International Adoption: Guatemala
by Erin

Note that the continuation of adoptions of Guatemalan children to US citizens is in jeopardy due to the US ratification of the Hague Convention in 2007. More information can be found at guatadopt.com.

Advantages to the Guatemala Program

• Foster care: Most adoptable children in Guatemala are in foster homes living in a family environment, not orphanages in which they may have very little one-on-one time with their caregivers. We know that a person’s early months are crucial to later development; the more physical, mental, and emotional stimulation an infant gets, the better.
• Information about the birth family: For relinquishment cases, which make up the majority of adoptions in Guatemala, a social worker interviews the birth mother to learn about the circumstances of the relinquishment and make sure she understands the decision to terminate her parental rights. Information about the birth family (in addition to a photograph of the birth mother and child taken at the time of the DNA test) is given to the adoptive family, who can then share this information with their child.
• Possibility of meeting the birth mother: It is uncommon in international adoption for adoptive parents to have the opportunity to meet the child’s birth mother. In relinquishment cases in Guatemala, however, it is possible if the birth mother agrees to it and your agency/attorney allows it.
• Infant referrals: Newborns are available for referral in Guatemala, and by the time the process is complete, the children are generally between 5-8 months old.
• Healthy children: Most children are relinquished due to circumstances of poverty, not because of they have physical or mental disabilities. Disorders such as Fetal Alcohol Syndrome are not prevalent in Guatemala.
• Frequent updates: Many agencies provide adoptive parents with monthly medical updates and photos. Adoptive parents find joy in the new photographs and comfort knowing that the child is receiving regular medical care.
• Relatively predictable timelines: Although timelines certainly fluctuate, adoptive parents do have a rough idea of how long each step in the process takes.
• Short in-country stay: Whereas some countries require at least one adoptive parent to stay up to a few months in the country, in Guatemala the stay is only a few days (adoptive parents can also choose to have an escort bring the child to the US in their stead). This means fewer food and lodging expenses for adoptive parents; if you are taking a leave from work, it also allows more time with the child once you are back home in the U.S.
• Ability to visit: For adoptive parents who are eager to visit the country of their child’s birth and begin the bonding process early, the ability to visit their child during the adoption process is a wonderful opportunity. Adoptive parents are encouraged to visit the baby in Guatemala before taking custody, so you can bond with the child very early in his or her life. In fact, if they wish, they can stay in Guatemala for 6-8 months and foster their own child.
• Geographical proximity: Being in Central America, Guatemala is closer than most other countries that allow international adoption to the U.S. This proximity makes it more viable for adoptive families to travel back to Guatemala as the child grows older.

The Process

The Guatadopt.com Resource Center provides very detailed information about the steps in the Guatemalan adoption process.

Resources

Guatadopt.com: Provides news, message boards, and information about the Guatemalan adoption process.

Soul of Adoption Guatemala forum

GuatemalaAdopt listserver, otherwise known as “The Big List”. Directions to subscribe can be found on guatadopt.com.

Choosing a Sperm Donor
By DI Mom

Why Would You Be Using a Sperm Donor?

Those most likely to use a sperm donor are heterosexual couples with male-factor infertility, lesbian couples, and single mothers by choice (SMBC).

[Remember that many people fall into the male-factor category including those who knew prior to trying-to-conceive that they would have trouble producing sperm including those who have a prior history of cancer, spinal cord injury, or a genetic illness. Some people who can produce sperm but are carriers of a genetic illness may choose to use donor sperm in order to not pass along those genes–Mel]

What to Expect?

The first step is usually to meet with a reproductive endocrinologist (RE). Your RE will perform various blood tests and ultrasounds on you, and your partner if necessary, to confirm the cause of the infertility, to rule out any STDs, and to verify that your cycle and hormone levels are with a normal range. You may also be required to undergo a psychological assessment.

You then need to select the sperm donor that you would like to use. The first decision is do you want a known donor that is chosen by you or do you want to use a donor from a cryobank?
Some women feel very strongly that the donor have a genetic tie to her partner. In this case, the couple may approach a male relative and ask him to be a donor. The other option is to ask a family friend to be a donor. If this is the path that you choose, you should consider what tests should be performed to verify your donor’s health, how utilizing a known donor may affect future family dynamics, and other unique challenges that may arise. Your RE can suggest various tests and resources if you prefer this route.

If you decide that you would prefer to use a more anonymous cryobank (AKA sperm bank), there are various levels of service that you should consider before you choose your bank. For example, some banks participate in an “open donor” program in which information about your donor may be released when your child turns 18. Others do not require that you be under a physician’s care, if you decide that you would prefer to perform the insemination at home. Many have online support groups for their clients. Some provide photos of the donors as children or audio of interviews with the donor. Once you determine which cryobank you would like to use, it is time to choose your donor.

All of the larger cryobanks have their donor list available in a searchable online document. Before you begin, it is helpful if you choose which characteristics and traits are important to you. If you are unsure if you will disclose to your child about your use of donor insemination (DI), you may wish to choose based on your partner (i.e. height, weight, eye color, hair color and type, blood type, etc.). Also, you can eliminate donors with a genetic history that you feel is problematic such as cancer or alcoholism. Many banks will perform photo matching where you submit a photo of your partner and they will suggest donors who have similar features.

You will also need to choose the specimen type, Intracervical Insemination (ICI) or Intrauterine Insemination (IUI). Discuss with your RE the pros and cons of the two types.

Once you have selected your donor, the next step is usually to contact the cryobank and place your order. You may have to pre-register with the cryobank so allow yourself enough time for the paperwork to be processed. Your order will then be delivered in a special nitrogen tank (dewar) and your doctor will help you determine your insemination date and time based on your ovulation cycle.

Problems that May Arise and Ways to Troubleshoot

The donor that you choose may be very popular, especially if he has reported pregnancies, so it is a good idea to have several alternatives in mind in case your top pick is not available. Also, cryobanks will keep specimens in quarantine for several months while some of the tests are run so a donor that is not available for your current cycle may be available for subsequent cycles. You can always ask the cryobank how many specimens are in quarantine and when is the expected release date.

Chart your ovulation date for several months prior to your insemination cycle so that your order will arrive at the appropriate time.

Personal Tips

Read over the personal tips that are in the Choosing a Donor Egg write-up. Most also apply to using donor sperm.

Before you begin, check with your insurance provider regarding what fertility tests and treatments they will cover. Get everything in writing and know the appeals process in the event your claim is denied.

Think ahead. If you think that you may want more than one child and it is important to you that they be genetically related, choose a donor with plenty of specimens available. When you become pregnant, you may purchase additional specimens and have them stored at the cryobank until you need them. If the specimens never leave the cryobank, you may be able to be refunded some of your money if you later decide that you no longer need them but check with your bank as to their specifics.

Depending on which bank you use, the type of specimen (ICI or IUI), whether you are under a doctor’s care or are performing the insemination at home, and other factors, one DI cycle will likely cost $1000-$5000. Before you begin, you should honestly assess your financial situation and determine how many cycles you can afford. Success rates are difficult to determine but are usually quoted as being around 10%. Some will become pregnant on the first try and others will require 12 cycles or more. You will need to decide what is right for you.

If you would like to read more about the in-and-outs of donor insemination, I highly recommend Helping the Stork: The Choices and Challenges of Donor Insemination by Carol Vercollone, Heidi Moss, and Robert Moss (Wiley, 1997).

Diagnosis: Anovulation
by Amy

What Anovulation Means and Its Impact on Fertility

Anovulation is the word used to describe a woman who does not properly develop and release a mature egg every month (ovulate). Women who are consistently anovulatory often have long, irregular cycles, sometimes not having a period for months or even years. The most common cause of consistent anovulation is Polycystic Ovarian Syndrome (PCOS). Other possible causes of anovulation include high stress, excessive physical exercise, obesity, overeating, birth control, hormone imbalances (thyroid, testosterone, prolactin, etc…), breast feeding, and even Premature Ovarian Failure (POF). Anovulation can be continual (such as with PCOS or other hormone imbalances) or it can be temporary (such as with stress or breast feeding). Doctors agree that even normally ovulating women can experience one or two anovulatory cycles per year. Anovulatory cycles obviously cannot result in a pregnancy (no egg = no baby). Medical intervention is needed when women are consistently anovulatory.

Diagnostic Process

Anovulation is diagnosed either via ultrasound and/or bloodwork (usually both). An ultrasound can reveal whether or not your ovaries are polyfollicular (PCOS). Bloodwork can be used to test hormone levels such as thyroid, prolactin, progesterone, and FSH levels (which can indicate POF).

Treatment Options

Treatment will depend on your diagnosis. If you are diagnosed with PCOS, you’ll probably start with clomiphene citrate (Clomid) and/or metformin (Glucophage). Generally, PCOS is treated with a combination of both. Specific medications and/or dosages will be adjusted accordingly, depending on each women’s individual response. For women who are anovulatory due to stress or exercise or if anovulation is deemed temporary, simple lifestyle changes can cause ovulation to return. For women with POF, treatment will probably be more in-depth and often includes In-Vitro Fertilization, sometimes requiring donor eggs.

Personal Experience

I, myself, am consistently anovulatory. However, my situation is slightly different because my anovulation is unexplained. All my hormone levels have been repeatedly checked and everything is within normal ranges. I do not have PCOS or POF. I am not stressed or obese, and I can safely say that I do not excessively exercise. No one has been able to tell me why I don’t ovulate. I did ovulate once on Cycle Day 50 of an unmedicated cycle and became pregnant (that pregnancy ended in miscarriage). Thankfully, under the care of a knowledgable Reproductive Endocrinologist (RE), we learned that with the right dose, I respond beautifully to Clomid. I have done nine Clomid cycles, eight of them ovulatory (my first round of 50mg of Clomid was anovulatory). I became pregnant on three of the eight ovulatory cycles. Unfortunately, all ended in miscarriage due to chromosomal issues having nothing to do with the Clomid. I am still using the Clomid (as of this writing, I am in the middle of my ninth Clomid cycle) to induce ovulation.

Diagnosis: Luteal Phase Defect
by Melissa

What a Luteal Phase Defect (LPD) Means and Its Impact on Fertility

In order to talk about the important things like progesterone levels, you need to know something about your cycle. Simply put, your cycle is broken down into two parts. Pre-ovulation, it’s called the follicular phase. As it sounds, this is the part of the cycle where the follicle is growing and preparing to release an egg. After ovulation, the second part of your cycle is called the luteal phase. This is the time where the embryo implants and (hopefully) gets cozy for the next nine months. If the embryo fails to implant–or going even more basic, the egg fails to fertilize–the cycle ends and begins anew with your period.

Follicular phases can vary in length. Sometimes, they fit the average 28 day cycle and the person has a 14 day follicular phase and a 14 day luteal phase. But the length of time is determined by the follicle’s rate of growth because the follicular phase will continue until the egg is released. That could happen earlier than 14 days or much later than 14 days.

The luteal phase isn’t really supposed to vary in length like the follicular phase. The length of the luteal phase is determined by the corpus luteum (the “yellow body” that is left after the egg is released from the follicle). The breaking down of the corpus luteum and the end of the cycle usually happens around 12–14 days after ovulation (unless the embryo implants).

But in some women, it happens much sooner. Or the corpus luteum doesn’t secrete enough progesterone. Or the progesterone it does secrete doesn’t build up the endometrial lining for implantation. Which means that the person either cannot become pregnant or maintain a pregnancy.

Diagnostic Process

There are several tests that are used to determine a luteal phase defect. The least invasive is what is called a “day 21 progesterone test.” It actually needs to be drawn around 7 days post ovulation (7 dpo). Therefore, it would only occur on the 21st day of your cycle if your cycle was 28 days long and you ovulated on the 14th day. Most doctors want to see at least 10 ng/mLs of progesterone and some give a diagnosis of low progesterone for anything under 20 ng/mLs.

Some doctors will treat a LPD with progesterone supplements and follicular-stimulating hormones without conducting more tests. But those who have normal progesterone levels and adequate follicles may have an endometrial biopsy performed if a day-21 sonogram (again, 7 dpo) reveals endometrial lining that is too thin. Whether or not your doctor progresses to performing an endometrial biopsy will be determined by his comfort with diagnosing from blood work and sonograms.

Treatment Options

The corpus luteum is only as good as the follicle that creates it. Therefore, many doctors begin by attempting to nurture great follicles which will in turn become strong corpus luteums. Doctors will prescribe Clomid (oral) or an follitropin like Follistim or Gonal-F (sub-cue injectible) to stimulate follicle growth. After ovulation, vaginal suppositories of Prometrium are prescribed (there are also IM injections of progesterone).

Personal Experience

We began suspecting there was a problem once I began charting my temperature. Most months, my luteal phase was only 10 days long (or less). But on other months, my luteal phase would stretch as long as 21 days without tipping a positive home pregnancy test (though blood work showed low hcG levels). Blood work 7 dpo confirmed low progesterone. My first blood draw had a result of less than 5 ng/mL. Every subsequent test showed under 3 ng/mL.

We took Clomid (days 3–7) and then Follistim (over the course of many days based on sonograms and hormone levels). After few days after an hcG shot to trigger ovulation, I took Prometrium twice a day until I received a negative beta (or in the case of the month I got pregnant, I continued taking Prometrium until my 15th week of pregnancy).

Uterine Anomalies
by TeamWinks and Serenity

What a Uterine Anomaly Means and Its Impact on Fertility

A uterine anomaly is a form of congenital birth defect – in that the uterus forms when the fetus is inside her mother’s womb.

About ten weeks after conception, the uterus is comprised of a pair of structures called mullerianducts. The top of the ducts (i.e. the ones closest to the embryo’s head) will become the fallopian tubes – they remain separated throughout development.The bottom of the mullerian ducts, however, begin to fuse together to become one structure that will become the uterus. At stage one of this fusion, they have formed a central wall, or “median septum” in the middle of the fused tube. This structure, when first formed, is a cylindrical structure of equal diameter.

Between ten and thirteen weeks, the central wall of this tube begins to expand at the top to form the uterus fundus. At the bottom of the uterus, this central wall, or median septum also begins to dissolve; leaving a continuous chamber that will become the uterine cavity.Between weeks thirteen and twenty, the median septum should dissolve completely from the bottom to the top of the uterus, resulting in a single, continuous uterine cavity.

Uterine anomalies result from the following:

• failure of one of the two mullerian ducts to form (unicornuate),
• failure of the two ducts to fuse completely (bicornuate), or
• failure of the two fused mullerian ducts to dissolve the median septum (septate).

Diagnostic Process

Some uterine abnormalities can be diagnosed with a simple ultrasound – a bicornuate uterus, for example, sometimes clearly shows two uterine cavities (or “horns.”) However, once a uterine abnormality is identified, it does take some work to fully diagnose it. The best method of diagnosis is generally a hysteroscopy and/or laparoscopy, but that requires the use of generalanesthesia and is generally more expensive.

A HSG & Saline Infusion Ultrasound, where they fill your uterine cavity with fluid/dye can give your RE a good idea of what type of abnormality exists. Your RE may want to perform a MRI, CT scan, and/or 3D ultrasound as well.

Treatment Options and Prognosis

Treatment of a uterine abnormality is entirely dependent on which type of diagnosis you receive and your RE. Generally, however, a septate uterus will present fertility issues in that the septum has no blood flow and will sometimes interfere with the implantation process. In that case, a hysteroscopy and laparoscopy will be recommended, where your RE will surgically remove the septum. Depending on its size, you may need multiple procedures. Unicornuate and bicornuate uterus diagnoses will often not be treated at all, since with both types there tends to be a normal blood flow to the uterus. However, there is an increased chance of preterm labor – since the uterus doesn’t stretch like a “normal” uterus would. Thus, when a woman with this type of anomaly becomes pregnant, some doctors classify them as high risk.

Personal Experience

TeamWinks’s perspective

Once you learn that you have a uterine anomaly, you can expect a whole lot of confusion. It is often very difficult to pin down exactly what your uterus looks like. Reproductive outcomes for women with these anomalies aren’t all that reassuring, and it certainly doesn’t help that there is a lack of literature out there to educate yourself. Be prepared to primarily read literature that was prepared for other doctors and not the average woman. They are often dense articles, and take time to work through. There is a wonderful support group on yahoo that does help (http://health.groups.yahoo.com/group/MullerianAnomalies/)

I am not sure whether I have a bicornuate uterus or a unicornuate uterus. My RE has been unable to pin this one down. Soon we should know for sure. I would say on a good day that having this birth defect can be difficult. Often women with a uterine anomaly have only one kidney. Thankfully I have two. They also have high incidences of PCOS, endometriosis, insulin resistance, high miscarriage rates, and pre-term labor. That’s a strong cocktail thrown at you at once. I truly believe you need a support system from the moment the diagnosis is handed to you. It’s important to remember that it isn’t a death sentence. However, it is important to ask as many questions as you can.

Serenity’s perspective

My RE thinks that I have a true bicornuate uterus, which was diagnosed last year after my hysteroscopy. But given our recent IVF failures and that we believe it might be implantation related, we are revisiting this at the end of the month, however, with a 3D ultrasound to ensure that he didn’t miss a septum earlier. The biggest thing to remember: the statistics and risks they throw at you when you’re diagnosed are often skewed. There are a lot of women who a have bicornuate/unicornuate uterus who have never been diagnosed; they have gone on to get pregnant and have perfectly normal pregnancies and healthy babies. My OB and my RE told me that having a bicornuate uterus was probably the “best” one to have, practically speaking, since I have good endometrial lining in both horns. They have also told me that the bulk of women who have this to go on and bear very healthy, normal children. So my advice would be to take the risks you’ll read about with a grain of salt.

Links for uterine anomaly research:

http://www.emedicine.com/med/topic3521.htm

http://www.sidelines.org/

Images of Uterine Anomalies

In addition, Preventing Miscarriage by Jonathan Scher has some information about uterine anomalies and their role in miscarriage.