I don’t drink very often, but I still feel the need to complain about the fact that I don’t drink during the two-week-wait. Because until it’s for something, it’s all for nothing! You skip the free French Martini at the open bar because you’re secretly hoping that you’re with child, and then AF shows up and you kick yourself because free alcohol doesn’t grow on trees!

Stirrup Queens need special drinks during their two-week-wait as well as any night that they need to give themselves an injection (real alcohol can be consumed on any evenings when you get a…don’t say it…BFN). Drinks that they can pour into a martini glass and feel shmancy.

I am currently drinking one of these drinks as I write, so in addition to making you send me your comments, blog addresses, write-ups for Operation Heads Up and every other little thing I demand from all other SQs and SPJs, I am now asking you to add your best 2ww drinks.

The Whoa-Nelly (tweaked from the Jen’s Delish of Northampton’s Haymarket Café)

1 cup decaf iced coffee (that’s the only drawback to this drink—you need to have the coffee cold so make it the night before)
1 cup milk
a few squirts of chocolate syrup
a few glugs of hazelnut syrup

Shake together and pour into chilled martini glass. Drink while staring longingly at that unopened box of pee sticks. Continue drinking while not testing.

International Adoption: China
(written on December 21, 2006)

Why Choose China?

(Note: this article addresses adoption of children without special needs. The process is somewhat different for parents adopting children with special needs.)

Some of the most common reasons parents choose to adopt from the People’s Republic of China (PRC) are

• • Ethics. The PRC’s program is well-established, complies with the Hague Convention, and has comparably fewer incidents of corruption.

• • Community. Because the PRC’s program is well-established, there is a correspondingly well-established network of parents who have adopted from the PRC.

• • Familiarity. Some people are drawn to the PRC’s program because they have a friend or family member who has had a positive experience with Chinese adoption.

• • Gender preference. Most of the children adopted from the PRC are girls, and there is an overall preference for adopting girls, especially intercountry adoption.

• • Certainty. Once parents obtain adoption approvals from their agency and home country’s government, adoption from the PRC is generally a matter of “when” not “if.”

• • Confidentiality. The PRC’s program is more “closed” than other countries, meaning that currently there is little or no possibility of contact with birth parents.

• • Economics. The fees for the PRC’s program are among the lowest of intercountry adoption programs, and parents are only required to travel once.

• • Health. The health report that accompanies the child’s referral is reportedly reliable, and evidence of in-utero exposure to drugs or alcohol is rare.

• • Humanitarianism. Some people choose the PRC because they have seen or read something that has led them to believe that there are children who would otherwise grow up in orphanages if not adopted by people outside the PRC.

• Culture. Some people choose the PRC because they are of Chinese (or other Asian) descent, or because they have an affinity for Chinese culture or people.

For a series of first-hand accounts by bloggers about why they adopted from the PRC, from the PRC, click here.

What to Expect

Outline of process

Adopting a child from the PRC who has not been identified as having special needs follows a straightforward and predictable process. Parents who qualify to adopt from the PRC first select an agency. Then, the parents obtain the necessary government permits and complete any paperwork required by the agency — for example, a home study, background checks, personal statements, and adoption coursework. This part of the process usually take a minimum of 3 months, but can take a year or more.

Once the parents complete their pre-adoption requirements, their paperwork — known as a “dossier” — is transmitted to the China Center for Adoption Affairs (CCAA). The date that the dossier is sent to the CCAA is called DTC (dossier to China).

The CCAA conducts an initial review of the dossier and then logs it into their system. The date that the dossier is logged in at CCAA is called LID (log in date). In general, the LID is about 2-4 weeks after DTC.

The CCAA processes the applications in LID order. Each dossier is matched with an available child, and the CCAA sends out batches of referrals to the agencies every 25-35 days. Usually referrals consist of photo(s) and a health report, and parents have the option to accept or reject the referral. Parents who accept their referral can expect to receive their travel authorization from the PRC 3-5 weeks later, and will travel 4-8 weeks after that.

Parents are given full custody of their children within the first few days after arrival and remain in the PRC for a total of about two weeks to complete official adoption paperwork. During this time, parents bond with their children and do a little sightseeing. Depending on where the parents live, there may be additional official paperwork necessary to complete the adoption upon returning home.

The CCAA requires families to file post-placement reports after the adoption is complete. These reports are due at 6 months and 12 months after adoption. In addition, if the child remains a PRC citizen, parents must file post-placement reports every 6 months.

Time frames

Time frames from DTC to travel have been increasing steadily since 2005. For example, families with LIDs in mid-August 2005 did not travel until December 2006 (approximately 16 months from DTC to travel) — about double the time frame from what it was for families with LIDs in late 2004/early 2005 (approximately 8 months from DTC to travel). See this post for a discussion about the current slow-down in referrals and application trends.

It is not clear how much longer the time frames will continue to increase, but the CCAA hopes that the upcoming revisions to its adoption criteria will eventually help reduce the time frames to 8-9 months from DTC to travel. To estimate referral time frames, based on current data, see the calculator at this website.

General qualifications

The CCAA’s requirements for adopting from the PRC are posted here. If you are a United States citizen, the State Department information on adopting from the PRC is here.

People of Chinese descent may be eligible to have their dossiers processed on an expedited schedule.

The CCAA is updating its policies and will soon announce revised criteria for eligibility to adopt from the PRC. These criteria have already been unofficially released to adoption agencies, and are expected to be applicable to dossiers sent to the CCAA after May 1, 2007. Some agencies already have the expected changes posted on their websites, but contact your agency for specifics.

COMMON ISSUES SPECIFIC TO CHINA

Eligibility under revised criteria

Parents who do not expect to be able to meet the revised eligibility criteria should get started as soon as possible to complete the necessary paperwork, including the home study and any government permits before early April 2007 (assuming it takes about a month between DTC and LID). In the US, obtaining advanced processing approval from the United States Citizenship and Immigration Service (USCIS) can take a month or more after the application is complete. In addition, all documents must be translated and authenticated before a dossier can be sent to the PRC. Expect additional time for completing these steps as it’s likely that there will be a large number of parents trying to get their paperwork in before the revisions take effect.

Expiring paperwork

One consequence of the increased time frames is that some adoption paperwork may need to be updated or renewed while waiting for referral. For example, the I-171H issued by the USCIS is only valid for 18 months, and FBI fingerprinting is valid for less than that. Also, most home studies are only valid for one year before they need to be updated. Parents who are currently preparing their dossiers should expect that their paperwork will expire and factor this cost into their adoption budget.

Personal Tips

Stay informed</em >

If your adoption or home study agency has a email newsletter, subscribe to it to keep abreast of changes in the PRC’s program. Many people also monitor this website and its forums for updates and speculation on referral trends.

Get support

You can connect with other parents adopting from the PRC online. There are yahoogroups, such as the very large Adoptive Parents China (APC) yahoogroup, as well as yahoogroups for individual DTC months and agencies. Also, the link to the “Why China” series of posts is a good starting point for connecting with the active community of Chinese adoptive parent bloggers.

You can also visit Families with Children from China to see if there is an FWCC group in your area where you can meet parents and prospective parents who have adopted from the PRC.

Become prepared

Adopting a post-institutionalized child can be challenging. Transracial and/or transcultural adoption can be challenging. This website is an excellent resource for information on attachment and identity to use as a starting point for parents and their families. There are links to websites with further information, as well as book recommendations.

Diagnosis: Unexplained Infertility
by Jackie

What Unexplained Infertility Means and its Impact on Fertility

Unexplained infertility is a diagnosis given after all other possibilities have been excluded. That is to say, after going through the diagnostic process (see below) there is no explanation for the infertility. The male partner has a normal semen analysis. The female partner ovulates and her hormone levels are all within normal limits. In addition, her uterus is free of anatomical abnormalities and the Fallopian tubes are open or patent. In addition to these physical findings, neither the couple’s nor their families’ medical histories indicate any reason why the couple should be infertile. Couples with unexplained infertility have substantially reduced cycle fecundity rates, 1-4% compared to 20-25% for normal couples. Pregnancy rates decrease with increasing maternal age and duration of infertility. Estimates place unexplained infertility at 10-20% prevalence among infertile couples.

Diagnostic Process

Male partner: medical history, family medical history, semen analysis.

Female partner: medical history, family medical history, physical examination, hormone tests (such as Day 3 FSH, estrogen, progesterone, prolactin, thyroid hormone, androgens), demonstration of ovulation (mid-luteal progesterone), hysterosalpingogram (HSG, to determine whether the tubes are patent). Other tests may be performed if indicated by the history. This may include laparoscopy to determine whether endometriosis or adhesions are present. The post-coital test to determine sperm viability in cervical fluid may also be performed although it has been determined that this test has poor predictive value for conception rates.

After the test results come back and no detectable reason for infertility is identified, the unexplained infertility diagnosis is given. This does NOT mean that there isn’t a reason for the infertility. It means that the science and the diagnostic tests are not advanced enough to detect the cause of infertility. Egg quality, fertilization, and implantation factors are difficult to test and may be the underlying problems.

Treatment Options

Since there is no known abnormality to remedy in unexplained fertility, all treatments are considered “empiric”. In general, this means the therapies have been observed to be helpful in getting over the infertility, but how? Unknown. All options are possible here and really are only limited by your resources, beliefs and desires.

1. Expectant management: Also known as wait and see, or my favorite term: keep on having the sex. At the end of three years, the pregnancy rate for women with unexplained infertility is about 30-60% without intervention. But can you wait 3 years for a cumulative 30-60% chance of getting pregnant? This is not the same as cycle fecundity rate. In fact, if you have a 28 day cycle, in 3 years, you will have had 39 cycles. My extremely rough math places the cycle fecundity rate at about 0.75-1.5%.

2. Clomid: This drug is a selective estrogen receptor modulator. Basically, it acts on estrogen receptors in the pituitary gland to increase release of FSH and LH and thereby increasing the quality and possibly quantity of mature follicles released from the ovaries. Clomid alone for unexplained infertility increases cycle fecundity rates only a couple of percent over placebo, so from about 1-2% to up to a whopping 4-5%. There is no benefit of using clomid alone for more than 6 cycles with unexplained infertility.

3. Intrauterine Insemination (IUI): One factor that can be difficult to ascertain is hostility of the female environment toward the sperm. The aforementioned post-coital test was more routinely performed until it was determined that the test is not a great predictor of pregnancy rates. To get around any potential hostility, the sperm can be prepared from a semen sample and injected into the uterus bypassing the vagina and cervix altogether. IUI has been found to have a small benefit over timed intercourse in unexplained infertility (5% vs. 2% cycle fecundity rate).

Fallopian sperm perfusion (FSP) also circumvents the vagina and cervix as well as the uterine environment by placing the sperm directly into the Fallopian tube using a laparoscopic procedure. Studies are divided on whether pregnancy rates are improved with FSP compared to IUI in couples with unexplained infertility.

4. IUI following controlled ovarian hyperstimulation (COH): This normally combines Clomid with IUI, but gonadotropins can also be used. Cycle fecundity is improved when ovarian stimulation and IUI are combined over either treatment alone. The average increase in cycle fecundity with combined therapy is about 10%.

5. In Vitro Fertilization (IVF), Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer (ZIFT): Assisted reproductive technologies offer the highest pregnancy rates among those with unexplained infertility. Most published studies indicate 25-50% pregnancy and live birth rates in those with unexplained infertility. These procedures are more costly and invasive that the other therapies and have somewhat higher incidences of multiple births.

A typical treatment trajectory goes from low cost, low tech for several cycles, advancing from Clomid alone to COH/IUI to IVF. Couples with more resources may opt for the higher cost, higher tech treatments immediately. Since the cause of the infertility is unknown, it is impossible to know how much intervention is necessary to get pregnant.

Personal Experience

My husband and I sought assistance after 18 months of unsuccessfully trying to conceive. Our medical histories are normal. I have extremely regular 28 day cycles (almost to the hour), I have never been pregnant, and I have never been diagnosed with endometriosis. For his part the semen analysis was normal. My day 3 hormone levels were spot on. My HSG showed open tubes with bilateral peritoneal spillage of dye. My mid-luteal progesterone was 9.6-definitely ovulating, but sort of mediocre. My RE’s office likes to see it closer to 15. Therefore, my first treatment was Prometrium, which elevated mid-luteal progesterone to about 25.

After 2 unsuccessful cycles, I have opted to try Clomid. In fact, I will take my first dose today. My clinic does not monitor ovulation by ultrasound so I will be peeing on sticks to determine the LH surge. The clinic will draw a mid-luteal progesterone which I expect will be higher than 9.6, but who knows. If Clomid doesn’t work, then we will move on to COH/IUI, and if that doesn’t work, then we will likely undergo IVF. We are definitely taking the low tech, low cost to progressively higher tech, higher cost route. All testing is covered by our insurance including a once-in-a-lifetime laparoscopy which I may elect to have performed sometime this year to definitively rule out any endometriosis.

I must admit that it’s quite frustrating, not knowing WHY. Any more frustrating than knowing why and not conceiving? That’s highly unlikely. And it doesn’t change the treatment options that much from some other “known” types of infertility.

Questions for a High-Risk OB (Maternal Fetal Medicine or MFM/high-risk OB)
By Tina

A pregnancy is classified as “high-risk” when a mother and/or baby are deemed in danger during any part of the pregnancy. For a baby, this means either being born prematurely and all the problems/risks involved with it, or defects/conditions found by prenatal testing that may or may not endanger the child’s life. For a mother, this means serious health issues that can threaten her life/her baby’s life or are known miscarriage risks, such as high blood pressure, blood clotting disorders, thyroid disorders, diabetes, etc.

Most women end up meeting with a high-risk OB once they are already pregnant and issues develop with the pregnancy. For women who are found to have conditions that cause recurrent miscarriage, they are usually sent to meet with a high-risk OB prior to pregnancy for a pre-conception consultation.

My list of tips and questions stem from my personal experiences in dealing with a homozygous MTHFR gene mutation (and high homocysteine levels) and elevated anti-thyroid antibodies (specifically, Anti-Thyroglobulin Antibodies [Tg-Ab]).

I ask that as other women read this list of questions, you e-mail the Town Criers to add any questions you think need to be added (and you be credited for your additions) – I can’t possibly think of all questions to ask, especially because I have not yet reached the hurdle of getting pregnant yet.

For your pre-conception consultation/first appointment:

Keep a running list of questions prior to your appointment (especially if this is a pre-conception consult, since you will most likely have a wait before the appointment). As your appointment date comes closer, re-read your questions and prioritize them so they are organized for the doctor. If you are sent to a high-risk OB on an emergency basis, try your best to remain calm and organize your questions as best you can. Have your partner help you with your list.
Bring/have faxed over any relevant medical records: Surgeries, results of any tests run, list of medications, etc. You cannot guarantee your referring ob/gyn’s office (or other specialists involved) sent over everything the doctor will need.

If the clinic/doctor does not send you the medical history/insurance paperwork ahead of the appointment, request that it be sent to you. You will have more time to complete it and bring it with you – and your doctor will have more accurate information to review.

If the clinic/doctor you are seeing has a web page, try to find it prior to the appointment so you have some working knowledge of the office. It will save you time in the appointment from simpler questions on office hours, etc. for the more important issues that need to be discussed.

If possible, have your partner accompany you to the appointment. Since family history will most likely be taken during the appointment (even if you fill out forms prior to the appointment), it is good for the doctor to assess both sides.

If you specifically are going in for a pre-conception consultation, find out about how much time is allowed for the appointment. You do not want to be rushed through your questions.
Always take notes during the appointment – and write down/highlight anything that is unclear so you can ask the question again.

Questions about the facility (specifically if this was not on the web or given to you by your referring ob/gyn):

• How long has this office/clinic been open?
• What are the office hours?
• What is the location of the office? If the office/clinic is located in a hospital, ask about parking and parking validation.

About clinic/office communication:

• Is there a case manager that handles each patient?
• Who is available for call-in questions?
• How can I leave a message directly for the doctor for questions?
• Is there a number for off-hours problems and emergencies? What is the protocol for emergencies?

About the MFM doctor specifically:

• Where did the doctor(s) earn his/her degree(s)? What is his/her training in high-risk OB?
  What hospital(s) are he/she/ affiliated with?
• How well does he/she/ know the referring ob/gyn?
• Will the doctor met at the consult appointment be the primary doctor for all appointments? If not, how many other doctors are part of the group? What are their rotations?
• Will all treatment and procedures be performed by the doctors or technicians?
  How often will I get to meet with the doctor face to face?
• How open is the doctor to discussing information learned about from other sources?
• Is genetic counseling recommended? (if this has not already been done)
• What books are recommend for reading?
• What is the doctor’s view on alternative treatments (acupuncture, vitamins, etc.)?
• Will the MFM doctor be present during delivery with the referring ob/gyn?

About treatment and procedures:

• What additional tests need to be performed to evaluate me/us?
• Will my treatment be individualized or will set protocols be followed?
• What procedures are performed at the clinic/office? Which in a hospital or ambulatory center?
• Are there set office hours for specific procedures (ie: Blood tests, ultrasounds)

About success rates:

• May I contact any of your patients who have had similar risks/treatments?
• What are your statistics for couples with our diagnosis?
• How do your statistics stack up against national averages for live births?
• What would account for these differences?

About specific tests:

• Will the doctor run a color doplar ultrasound to rule out a condition called Vasa Previa(women who conceived via IVF have a higher risk of this condition)?–added by Linda.

Personal tips and things to keep in mind:

If you know you have a condition prior to pregnancy that will ultimately make you high-risk and your ob/gyn does not suggest seeing a MFM clinic prior to pregnancy: Insist on it. The more eyes watching over the high-risk pregnancy, the better – even before the pregnancy occurs.

Your ob/gyn and MFM doctor may not always agree on care when you see them individually. If you hear one thing from your ob/gyn and something else from the MFM doctor later, ask that they confer on your case so 1) you get a straight answer and 2) you get the right answer.

You will be seeing your health practitioner more often – possibly every two weeks instead of every four weeks from the start because you will alternate between your regular ob/gyn and your MFM doctor. Nearing the end of your pregnancy or if some other issue(s) comes up, your doctors will want to see you more often – possibly once a week. If you are working or need to arrange for childcare, you should keep those visits in mind.

Ask if you can set up appointments in advance so you can coordinate them with your ob/gyn and other specialist visits.

Make sure you continue to see any specialists that you need to treat pre-existing medical condition(s). These specialists can work closely with your doctors to help supervise your pregnancy.

Ask for all copies of reports on tests run, bloodwork, etc. so you have it with you when you need it, including when you go in for delivery. Remember: No question is to small or too “stupid” when it comes to high-risk ob. Don’t be embarrassed by any questions you may have. As with a non-high-risk pregnancy, it is vital you quit smoking, drinking alcohol or taking illegal drugs, or anything else that would be detrimental to the baby.

Gestational Surrogacy
by Tara

Why would you be using surrogacy?

Infertile couples generally move to surrogacy after being given a definitively negative diagnosis about their ability to conceive. While there are many, many factors that contribute to the decision of using a surrogate, some broad examples of diagnoses that lead to surrogacy are endometriosis, hysterectomy, and poor egg quality. A couple may also choose surrogacy if they are told they cannot safely carry a baby to term.

There are two types of surrogacy: Traditional Surrogacy (TS) and Gestational Surrogacy (GS).

With TS, the carrier’s eggs are used and the child is biologically related to her. With GS, the Intended Mother’s (IM) or a donor’s egg is used and the child is either biologically related to the IM or to the donor. With both TS and GS, either the Intended Father’s (IF) or donor sperm can be used.

What to Expect

1. Time. The surrogacy timeline is not usually very short. Expect at least 4 months to pass between the time you decide on surrogacy until you are waiting for the call from the Dr. with your pregnancy test results.

2. Finding a carrier. Whether you are using a TS or a GS, finding the best carrier for your family is the most important part of the process. In an ideal world, we’d all have a friend or family member willing to give us the special gift of carrying our child. But since that isn’t possible for everyone, it’s important to do your research and find a good agency or surrogacy service that will match you with the perfect partner. Sometimes partners match independently without the use of a service and many of these matches are made online. I have read some beautiful stories as a result of Internet matches, but of course, as with anything on the Internet, anyone seeking a match this way should proceed with caution.

3. Legal issues. The laws regarding surrogacy are different in each state. Finding a good surrogacy lawyer is imperative as is having a contract drawn up between the carrier and the intended parents. This process can take quite some time, so starting early is important.

4. Money. Surrogacy is not an inexpensive option. The major fees are legal, compensation for the surrogate, and medical fees. The range is wide—but no matter your situation, you shouldn’t expect to pay any less than $10,000, and many people will pay up to $50,000 or even $100,000 depending on the situation.

5. Insurance. In most cases, the carrier’s insurance will cover the pregnancy. Your lawyer should advise you to carefully read her policy to make sure there are no significant exclusions. If the carrier doesn’t have insurance, you may be required to purchase insurance for her (or you may want to find a carrier that does have insurance).

Problems That May Arise and Ways to Troubleshoot

It would be impossible to consider ALL of the legal issues that might possibly arise as the result of a surrogate pregnancy. Therefore it is so important that you find legal representation from someone who has extensive experience with surrogacy. You’ll be surprised at the number of things you have to work out before you can even start the meds or go to transfer! It’s also important to make sure you and your carrier are on the same page concerning some major issues such as compensation, number of embryos to transfer, number of cycles to try, pre-natal testing, and difficult decisions such as selective reduction/abortion. Figure the tough stuff out before any money changes hands.

Personal Tips

Don’t do surrogacy until you’re emotionally ready to do it. If you think you’ll be too angry that someone else can carry and you can’t, you might not be ready. On the other hand, it might be healing to you. You will know when/if you’re ready.

Have the carrier’s major testing done before paying a lawyer to draw up your contract. (You will likely have to pay a retainer fee, though, to get you started with some things). Be completely honest with your carrier from the very start. Keep as open a relationship as possible. And do the same with your partner!

It’s easy to feel separated from the pregnancy since you aren’t cycling or carrying. Keeping a blog or a journal during the process might help you feel more connected.

Some online resources:

http://www.allaboutsurrogacy.com/

http://www.surrogatemoms.org/

http://www.surromomsonline.com/

http://www.surrogacy.com/