Checking in: 29 weeks

Random things in bullet points:

• My OB did get back to me after I finished my last post, saying that the surrogate DID need to be given the anti-D shot. Her assistant had not put that on the report. I then had to get the prescription ordered and get the surrogate to Dr. Bhansal who agreed to give the shot, and I reluctantly decided to get the ultrasound done too, because we were going there anyway. As I was on my way there (with slight trepidation in my silly heart as I was going alone for the first time to an ultrasound), my mom called and told me she had missed her flight and could make it there anyway. YAY. Thank you Universe.

•  I got proof that fetal biometry readings should be taken with a giant pinch of salt: Remember a while ago that I was mildly nervous that the head circumference (HC) was in the 12th percentile? This time, it was around the 50th percentile, while abdominal circumference (AC), which was around the 50th percentile the last time around, had now fallen to the 7th percentile. The only thing that has been consistent is the femur length, which is around the 80th percentile in each scan. So yeah, fetal biometry, not seeming hot, really.

• I also met a lawyer to take care of the legal stuff for getting the baby back to the States. Her first question was, where did you do your IVF treatment? She asked me this because there are apparently some doctors in Delhi who have put other people's embryos in a surrogate, and the poor parents have a bone jarring shock after birth when the DNA test revealed that the baby was not theirs. If you are a foreign national who planned to return to your home country with your baby, things get impossible, and there are families in limbo and babies in limbo because of this. Horrifying. She did tell me that she had handled some surrogacy cases coming out of the Malpani clinic, and they had been ethical and did not pull such horrifying cons. It is unbelievable that there would be doctors out there who would do stuff like this.

• The baby is just past 29 weeks now, and should hopefully approaching 3 pounds soon. Still so utterly tiny. Nearly every day, I google fetal survival and fetal weight and go over information I should be able to recite in my sleep by now. Previously, 28 weeks was my safety mark. Now, it is 34 weeks, where the only issue a baby may have may be an initial inability to suckle. It is also getting more real now: I've been my own person my entire life. It is terrifying and exciting that I may be getting a little person who will take over completely. 

• I told my aunt (who I am pretty close to) the news. The last time I told a family member I was trying this, their reaction was so ugly that I was badly burned and decided not to tell anybody in the family till the baby was here. In contrast, my aunt's reaction was wonderful. She just kept repeating that she was happy for me that I am getting a child of my own, but so sad that I had gone through 3 miscarriages and such a difficult journey by myself, and that she was just so glad that my parents had been there for me and had known all along. It was a lovely, lovely response, and I am so lucky to have her in my life.  

More glimpses of the realities of surrogacy in India

J goes to Hiranandani hospital for her routine OB-GYN checkups. I went with her for her very first checkup, and it was an intensely disconcerting experience. There are about maybe 12 surrogates gathering and waiting for anywhere between 1-3 hours. The OB-GYN's assistant shows up, and starts seeing this procession of women. They get a doppler check and their blood pressure and weight read, all while the next 3 patients are queuing up on the other side of the curtain while the first patient is in the bed. My mom likened it to the situation in the poorest, most strapped municipal hospitals, where she worked briefly as an intern

After that first painful experience where I waited over 3 hours for a 15-min cursory check complete with an ancient-looking doppler, I never went again, and instead only go with J to the wonderful, detailed ultrasounds that are run at the Mediscan testing center by the very capable Dr. Bhansal.

This past Wednesday marked 28 weeks, and J went for her checkup at Hiranandani. I contemplated going, but I decided to just trust the system and sent her off with all the reports and expected her to get both the Rhogam shot and much discussed mandatory steroid shot. Too many times where I decide to just trust the system here, it has turned out to be a Bad Idea. But that is a topic for another post.

I talked to J after the appointment and find that no injections were given. I then try to find out what happened. If you go to an agency like Surrogacy India, they have this system where all the reports are scanned and uploaded and are available online for the parents immediately. Here, with the Malpani Clinic, there is no such centralization. I've spent 3 days waiting to find out what exactly was done at that visit. The surrogate handler claims that she gave the report to the receptionist at the clinic, who then claims to have emailed it to me. No such email was received. The handler claims she reminded the receptionist of it again one day later, and that she apparently mailed me. No mail was received. I've asked the doctor what was happening, and have received no word. I am SO very glad that I have to deal with this system only for another 10 or so weeks.

But here is the deal: they don't give the steroid injection at the hospital, they only write the prescription for it, and expect that some local nurse or some local doctor will give it. In the case of the Malpani clinic, the person who gives the shots is no trained nurse, but the handler herself.  A little background on the handler: This is a woman who has gone through surrogacy herself, comes from the same socio-economic class as the surrogate, and is partially literate, but at best studied till high school. In general, these are not people who are professional and impartial: they may not above lying for the surrogate (remember the story I posted about the handler who helped a 42 year old surrogate propagate a lie that she was 28?). 

In this case, the handler will give the shot at her home.I have to pray that the she is atleast trained in sterile techniques. I asked my RE about this, but as with most situations, I got resounding silence.

Here is the other thing: J told me that Dr. Malpani thinks that the Rhogam shot at 28 weeks is not necessary. He has not bothered communicating this directly with me, and nor has the OB-Gyn.

The person who did seem to think it necessary is Dr. Bhansal. She is a fetal metal specialist who works with high-risk pregnancies. She is also the go-to person for detecting fetal anemia, and is also the go-to person to give transfusions in the situations where it does develop. I'll have to talk to her about the necessity of this again. I totally hear you guys about the many places that do not give this prophylactically at 28 weeks. The one reason why I'd be more concerned here is because this is a surrogacy, and J may not be as prompt as required if something goes wrong (if she falls, etc).

But, in happier news, we have crossed the 28-week mark. This is the point after which the complication rate falls considerably. I was supposed to go in for an ultrasound tomorrow, but my mother will not be in town. A while ago, my friend M told me to always take my mother with me to the ultrasounds, because she is my lucky charm. I take that advice very seriously: she has come for every appointment, and I'm far too chicken to go in without her now. The next ultrasound should happen in the middle of next week.  

Also, I want to celebrate the surprise (to me anyway, I had NO idea) pregnancies of 2 bloggers who are very close to my heart, who have stopped actively blogging. I think it is rather cool that two such very wise women who I thought were actually quite similar (in their outlook on things and their utter sensibility)  are so synchronized with their pregnancies; they both just crossed 24 weeks. Adele and Arohanui, so very happy for the both of you!

Checking in: 27 weeks

ICLW (IComLeavWe) collided with my vacation in the lovely Maldives. I naively thought I could comment from my phone while I was there (HA), but none of that happened. But anyway, I got away and snorkeled and gazed at insanely blue water to my heart's content. I got back last night and I'm still getting my bearings back.

Tomorrow marks 27 weeks. I have not bought a single thing for the baby yet. Not one bloody thing. Almost all my essentials need to come from the States. I have to figure out how to transport baby bottles (I'm going for stainless steel ones), a gzillion tins of Myenberg Goat's milk powder, and random things like DHA and vitamin drops and probiotics (formulating a very useful post on this one, which will most likely go up on my new blog) and blackstrap molasses. I'm far too terrified to go shopping for cribs and onsies yet. None of this feels real. I wish I could get the gender now---in some funny way, I feel like this would make all this seem a little more concrete.

Next week marks the timepoint to give the steroid shots, and J would also have to get the Rhogam shot or its equivalent. Turns out in India they have a monoclonal IgG shot available that is free of thimerosol, but it comes with its own wrinkles. I'm trying not to overthink and read the literature and decide whether to forgo the 28-week shot or not (there is some mild controversy here) or think of the nebulous risks of giving the shot, or the more easily imaginable repercussions of *not* giving it.I'm so PISSED that this pregnancy has to go through this easily avoidable issue. 

I asked my mother to talk to the NICU chief at the hospital that has the milk bank, and that conversion was again a door clanging shut in my face. No milk (they get super low amounts, apparently); they advised me against a wet nurse because even if you screen for diseases, you miss out on the window period where they could have contracted a disease but do not test positive for it yet.

All in all..hello formula from day 1, goodbye milk. I totally get the desperation of parents to get breast milk to their babies,if only for a few days.  There is a rather poignant/sad yet comical story I heard about a mother who was desperate to get her baby milk after she was born from surrogacy. She paid the surrogate a lot of money to provide the milk on the sly (the doctor had told her it was not in line with their policies), not realizing that the doctor had given the shots that made the surrogate's milk dry up. They apparently tried for
days and nothing happened. I can only imagine the collective frustration of everybody involved.

How important IS breast milk? Apparently, as a baby, I got no breast milk either (and maybe did not suffer at all for it, or mildly did---these things are impossible to judge), and the same will be true of my baby. It is impossible to gauge how your choices hurt or help things along, and I've been determined in theory to not beat myself up for things I cannot help...yet...that stupid urge to nitpick my choices and wonder about what the possible repercussions could be just does not go away. Parenting lesson #1, maybe?   

ICLW #3

Welcome to ICLW! Excuse the typos- I'm typing this post from my phone.

A quick introduction- my story has to strech back to when I was 25, when I decided that if I did not meet the right guy in the next 5 years, I was going to try to have a baby by myself.  To my own shock, I went ahead with this audacious plan the month I turned 30. I tried to get pregnant. I succeeded on my first try. I lost that pregnancy. I tried again two months later. I lost that too. I took a year long break and tried again, only to have the worst pregnancy/loss ever. At this point, I had severe pregnancy PTSD, and the thought of having an ultrasound to see if there was still a beating heartbeat made me sick with anxiety. I returned to my India (the country I grew up in) for the more affordable fertility treatments (including surrogacy)  and the support of my family. My first IVF was an unmitigated disaster. The second (where I designed my protocol myself) resulted in about as good a response as one could hope for, and a surrogate, after rejecting 3 of my high grade day-5 blasts, got pregnant with one of them.

That pregnancy hits 26 weeks tomorrow. It took a lot of superstition squishing to get me to participate in ICLW-- the first time I signed up for this, I discovered a pregnancy loss about 2 days in. I'm trying to recite this mantra from one of my favorite books: Hope strengthens, Fear kills. Well, not literally, but you can miss out on quite a bit just because of your stupid, irrational fears. So here I am, kicking one of my superstitions in the nuts and hoping it does not reciprocate.

My blog is not just a recounting of my story...I'm a scientist and an information junkie, and I'm determined to make this experience as positive as possible by dispersing how much ever information I can. And this I have done, to the point of making your eyes glaze over. If you are so interested, the 'Science of Infertility' page summarizes a good part of it.

So welcome. Thanks for stopping by, and I look forward to reading your stories!

25 weeks...and a shocker

First, thank you all, all the people who "derlurked." I've saved the blog addresses of those who were not on already my reading list, and I look forward to reading your stories.

Apparently, there is an ultrasound every month from this point on. I was pretty darned happy to hear this, and I went back to Mediscan, where I've had all ultrasounds done so far. This is a lab chain that specializes in fetal testing, and the doctor here is one that I absolutely have come to like and respect. Her name is Vandana Bhansal, and I highly recommend this place (and her) for antenatal testing.

The ultrasound was going well. Dr. Bhansal then casually asked J what her blood type was. Both my mother and I were shocked out of our wits when she replied "B negative." Negative?!?! That means she does not express the Rh antigen. I do express it, as does my donor.

Rh- moms need specialized attention when they are carrying an Rh+ baby, because if there is is mixing of fetal and maternal blood, the mother will make antibodies against the fetal Rh antigen. Those antibodies can then cross the placenta and can cause fetal anemia and jaundice. Severe anemia can even result in fetal demise. If the mother is sensitized to the Rh antigen in one pregnancy, then all the later pregnancies are at risk. To prevent this, the mother should be given the Rhogam shot at 2 points: at 28 weeks of pregnancy when the chance of fetal blood mixing is 1%, and at delivery, when it goes up to 10%. If an Rh- mother has a miscarriage or trauma during pregnancy, the Rhogam shot is administered at that point as well.

Now, Rh negativity is sort of rare. It is high in the native American population, and rare amongst Caucasians. I thought it was rare amongst Indians as as well...I found out that it was more common than I thought, coming in at about 10%.

  

I never dreamed that a Rh- surrogate would be selected, especially given the masses of women available for surrogacy in this country that are Rh+. I never got the surrogates initial  screening tests (I had to literally  badger my RE for the initial thyroid testing results); had I seen this, I would have gone with somebody else. I'm shocked that I had to find out by accident, and I am so grateful that I got Dr. Bhansal; had I not, this may have never come to light, and I'm not sure if my RE told the OB specifically about this, or was aware of it. 

So here I am, having to live with this wrinkle as well. We immediately had her tested...as of now, she does not have antibodies against the Rh antigen; she has received one of the two mandated injections (the one given at the time of birth) following all her pregnancies. Not being the sort to take chances, we will have to administer the Rhogam shot during pregnancy as well. Now, Rhogam used to contain thimerosol (ethyl mercury) as a preservative. It was recently removed in the version administered in the US, but I don't know whether the older version is still in use in India. I'm stuck with the headache of ensuring that a thimerosal-free version is given. 

All was well in the ultrasound too: the thing that made me slightly worried is that the head circumference growth is lagging--it went from above the 50th percentile at 19 weeks to the 12th percentile at 25 weeks. The one thing that is absolutely ahead is femur length, coming in at the 84th percentile.

 I'm trying not to think about microcephaly, and I'm trying to remind myself that I have an absolutely tiny skull as well, and was apparently incredibly low birth weight (under 4 pounds at 41 weeks!!), and I turned out to be perfectly healthy. This baby is sort of like how I've been all my life---small head, long legs, so worrying is stupid,right?

Say hello (International Delurking week 2014)

After 3 years of trying to have a baby, I have finally reached “viability.” Today marks 24 weeks (!!). This is a milestone that I did not think I would get to, and when I find myself passing it, I feel like it needs a wee celebration, if only in my own head.

Coming to the topic of this post, Mel announced that this was International Delurking Week. I am a huge fan of that concept.

When I first started blogging, I made an intense effort to connect with other bloggers and find new blogs regularly. Now, I barely find time to post all the things I want to talk about, and when I find a new blog I want to follow, it is quite by accident. This seems like a great opportunity to find many blogs at a single go. If you step out of the shadows, say hi, and share your blog address (if you have one), I would love to follow your journey, just as you follow mine. I will probably be a godawful commenter for the most part, but I will be there silently reading, which is hugely comforting in itself.

If you do not have a blog, step out and say hello anyway.

Finally…we all fall into different camps here. Are any of you single moms by choice? Are any of you Indian? Are any of you an incredibly rare combination of the two, like myself? Are any of you fellow recurrent pregnancy loss warriors?

Please, tell me your stories, and connect with me, and with each other.

No choices, no milk

I had an interesting consult with the OB today. Incidentally, she is the doctor who handles most of the surrogacy cases in Mumbai (apparently), so she is also the person with the most experience in dealing with surrogacy, and that should not be taken lightly.

But what I heard was distinctly disheartening. Remember that choice to waive the steroid shot that I mentioned? She clearly had told me that the first time I talked to her, but today she told me that it is her protocol, and she is going to do it. I could try some things to prevent that, but that would be both counterproductive and foolhardy, so I will just have to go with the flow.

I then asked her whether J could express colostrum and feed the baby (followed by pumping after the first couple of feeds) for as long as she is in the hospital with the baby? She was like...nope. No surrogate can feed the baby. They actually give them shots + pills to dry up their milk as soon as birth occurs, so even if both parties (the birth parents and the surrogates) want to do this, they cannot. She basically told me, this is my protocol, take it or leave it. Unfortunately, I do have to take it, and the sooner I make my peace with all this, the better.

Just FYI for people doing surrogacy in India: Dr Pai in Anand, Gujarat allows/encourages breast feeding.

In the defense of the people in Mumbai, there is a logical reason they shut off the milk supply: if the milk flow is established, and there is no baby to drink it afterwards, there can be breast engorgement that can lead to an abscess. I had already factored it in, and had naively thought that J could go donate at a milk bank (she lives really close to one) and maybe make some money (I hope to god they pay them) and everybody could win, if she was open to this. But nope, her milk supply will be shut off immediately after birth.

AAh....the stuff I wish somebody had told me about, before I signed up for all this.

I also heard a hair raising story about a surrogate, which is an excellent illustration of why one needs to thoroughly investigate the situation before initiating surrogacy in India: A surrogate shows up with insanely, dangerously high blood pressure at a mere 10 weeks of pregnancy. She claimed she was 27 years old. The OB refused to believe her, and on further grilling of the handler, it was revealed that she was 42 (!!!) years old. Her daughter had been kicked out of her home by her own husband (I think) who had told her she had to produce Rs 200,000,  to get back in.

This woman,  in desperation, lied about her age and her medical history and entered a dangerous pregnancy to get that money for her daughter. The surrogate handler propagated the lie, and I have no clue what the RE was doing.

 Everybody was shortchanged here....the poor woman who was the biological parent, the poor baby, and the surrogate, who risked her life for money. Such a situation can only be prevented by investigating the heck of out the surrogate, investigating her previous medical history as thoroughly as possible to ensure that this is not for 5th of 6th or 7th pregnancy...they can lie about this as well.

 Bottom line: based on everything I've heard and my own experience, I''ll say this to anybody who is thinking about surrogacy in India: Ask a LOT of questions before you start. Make sure your doctor has investigated her past pregnancies as well, and has gotten her previous medical records from whereever her last pregnancy was, all of that. I'll come up with a comprehensive list of things to investigate before you start.

A new year, and an interesting quandary (blanket steroid shots!)

Today marks the completion of the 23rd week of pregnancy. I have such hopes for this new year. As I hugged my parents at midnight, each of them whispered to me that they hoped that this turns out to be the year where I finally get what I've been striving so hard to get. I hope so too.

2013 was a lot of things for me, but I hope I can get to remember as the year in which the most important thing in my life came to be.

As for this new year...I hope it brings good things to as many of you as possible.

We did the glucose tolerance testing. In an odd turn of events, I have the 2-hour glucose levels and the glycosylated hemoglobin values, but not the fasting levels yet. The 2-hour glucose level was 94, and the glycosylated hemoglobin came back at 4.8%. Both tell me unequivocally that J does not have to worry about diabetes. YAY!

I have to go talk to the OB tomorrow to discuss one important point, and it is something that will probably make a lot of jaws drop: In India, apparently, every surrogate pregnancy is considered a high risk pregnancy, and what they do is give every surrogate the steroid shot at 28 weeks to induce fetal lung maturation, no matter what the individual situation may be. The first time I heard this, I nearly bit the head off the poor hapless doctor's assistant who informed me about this, because this seemed insane. Even my very restrained mother freaked out when she heard this: a blanket steroid shot?!

The benefit of a steroid shot far outweighs the downsides (it can negatively affect the developing  immune system of the baby; it can aggravate gestational diabetes in the mom, and so on)  in a situation when pretrem delivery is imminent, and this shot has helped improve the health of innumerable babies worldwide.

But to give it in a perfectly normal pregnancy? Obviously, they make the decision to give this based on the statistics. Apparently, most of the surrogates are preterm (At or before 36 weeks), for any number of reasons: a higher incidence of multiples pregnancies, poor nutrition, low vitamin D levels, the strain of having borne many children, etc. Additionally, when they are not under the supervision of a doctor, if things move very quickly say, around 32 weeks, then there may not be time to give the shot: the situation IS different from that of a regular pregnancy.

But a blanket shot when things look fine? This is such a difficult call to make, and I have the choice of refusing this shot. I just don't know what to do. If any of you have any input to offer one way or the other, it would be most welcome.

Also, I have majorly revamped the "Science of Infertility" page, summarizing a lot of what I have discovered/realized in the past year. It is worth a read especially if you are still in the trenches.

On induced lactation

Claire, Michelle, Rebecca, Pam, Josey, Meg, Sloper (OMG, how did I miss out on your second pregnancy?!?!), thank you so much for your inputs.

I started reading up on induced lactation. Reglan is a no-no because it can cross the blood-brain barrier, and has one potential really scary side effect, tardive dyskinesia. My brother actually had that as a child.

Domperidone appears to be safer. Still, it can have cardiac effects---it can prolong something called the QT interval, and hence cause arrhythmia, which could potentially cause your heart to stop(!!). Here is a blogpost on the subject on the Skeptical OB blog, though I would say, this post does not seem to be wholly objective. The truth most likely is that this drug is safe in the majority of women, and would be dangerous for a smaller subset. Obviously it is more dangerous if you are mixing it with other medications that also prolong the QT interval, or you have underlying conditions that you are unaware of. The evidence for both intravenous and oral Domperidone causing arrhythmia comes from studies they did in people over 70 years of age.

But what genuinely scares me about this drug is the fact that the baby may get a tiny bit of it through breast milk, and if the baby has any underlying cardiac issues (one unverified source mentioned that 1 in 100 babies born have some sort of cardiac issue), this could be a bad combination. It is probably safe for 99 out of the 100 babies, but what if you are the 100th one?

So...if you are taking it, exercise caution with respect to dosage, be aware of your other medications, and I would suggest talking to your doctor too. I was also a little freaked out by Claire mentioning that her liver enzymes were elevated. So all in all, I'm going to give induced lactation a pass.

Human milk banking exists in Mumbai. However, the milk is pasteurized, which destroys most of the good stuff. I AM going to try to use the milk bank to find a wet nurse though, and if all else fails, supplement the goat milk formula with banked milk.

But all this is a ways away. I want to start doing stuff, but there is no way I will before I get to the "safe zone" of beyond 28 weeks, which I feel I am crawling towards one slow inch at a time. I'm sad to say that I'm not somebody who stops to smell the roses and celebrates what I have today, instead of thinking about tomorrow. I can't celebrate that the J has completed 22 weeks of pregnancy today...all I can think of is how much more time has to pass before we are in the relatively safer zone of 28 weeks and beyond.

But this is folly, because once you decide to have a child, there is no safe zone anymore. After birth, you worry about SIDS and diphtheria and the flu. You worry about Autism. Then one day you worry about your child being bullied at school. You worry about predators----it never ends.  Somebody described parenthood as having your heart walking outside of you, unprotected and vulnerable, for the rest of your life. And here we all are, eagerly signing up for all this.

Merry Christmas everybody. I'm so very happy for everybody who has gotten what they wanted for so long this year. For the ones who are still waiting or have had their hearts badly damaged, all I can say is that I am thinking about you. There are no words to make it better.

Checking in: Week 21

I did some more investigations on surrogacy options in India today, and I'm starting to get a much clearer picture of things. I wish I had acquired all this knowledge months ago, but that is not how it works. Sometimes, even the less than ideal choices we make can lead us someplace good, and sometimes, doing everything correctly and logically will still not garner success.

Still, others will benefit from what I have learnt, and that makes me pretty happy.

One thing I did learn today--finding a human milk source in India will be extremely difficult. Everybody knowledgeable in this area is telling me that getting the surrogate to do this is a bad idea. I atleast want the colostrum, and I hope to god I can get that.  

Now, I have to seriously consider induced lactation. People who started this....what was your timeline? How long were you on the pregnancy hormones and domperidone before you stopped the hormones and the milk production began? I totally want the crash course and not the long drawn out process.

Finally: a question about the final stretch in the 3rd trimester: what gets done in each appointment? From my conversation with the surrogate handler, every checkup, all we can get done is the doppler to hear the heartbeat. That is it. There seems like there should be more, right?