Thursday, December 29, 2005

One interview down, two to go

The interview was fine. Mostly a lot of questions similar to our PRIDE homework, and asking about the goals of PRIDE. We also talked about how I was raised, disciplined, my relationship with my family, my marriage, and my infertility. I did tell her that I drank wine daily, I hope that wasn't a mistake. She just asked and I wasn't on guard enough to lie about it, and I didn't think I should lie. I did tell her that I stopped easily when I was pregnant and wouldn't drink around my child. Ack, I should keep my mouth shut. But it wasn't bad, just long. And I love holiday weeks - the traffic at rush hour was nothing and I made it home in a normal amount of time. David is going in today, and she thinks she can probably come out next week to finish up.

Thursday, December 22, 2005

Our first home study interviews are scheduled!

FINALLY. It only took 23 days to get these interviews scheduled, far too long in my opinion. After I spoke with Cindy a couple of weeks ago, the contract social worker never called me. I started calling HSM to find out what was up, and of course got the run-around for a long time. Yesterday I got an email from Cindy that said "did you make contact with her?". Um, hello, how am I supposed to make contact? I don't know the woman's name or phone number. Cindy was in a very bitchy mood, and wasn't too pleasant to talk to. She even intimated that there could be further delays if something were wrong with my home study. Thanks, hon, for making me paranoid. But she said she would call the contract worker and have her call me, and lo and behold, she did! We have our individual interviews scheduled for Wednesday, December 28th, and she even likes dogs. And she agreed to come to Clear Lake, which saves us a trip into town at rush hour.

The Case of the Missing Period, Part 2

Doesn't that sound like it should be a Nancy Drew mystery?

Anyhow, I saw the RE this week. The 12 days of prometrium did not bring on a period, so I had a consult scheduled. She gave me a dildo-cam and said everything looked fine. The lining was very thin, I guess the estrace didn't do much, but it looked normal. She checked for scar tissue at the cervix by poking a catheter through there and nothing is blocked. She is stumped. I quit the estrace and today I had a full blood panel done. I should get some of the results today (E2, FSH, LH) and some next week (thyroid, corticol, and some other tests).

Part of me is worried that it is early menopause. I am almost 38, and my FSH has always been borderline high (8-10) and I barely passed the Clomid challenge. My mom was also perimenopausal in her mid-40s, which isn't that far away. I have also been having terrible night sweats and hot flashes, David has been teasing me because I'm sleeping with no blankets and he's huddled under the down comforter, opposite of how we normally are. But in some ways it would be good, because I could let go of the ridiculous idea that I might get pregnant on my own. I do really want to have a period though, because I keep marking the date since my miscarriage, and that's a date I'd like to put out of my mind as much as possible.

UPDATE: I got my in-house bloodwork back, and things don't look great. My LH, E2, and FSH were all elevated. I had my highest FSH yet, at 11.6. E2 was 68 and LH was 12. Of course we have no idea where in my cycle I am, but the look of the lining and ovaries indicated fairly early in the cycle, so these should be roughly equivalent to day 3 levels. Sigh.

Monday, December 19, 2005

D'var Torah, Parshat VaYishlach, December 17 2005

I gave the d'var Torah at shul this weekend, and this is what I said:

Infertility in the Torah: A Jewish Perspective on Assisted Reproduction Techniques (ART)

I know that most of you are used to seeing me standing up here with the Torah in front of me, but I figured it was time to talk about some of the contents of the Torah. I am not going to discuss this week’s parsha, VaYishlach, in particular, but I could have given this d’var any time in the last several weeks, as we’ve been reading Bereshit. I’d like to discuss a subject that unfortunately I have become an expert on - infertility and assisted reproduction. As most of you know, David and I have been struggling to have a baby for the last three years, and this is a subject that is rampant in the Torah.

Bereshit 1:28 says, "Be fruitful and multiply, fill the earth and subdue it".

Unfortunately, Sarah, Rebekah, and Rachel all had a difficult time fulfilling this commandment. Let’s take a look at each of our matriarchs and how they dealt with infertility.

First we have Sarah. Bereshit 11:30 says, “and Sarai was barren; she had no child”. Eventually she offers her handmaid, Hagar, to Avram, and Hagar becomes pregnant. This is the first instance of some type of assisted reproduction in the Torah, and was very common in Biblical times. But Sarah then feels that her social position has been diminished, because Hagar was merely a servant and she is the wife. Yet G-d continually promises Abraham that he will be the father of a great nation, and Sarah surely wonders when this is going to happen, if ever. We know that Sarah was bitter in her old age about being infertile, to the point where she laughed when G-d’s messenger told her she was finally going to become pregnant. I would laugh too, if I had given up all hopes of ever having a child of my own, I wouldn’t believe it and would be totally surprised. Bereshit 21:1-2 says, “And G-d remembered Sarah as He had said, and G-d did unto Sarah as He had spoken. And Sarah conceived, and bore Abraham a son in his old age, at the set time of which G-d had spoken to him”.

Our second infertile matriarch is Rebekah. The only mention we have of her infertility is Bereshit 25:21, which says, “Isaac pleaded with the Lord on behalf of his wife, because she was barren; and the Lord responded to his plea, and his wife Rebekah conceived.” I am not sure why Isaac pleads on her behalf, rather than her asking G-d directly. But Isaac’s prayers are answered and she becomes pregnant with twins. However, it is a difficult pregnancy, and she is worried through the entire pregnancy that something is wrong. This is a very common reaction for a woman who has finally become pregnant after years of infertility. She just can’t believe it’s real, and she has so many friends who have miscarried that she is convinced it will happen to her as well.

Our third infertile matriarch is Rachel. She is not only infertile, but she also has to deal with an infertile woman’s worst enemy – the uber-fertile sister. Every time Leah becomes pregnant, Rachel’s pain becomes more and more magnified. She anguishes over when it’s going to be her turn, or if it will ever be her turn. Finally she becomes so desperate that she says to Jacob, “give me children or I will die”. Rashi explains that this statement signifies that a childless person is accounted as dead. Rachel's next act was even more desperate. Reuven, the firstborn son of Leah, returned from the field with some plants called "dudaim" (Bereshit 30:14). The biblical commentator Nachmanides suggested that these plants were herbs which promoted conception. Reuven presented them to his mother for her use (although I don’t know why she would need them, since she already has 4 sons at this point). Rachel observed this and begged her sister for the plants. Then she made a deal: in return for the dudaim she would allow Leah to spend one night with Jacob. Ironically, Leah's fifth son was born as a result of this deal. Finally after seeing Leah give birth to two more children, Rachel’s prayers are answered and G-d opens her womb and she gives birth to Joseph. Immediately, she asks for G-d to give her another son. Even though Rachel’s prayers are again answered, sadly, she dies in childbirth with Benjamin.

There are some other lovely stories in the prophets about infertile women, such as the famous Hannah whom we read about on Rosh Hashanah, and the story of Samson’s unnamed mother.

Infertility was not only a painful and tragic experience for the Matriarchs. It continues to afflict many Jewish couples. The biblical notion of infertility was that it was due to the female (notice how Hagar got pregnant immediately, in contrast to Sarah). Among all cases of infertility, about 20 percent can be traced to male factors, 38 percent can be traced to female factors, 27 percent can be traced to factors in both the male and female partners, and 15 percent cannot be traced to obvious factors in either partner. Infertility should therefore be viewed as a “couple” disease, regardless of which partner is affected. The Conservative movement has also created a ritual for coping with infertility, so that the pain need not be borne alone. You may recall that Rabbi Strauss did a lovely prayer for us in the synagogue about a year ago. This ritual can be performed in public or private, as the couple wishes.

In modern times, we have many assisted reproduction techniques to help infertile couples, and Judaism is fairly liberal on the use of ART. In fact, in Israel, in-vitro fertilization is covered by the state health care. Judaism also appreciates medicine as an aid to G-d, so these techniques are not considered abhorrent. In general there is no problem in Jewish law with seeking out any treatment where the woman’s eggs and the man’s sperm are being used. Halacha becomes interesting when you are using donor eggs, donor sperm, or a gestational surrogate, and I will talk about these issues in a moment. Another interesting point is that if a couple is diagnosed as infertile, they are released from the commandment of “be fruitful and multiply”, and are not obligated to pursue any ART (they may, however, choose to do so).

First, let’s answer the question: What is infertility? The International Council on Infertility Information Dissemination (INCIID) says that infertility is the inability to conceive after a year of unprotected intercourse in women under 35, or after six months in women over 35, or the inability to carry a pregnancy to term. The first step in seeking treatment is to determine if the woman is ovulating regularly, and to do a semenalysis on the male partner. Both of these tests are simple and painless, and can save time down the road. Also a test called a hysterosalpingogram (HSG) is done, in which dye is injected into the fallopian tubes to ensure that they are open (side note – this was by far the most painful procedure I went through). There are drugs such as Clomid that can be taken orally in order to help regulate anovulatory or irregular women. If natural conception (with or without Clomid) does not work, then the woman will find a reproductive endocrinologist, who specializes in infertility disorders. If the woman is ovulating and the male partner is normal, generally the first line of treatment is to try artificial insemination, also called intrauterine insemination (IUI). In this procedure, a semen sample is collected from the male partner, and the sperm is injected directly into the woman’s uterus, after being treated to remove proteins that could cause shock and even death in the woman. Many more sperm can be injected into the uterus than would find their way naturally. Hopefully the sperm will find their way into the fallopian tubes and fertilize the egg. There is some controversy regarding how semen may be procured for the procedure. Since there is a biblical admonition regarding the "spilling of seed", some rabbis insist that the husband may not ejaculate to provide a specimen. However, since the intention of the procedure is specifically to enhance procreation and the semen is not being wasted, ejaculation to produce the semen may indeed be permissible. Artificial insemination has been performed for many years, and the question of the halachic validity of this procedure has been discussed by many sources. Most rabbinical authorities approve of artificial insemination if the husband's sperm is used.

The next line of treatment is to use injectible hormones for the female partner in order to hyperstimulate her ovaries, so she is producing multiple eggs (on the order of 2-6) to fertilize. As long as there is no male factor, this technique can be successful with IUI. Giving the sperm more “targets” can increase the likelihood of one of them finding its way. If IUI fails, often laparascopic surgery will be performed in order to assess the condition of the woman’s uterus and uterine lining. Endometriosis is one of the main causes of female infertility, and often removing the endometriosis can remove barriers to contraception.

After IUI doesn’t work, the next line of treatment is in-vitro fertilization (IVF). In this case, the woman’s ovaries are hyperstimulated with a regimen of injectible hormones in order to produce many, many follicles (10-20), and when they are mature, they are removed in an outpatient procedure. The husband provides a semen sample, and the eggs are then allowed to fertilize in a dish in the laboratory. After 3-5 days, the best embryos are chosen, and they are returned to the woman’s uterus, where hopefully one of them will implant and make it 9 months.

When more than one fertilized egg is implanted into the woman, this may result in a multiple pregnancy. When there are three or more fetuses growing in the womb, this results in a high risk pregnancy, and selectively eliminating one or more of the fetuses, may be recommended. Is this halachically permissible? Ending the life of a fetus is not considered murder by halachic definition, but it is not permissible either. The Conservative movement ruled that it is halachically acceptable in certain cases – in order to protect the woman from a serious threat to her health, and of course with the justification of protecting the remaining fetuses. However, Jewish law recommends transferring no more than 2 to 3 embryos in order to minimize the risk of selective reduction.

One procedure associated with IVF is preimplantation genetic diagnosis (PGD). In this case, a cell is removed from an embryo in the early stages of development and the DNA is tested for genetic disorders. This procedure is acceptable in Jewish law in order to avoid having a child with a severe genetic disease. PGD should certainly not be performed purely for the issue of gender selection, unless there is a disease that would be genetically linked to a specific gender.

Another issue with IVF is that when IVF is performed, the woman is stimulated by hormone treatment so her ovaries can produce up to 20 eggs per cycle. The eggs are harvested and fertilized, but only three or four can be used in that cycle. The rest can be preserved by freezing. How does Jewish law address the issue of extra embryos? The fate of extra embryos could include: (A) Use of them by the original couple to establish future pregnancies (rabbis affirm this use). (B) Destruction of the extra embryos (permissible halachically if this is done passively, by letting them thaw out and die on their own). (C) The use of these extra embryos for research. Since this is an active process and results, ultimately, in their destruction, this is not generally acceptable by Orthodox rabbis. (D) Donation of the extra embryos to another infertile couple. This option is not approved by many Orthodox rabbis because the "adopted" child may inadvertently marry his/her genetic sibling, resulting in incest. However, the Conservative movement has ruled that after careful consideration of the implication of their actions, a couple may donate embryos to another couple to have a child.

The issues involved in using donor sperm or eggs can create halachic problems. Some rabbis object to the user of donor insemination on grounds of adultery. In this case the child would be illegitimate (a mamzer). There is also the possibility of unintentional incest in the next generation if the sperm donor is unknown. This issue is resolved in Jewish law if the donor is known and the children avoid his offspring as mates. The Conservative movement has ruled that donor insemination does not constitute licentiousness or adultery, and the child conceived is fully legitimate. For purposes of priestly status, the child follows the status of the semen donor, if known, or else adopts the default status of Israel.

In the case of egg donation, the procedure is more medically risky than in the case of donor sperm, since the egg donor is treated to hyperstimulate her ovaries and obtain as many eggs as possible. Jewish law does not permit one to endanger onself unduly. Egg donation should only be used, therefore, when the couple has seriously considered all other options, including adoption.

When an egg donor provides an egg for an infertile couple, the recipient, usually a sterile woman who cannot produce eggs, serves as the gestational and birth mother and she gives birth to and raises the baby as her own. In this case there are two categories of motherhood: a genetic mother, and a gestational/birth mother. These functions can be performed by two different people, who may or may not be related to each other and may or may not have any connection with each other (other than their individual contributions to producing and raising the child).

There are rabbinical authorities who reject outright the idea of using donor eggs. Others believe that a woman may receive donor eggs as long as her husband has consented. The question of who is the mother is extremely complicated to answer. This is certainly a critical question as it impacts on the status and identity of the baby. According to traditional Judaism, the status of "who is a Jew" is determined by whether or not the mother is Jewish. In the case where the genetic mother and the gestational mother are the same person, then the issue is clear. What happens when the genetic mother is a different person from the gestational mother? Which mother is considered the mother for the halachic decision on religious status? If the genetic mother is not Jewish and the gestational mother is, what is the status of that infant? Rabbi Moshe Heinemann, Rabbinic administrator of Star-K Kosher Certification, states unequivocally that if the egg is from a non-Jewish woman, then the baby is not Jewish. In this very stringent ruling, when a donor egg is used, the birth mother is not considered the halachic mother.

Other rabbinic authorities have also addressed this question and have concluded that there is halachic uncertainty regarding who is the mother. Rabbi Moshe Tendler writes: "the contributions of the gestational mother are quite consequential" (Pardes Rimonim, 1988). In fact, many halachic authorities regard the birth mother, rather than the egg donor, as having maternal status. The halacha on many issues relies on what can be readily observed with the naked eye. For instance, microscopic or small amounts of non-kosher contaminants in kosher foods, do not necessarily render the food non-kosher. Thus, the decision on maternity may be based on which mother gives birth (an action which is incontrovertible, and readily proven), rather than which mother provided the egg (a microscopic contribution, albeit a critical one). On the other hand, considering the important role that inherited status plays in some Jewish circles, genetic status could be of paramount importance, and perhaps the mother who provided the egg should determine Jewish status. The Conservative movement ruled that egg donation is not licentious or adulterous. The identity of the mother for the purposes of Jewish law follows the bearing mother – i.e. the child is Jewish if the woman who bears the child is Jewish.

The use of a gestational surrogate, where the couple’s own embryos are implanted into another woman who then carries the baby to term, is still a relatively new area of Jewish law and opinions are divided. Rabbi Elie Spitz says that surrogacy is a new legal construct, and that Jewish law has no precedent for splitting biology and gestation. However, he believes it would be wrong to outlaw a procedure that has the potential to help so many couples overcome infertility, as long as one is aware of all the ramifications. The surrogate should have her rights protected, and be allowed to make any medical decisions regarding her health. There should be concern for the well-being and rights of the child and to avoid exploitation of the child or the surrogate. Rabbi Spitz concludes that it is permissible to employ a surrogate, and that the man fulfills the mandate of procreation in this case.

In contrast, Rabbi Aaron Mackler says that surrogacy cannot be halachically recommended, and in most cases would be forbidden by Jewish law and ethics. He is primarily concerned with exploitation of the surrogate and the child, particularly if the surrogate already has a family; and about the legalities that we discussed in the case of egg donation about who is the child’s mother. He believes the surrogate should be allowed to request custody of the child at birth, while Rabbi Spitz believes the surrogate is obligated to release all claims to the child once it has been born.

Most of these issues can be overcome by converting the child at birth, to ensure that they are halachically Jewish.

David and I underwent most of the treatments I have just described to you, and we chose to end treatment after our third IVF cycle ended in miscarriage. Our diagnosis sadly falls in the “unexplained” category of infertility, although my doctor has suggested the use of donor eggs simply due to my advanced maternal age (yes, since I’m over 35, I am advanced maternal age). We have chosen instead to build our family through adoption, because it is the one treatment that is 100% guaranteed to result in a baby. I have struggled a lot with my faith during these last few years, especially when I read the stories of the matriarchs and how their prayers were answered. Lord knows I have prayed enough for my womb to be opened, and it hasn’t happened yet. Deuteronomy 7:12-14 says “if you obey these rules and observe them faithfully, the Eternal, your G-d, will maintain for you the gracious covenant that G-d made on oath with your forbears. G-d will love you and bless you and multiply you … there shall be no sterile male or female among you.” For an infertile woman, the implication seems to be that fertility is an integral part of the covenant. Is barrenness next to godlessness? I choose to believe the answer to this question is a resounding “no”. I believe that G-d will answer my prayers to be a mother, just in a different way.


Note: much of the information in this d’var was taken from an article written by Dr. Miryam Z. Wahrman, who is a Professor of Biology at William Paterson College in Wayne, New Jersey. She set up and ran the first In Vitro Fertilization laboratory in New York City. I would also like to thank Rabbi Steve Morgen for loaning me the Responsa of the Conservative Movement to help me with the legal issues.

Wednesday, December 14, 2005

A letter to my mom

Dear mom,

After we spoke last night, I still didn't walk away from the conversation really believing that you believe this adoption is happening. You had that "ohhhhh-kay" kind of tone, which generally indicates that you seem like you're agreeing with me, but you really aren't.

This is the first time since we've started trying to have children that I honestly believe I am going to be a mother. The beautiful thing about adoption is that you have a 100% chance of walking away a parent. That is something no reproductive doctor can tell you. I can't tell you what a relief it is to know I finally have a 100% chance after all we've been through in the last few years. Adoption has its own ups and downs - there is a lot of waiting, we don't know exactly when we're going to get our baby, a birth mother could always change her mind, a foster/adopt situation could be reunited with the birth parents. We are aware of these risks and feel that they are minimal compared to, say, the odds of having a miscarriage. But we are also trying to minimize the risks.

The agency I am working with specializes in infants and toddlers who are relatively healthy, and have a low legal risk. This means that the judge has already recommended termination of parental rights before I get the baby (although the TPR has not yet happened), and these cases are very rarely overturned. My agency works with a judge that normally recommends TPR at the initial hearing, so there is little legal risk for me. My agency also realizes that I have been through years of infertility treatment and a loss, and they would never match me with an infant that had a high likelihood of being reunited with his/her birth parents.

I am also working with a facilitator to pursue a private adoption. There is a risk in this situation that the birth mother could change her mind after giving birth, but they provide counseling for the birth mothers to try and ensure they are ready to give up their baby. They only match us with women who are in the last trimester of pregnancy, because these women are less likely to change their minds.

I know this baby doesn't exist yet. But I will be a mother in 2006, probably no later than the summer and most likely in the spring. Preparing the room and buying things for the baby is very therapeutic for me. Having people give me gifts for the baby is also very exciting, because it recognizes that there finally is going to be a baby. If I were 29 weeks pregnant, which is where I would be right now if I hadn't lost the baby, would you feel comfortable buying things for the baby? Would you feel comfortable throwing me a baby shower? I know I am only "paper pregnant" which makes it harder for you to envision the end product, but this paper pregnancy is far more real to me than the pregnancy I lost. I would love for you to be just as enthusiastic as if I were pregnant. I would love for you to ask how things are going with the adoption when we talk. I would love for you to start knitting things for the baby, and send my childhood books for the baby, and recognize that there is going to be a baby.

Love,

Melissa =)

Thursday, December 08, 2005

A very bizarre wedding anniversary dinner

We had a really nice, but incredibly bizarre dinner last night. We went for sushi, and at the next table were three adults and three little girls. Two of the adults were a couple, a blond woman and a hispanic man, and the other woman was hispanic. The kids had these strange bottles of something they were drinking, and I scootched over and started asking the oldest girl (around 8, back of photo) what they were. She told me it was Japanese sprite and told me in great detail all about how the bottle worked (it had this weird marble like thing in the top that provided the carbonation and cooled it). The other little girls started talking to us as well, and the littlest one (4, on my lap) gave me a big hug and asked if she could sit on my lap. So David and I are playing with these little girls, and the mom (the blond) comes over to the table and asks if they're bothering us, and we assured her they weren't. I had been staring at them all evening because they were all so cute, and I was wondering if she thought I wanted to kidnap them. We were joking about stealing them etc. Mom was kind of drunk, offered us sake, etc. She went back to her table and said "you really need your husband to impregnate you". As we were leaving, they were leaving as well, and I told her that I couldn't have kids and we were adopting. She immediately said "I'll carry one for you". I said that's what I needed, was a ute that worked. We all walked out together, said goodbye, and I got in our car. David realized he had forgotten the umbrella and went back. She tapped on the door and I opened it, and she says "take down my name and number". She offered to donate eggs to me, and said she was being a donor for the other woman and that's why they were all having dinner together. The other woman came over and was telling me how great this lady was for doing this for them, and if they had leftover embryos I could have those too because she and her husband were Catholic. The mom said she loves children so much, and she gets pg easily and has easy pregnancies, and she would be happy to surrogate for me or donate for me. Then she added "and plus I'm cute" (she was, in a blond average looking kind of way). I thanked her, took down her numbers, and we parted ways.

How bizarre was that? David and I were totally freaked out, but in a kind of cool way, especially since it was our wedding anniversary. We decided though that we're sticking with the adoption path, but we may contact her in the future. Who knows? But how kind of a total stranger to want to do something like that for me, it really touched me to know these women exist.

So, to all of you egg donors and surrogates out there, thank you from the bottom of my heart.

She finally called!!

THE SOCIAL WORKER CALLED ME!!!!

I was in shock, because I heard that she was out of the office yesterday, so I definitely didn't think I'd hear from her. OK, here's the poop: they have a contract SW who is going to do our home study. She is finishing up some agency-specific training this week and we are going to be her first clients. She will schedule with us next week. There should be no problem doing the interviews before the holidays and the home visit in January. She says I shouldn't have to wait more than 6 months for a referral. Hallelujah!

If we end up using the facilitator to get a referral, I can use HSM to do a "designated adoption" and we can use their home study, counseling, and legal services, for a fee of around $10K (plus the birth mom fees). If however I hire a private adoption attorney, I would need to do a new home study at my expense.

HSM also has a maternity program, and she said we can pursue the foster/adopt and the straight adoption simultaneously. We don't need to do any additional work, and the fees are around $23K. She also said (without me asking) that David and I look really good on paper, and that if a really great match came along, she felt confident that we would be chosen over other couples (AHA - there is competition).

So, we are on target for the arrival of our baby in 2006.