buck" through foster care. Most, in fact, were wealthy enough to support as many kids as they could cram into their six-bedroom mansionettes. Their incentive was deep inside their psyches. And they were a good representation of the shadowy difference between love and need, although they were unclear themselves on that nuance.

When I read that this particular surrogate felt "desperate" to carry another person's baby, the word pinged around my brain. I've heard it before, the sense of desperation that (mostly) women feel about getting pregnant. But here we're talking about a woman who has all the children she wants, not a woman who desperately wants to finally be a mother.
 
What IS that desperation? Third-party advocates will tell you it's the very drive that makes a great surrogate. They "love being pregnant." So maybe it's just this woman's word choice in the article that's sticking in my throat. But I don't think so. As I've ranted about plenty in the past, word choice is a big deal, a window into our minds, often revealing what we "really" think even if we're saying what others find soothing to hear.

So here's another bold opinion in writing: Women who feel "desperate" to be a surrogate should be more carefully screened. Not just to avoid the potential "oops she changed her mind" scenario, but because it's the ethical thing to do. Third-party reproductive professionals are putting their own humanity on the scale, in addition to their reputation, if they do anything other than help prospective baby-carriers assess their own psychological base regarding parenting, tease out motivations that may belie deeper issues impacting choices and behavior, and refer some on to appropriate sources of help.
 
Admittedly, I don't wallow in the world of baby-making. I get in there, do my job, and get out to live My Life (which is currently awesome, by the way.) So perhaps I'm too out of touch to know if prospective surrogates are screened and then referred on to help if needed. Maybe this point is, in fact, being taking into consideration and to heart by the people in the business. I hope so. But I bet not so much.

Sharing News That's Not Really News

Here we go again. Me, ranting. But it's been so long, I thought I owed you one. So here you go.

I like hearing about data points that help the monkeys leave the cage. And as some of you may recall with a wince, I'm not exactly pro-medicine. Not anti-medicine, either, but I do indeed believe that we hairless monkeys have bought way too hard into The Search For Magic & Hopefully Instant Cures.

For example, I dig when something like nutrition gets a hand up in the clambering for attention we call "media". I'm into the idea that the stuff the earth provides might be all we need, if we can just figure out how to make use it well (and "well" includes sustainably).
 
So on a related note, since this blog is about fertility topics, my eye was drawn today to this headline: "Antioxidants may help treat infertility" which was followed immediately by "Antioxidants can help with infertility: Study".

Wow, I thought, two headlines in a row on Carrots Vs Infertility -- must be good!
Me being me, I scanned the first piece to find the names of the researcher and the publication in which the study could be found. Along the way I ran into this additional headline: "Antioxidants of Growing Interest to Address Infertility, Erectile Dysfunction".
 
In three headlines, antioxidants went from being possibly helpful to helpful and then to merely interesting.

And in fact, there's no real news to share. It's bonus points for the study authors of "Antioxidants to enhance fertility: Role of eNOS and potential benefits", published in Pharmacological Research. Their paper is an analysis of data that's been culled by other research, the sum of which author Tori Hagen calls "equivocal" due to study size and focus. She says that while the "jury is still out," data from previous lab studies is "very robust". Says we can look forward to "enormous" potential benefits.
I'm all for telling the monkeys where the key and the lock are located. I get that it's harder to instruct them on using those tools together to open the cage door. I'm just a disappointed monkey when headlines lead me to think that I'm going to be told more than "Yep, there's the lock and there's the key."

Btw, Toronto Sun loses with their version of the "story"... 

Follow-up note, from Jessie Gruman's PreparedPatient Forum at the Center for Advancing Health:

... health care journalists are under pressure to excise the uncertainty inherent in scientific inquiry and medical practice from their coverage.  Learning about the uncertainty is what we need but not what many of us want. 

What she said. 

Where I Imply That You May Not Have a "Right to Life" (or anything else, for that matter)

Oh, boy. Another time and post where I set about putting myself out there and quite possibly inserting my foot into my mouth. But at least I'm clear on the risks. 

Let's start here: I think harming other lifeforms is not The Thing To Do. 

And here's another facet of that whole What Do I Believe About Life gem: I think telling someone else what to do with their life is not The Thing To Do.

And how about this addendum: I believe that reasonable, flexible boundaries are a prerequisite for peace.

You can argue against and around all of the above. But I bet nobody would argue against this one: I think every human wants to feel peace.

What does any of that have to do with the infertility industry? This: In our silly national debates over health care, the apparition of rights -- right to access health care, right to insurance coverage specifics, and accordingly, the right to life -- is wafting through it all like the ever-present, silent mist that nourishes a life-filled rain forest (on a good day).

With any luck, we will all get very wet from the debate process. But who's listening?

Three pieces today -- and just three, but there are more; have been and will be -- that conjured up this morning's philosophical nature in me:

My morning ramble's starting point: The video that's making the community's rounds, Is Infertility Treatment a Right or Privilege? 

[insert Big Sigh] How unfortunate that this is a Fox-produced video. I extricated myself from the Hell of TV Watching years ago, so on the occasional glance I take to spy on What Others Are Viewing, I have to remind myself that I wasn't around for the slow, hair-growth-like transformation that TV Watchers underwent in their tolerance levels. After I shake off the unnerving feeling that I'm being yelled at by talking heads, I do my best to watch this drivel with a little bit of calm objectivity. The only good I see coming from such "debates" (how special that the "journalist" is a new RESOLVE Board member! did I hear that right?) is that maybe -- just. maybe. -- thoughts about the bigger picture will be conjured up in a wider swath of minds.

Then, in a media format a little more palatable to my out-of-sync brain, a piece by Liz Zemba on the Pittsburgh Tribune-Review's site, Debate swirls around overseas surrogacy 

It's a good introduction to what Arthur Caplan calls "a weird version of medical tourism." Weird, indeed. Another term you might use is "nauseating." 

My eyebrows first furrowed in paragraph one, where the couple who's started a surrogacy service gave up on adoption "after 22 years of marriage" -- where's the 'why'? On their business website, that's where. The Hui-Wee's cratered under the adoption option because of "too much red tape, too expensive, or too much competition." Their surrogacy journey wasn't a piece of cake, either, but at least they got a baby out of the deal.

On The Telegraph, a review by Jim Endersby of the book "Unnatural: The Heretical Idea of Making People" by Philip Ball

I've always enjoyed using phrases like "making people" (usually "making babies" when I can get away with it) because it brings down to a fine-point all the more euphemistic terms, many of which I generate right here at my laptop, in the field of reproductive medicine. 

Endersby's review is the first I've heard of "Unnatural", and it's a positive one. He does finish his coverage by stating plainly, "I found myself persuaded by Ball’s ethical and practical arguments, yet unconvinced that the benefits of making artificial people are sufficient to justify the costs."

Instead of meander on and on about what I think or how I think the dots are connected up there, I'll just rest my fingertips and let the silence do the talking.

 

M/C = MI. Okay, NOW You'll Freak Out with Me, Huh?

You know me... or at least some of you do. Always whining and crying over the spilt milk that was my seeming inability to keep a fetus intact for more than a trimester. And if there's one thing I learned (and yes, there was a lot more than one) from my experience of recurrent miscarriage, it was that everyone has a compassion limit. Even the people who love you the most in the whole universe actually do get kind of sick of hearing about your troubles when they happen over and over and over and over. It's okay, really, I'm over it, too -- their being over it, I mean.

Apparently, though, I will never be over the experience of what felt like an endless cycle of hope-and-loss. I don't feel the sadness (hardly ever), but my eye is still drawn perpetually to the most oblique references to miscarriage and pregnancy loss. Most of the time, it's not so much that I'm really interested in knowing the details of these research studies and media claims. It's more a sort of OCD checking-in out of a macabre (or not, depending on your perspectives on death) sense of loyalty to the population of people who've lost children during pregnancy. It goes like this: I'm subscribed to a jillion media sources who bombard me with all manner of subject lines. If the words "miscarriage" or "pregnancy loss" or similar are in the line, I can feel my pupils widen. Whether or not I actually open the mail and look at it, well, that depends on too many things to list here. Suffice to say, I usually don't.

Today, I did. Because today's news is disturbing to me on a present-day basis.

A large study cohort study in Heidelberg (the EPIC, European Prospective Investigation into Cancer and Nutrition) has teased out this tidbit that made my heart race: "women who experience spontaneous pregnancy loss are at a substantially higher risk of MI later in life."

And they mean substantially. From their huge database the researchers gleaned 2876 participants who'd had at least one miscarriage, 2053 who'd had at least one abortion, and 209 who'd had at least one stillbirth. At follow-up through 11 years, 82 cases of MI (myocardial infarction aka 'heart attack') and 112 cases of stroke were confirmed by records within this group of women.

Okay, here's the part where I thought I might just have my own little MI right here at the kitchen table: Recurrent miscarriage (that is, more than 3) was associated with about 9 times the risk of MI.

And yes, the researchers controlled for a lot of factors, including age, smoking, alcohol consumption, body mass index, waist to hip ratio, physical activity, education, number of pregnancies, hypertension, hyperlipidaemia and diabetes mellitus.

:::trying not to hyperventilate here:::

To calm myself down, I recognize that there's not really anything new happening here, it's just science closing in on understanding what already happens. As the study authors say, their findings "have a great deal of biological plausibility" based on what is already believed to be the case with medical conditions that predispose a body to miscarriage and to heart disease. Some good RE's are already on the ball and treating patients for tissue factor (TF), an inflammatory protein that research points to as playing a role in fetal death. This study's authors also postulate about the connections between miscarriage-related infection and cardiovascular disease, endothelial dysfunction and both m/c and MI, and high homocysteine levels' relationship to both, too.

There's a lot of good, thick stuff in this report, published by the British Medical Journal's Heart issue that came out yesterday. The abstract is free, but you need to subscribe to read the details, and they have a 30-day free online trial if you're like me and are too cheap to pay for the journal but too panicked to keep from registering. Even if you're on Internet that's a smidge faster than dial-up and the reg process takes you a good hour. Because you're freaking out now about your ramped up chances at having a heart attack. Like me.

But in the name of responsible journalism, I don't want anyone to think this report says that if you've had multiple miscarriages, you will also have a heart attack. The study does not say that, at all.

I feel better.
I'm going to stop eating cheese and peanut butter so often, I think.

....

Original article: Pregnancy loss and risk of cardiovascular disease: a prospective population-based cohort study (EPIC-Heidelberg)

• Elham Kharazmi,
• Laure Dossus,
• Sabine Rohrmann,
• Rudolf Kaaks

Heart hrt.2010.202226 Published Online First: 1 December 2010 doi:10.1136/hrt.2010.202226

More Evidence of My Wandering Mind: Baby-Making With The Force

Life is full and huge and crazy and satisfying. Yes, I'm totally distracted by virtually anything that's not virtual at this time. Still, I can't escape the reality that my existence has revolved for 15 years now around the energy and power of one over-riding topic: baby-making.

No matter how quietly I slink away, it's everywhere I go.

Without further ado, here's yet another video that my Editor (whose only interest in the topic is related to my profession, we assure you all) has stumbled upon in his ongoing attempts at alleviating End o' Semester-itis (and congratulations to the happy couple...):

Making Babies with Zack Booth Simpson

It may not seem like it, but I really do take every opportunity to see outside my little repro med box. In fact, you should know that when my blogging grinds to a halt, it's because I'm doing just that -- peering over the edge, maybe even venturing a toe into the world out there where not everyone is fascinated with baby-making. Or at least, not obsessively (or consciously...)

(I know. Who ARE these people?)

So when my attention is directed away from my typical fare by someone outside of my usual day-counting, hormone-injecting, finger-crossing crowd, I am extra delighted when the subject is actually the same topic, different window.

Because after all, it is ALL about baby-making, isn't it?

Zack Booth Simpson may be a scientific artist genius-type, but he knows what's important. Baby-making. And in The birds and the bees he tells his little one how babies come to be.

Chalk him up to yet another reason to hang out in Austin.

Zack's explanation is so exquisitely male in my eyes. It's a viewpoint that will, I guess, be forever less represented. (And I don't know, but I'm thinking guys really have it going on with the whole scarcity-value relationship thing when it comes to heartfelt expressions about creating progeny...)

All whining aside, here's to Zack and dorky nerds like him who take time away from their discussions of molecular computers to grace us all with their tender side.

{Edit 7.8.09 9:50 PM ET: And just to demonstrate how good my taste is (and that of the friend who first directed me to Zack's blog) -- the link to 'Birds and Bees' is currently dysfunctional because Zack, himself, is awaiting word from an unnamed highbrow publisher who might just give it a go in bigger territory. Stay tuned to find out if I get the a-ok from Zack to reinstall a link to his blog, or (better yet) if I get to link to the even more glamorous publication.}

{Final Edit 7.29.09 9:55 PM ET: Zack's informed me that the 'other' publication failed to respond to his query in a timely manner, so he's taken matters into his own hands and re-published "Updated birds and bees"... a must-read.}

The Right Time to Have A Baby

When is the time right to pursue pregnancy and have a baby?

In her blog today, Pamela Madsen of SIRM talks more about CGH and egg freezing and how she views those two particular techniques as The Cutting Edge of repro med right now. She says "everyone is working on this technology - it will change the face of the practice of reproductive medicine."

True. Just like all the other, now-standard techniques did before them. Good thing about science: it just keeps rolling.

So here we are again at the junction of We Can and We Should.

Like some of my infertility blogger compadres, my perspective is now tempered by not just pregnancy or having a baby, but by a quite-eventful life filled with some of parenting's best and worst moments. I can't help it. If you haven't had your hoped-for child yet, trust us: there will come a time when you won't be able to help yourself either. The world just looks different when someone's life is in your hands.

The point I'm pondering now -- and as some of you know, a point around which I've wandered for a few years now -- was ruffled up again when I read in Pam's blog today this sentence: "It is not just about preventing pregnancy until we are ready - it is also about having a baby when we are ready." She says egg freezing will do that.

The increasingly available and more-proven technology of freezing egg cells will allow women to have babies when they are ready.

Without intending to go too high-brow on everyone -- when is that, exactly? What does "ready" mean?

It's my favorite part of this whole baby-making puzzle, the part that almost never gets brought into the picture by the repro med experts.

Is it really as simple as "My entire being is craving the experience of reproduction, therefore I must be 'ready'?"

Is being ready the same thing as financially stable? Maybe that, combined with having achieved the level of education and experience perceived to be necessary for being a "good" parent?

I can hear some of you parents getting twitchy, remembering all those pre-baby things you said you'd do or never do. Right. No fast food for MY kid, by golly. And only educational television, if any TV at all. My child would never hear his parents argue. He would witness and learn through the osmosis of our carefully prepared existence the fine balancing acts of life that pit need against want, pair art with science, reason with faith, and all in steadily practiced moderation.

Because I was an educated planner.
Chances are good that, like me, you started out believing (rationalizing?) you were "ready" and became steadily, even if in tiny increments, less sure along the way. Remember that feeling the first time you went into labor and realized the true meaning of "no turning back"?

Ready or not, life happens. Don't get me wrong -- I am a whole-hearted proponent of family planning. I cared for too many abused and neglected kids to feel otherwise. Even the reasons for egg-freezing by healthy young women, I get. It's the notion of this focus on "being ready to have a baby" -- combined with what seems like an absence of conversation about what that term means -- that's losing me.

I'm recalling a PSA from long ago -- I've tried to locate it online, to no avail -- that spouted out a few typical societal rationales for having a baby, and ended with the big smooshy DUH: "The only good reason to have a baby... is because you really want one." Helpful.

So we need a sort of barometer of both desire and readiness.

Or we could try the old standby of attempting some foresight... Let's imagine a world where freezing gametes is the standard for planning parenthood. I invite reader participation for this project. In my mind, there are myriad possible outcomes, not all bad or good. In fact, I'll not try to squeeze every related idea into this one blog post, but will try to revisit it from time to time when more thoughts from Prophecy Lane come wafting my mind's way.

Here's a kickstart -- based on my assumption that this New World of Lotsa Frozen Eggs will inherently mean even more middle-aged new mommas:

In their trendspotting blog "Intelligent Dialogue," the public relations agency Porter Novelli compiles admittedly not-so-new stats  to synthesize a picture for use by marketers and corporations of the changing concepts in "Cradle & Grave". While they plug aging first-time parents as having done "a lot of soul-searching," their white paper adds the oft-overlooked financial disadvantage: late-30-somethings and 40-somethings may be more financially stable at the start of Project Baby, but older parents will quite likely be trying to fund their precious kiddoes' expensive teen activities and college education while generational peers are starting to draw on pensions.

Get ready to work til you drop, Pops!

Sure is a good thing that "50 is the new 40" or is that the "new 30"?

What do you think the world will look like when the average high schooler is trying to decide on both which college to attend and which egg-freezing facility to use? In what conversations should we be engaging young people today about what "being ready to have a baby" means -- beyond the romantic cliches?

Moderation is Key: Case in Point

This rather sad personal tale by Julie Suratt in Boston Magazine illustrates the concept of "too much of a good thing" -- an unfortunately recurrent theme in the world of infertility treatment.

It's not all doom and gloom. Suratt manages to pull some humorous anecdotes and even a bit of poignancy from the trials and tribs of her own MOT (mother of twins) experience and those of her similarly-saddled compadres.

As a still-ecstatic mother of a 9 year old only, but mostly as someone who studied and worked directly with families and children for a couple of decades before having my own, it's impossible for me to read such essays without a taste of bitter in my mouth.

Suratt's angle isn't so much just to whine about her situation -- she adeptly connects it to the rather intriguing problem that's erupted in her state of residence, Massachusetts, due in large part to how well-insured they've been there for years. Everyone's wanted their state to follow Massachusetts' lead to infertility insurance mandates. People have moved there just to get the goods, in fact. So now the place finds itself literally crawling with multiple babies and all that results from such.

Oh, if I only had a nickel for every mom who uttered online that she'd LOVE to have twins, even triplets, if only she could get pregnant.

But the bitter old family services worker in me offers this up: Why did any one of these folks expect parenting to be peachy? It matters little how many you push forth into the world. Bad things happen. If they haven't happened in your cocoon yet, you can bet they will. It's that simple.

So whether your troubles stem from the fact that you took full advantage of your insurance and had a brood in one fell swoop, most likely too early in their gestation to go without a bushel-full of dollars spent on keeping them alive and fixing up a few health conditions, or from your simply getting pregnant the old-fashioned way and having a single baby -- you'll be having your share of troubles and more. We don't get to choose. Welcome to Parenthood.

Double Trouble - Boston Magazine.