Pros and Cons and Myths about Surrogacy in India

So this afternoon I get a call from CBS News, who are working on a news story about surrogacy in India. As expected, they are fishing for stuff that could go wrong, though I guess if they didn't it wouldn't be a news story. So they went surfing the net and sure enough they found folks like me, though with everything that went wrong I still consider us a case gone right. 

I worry because I have seen so many poorly researched news stories that sensationalize a few well known problem situations or clinics without telling the whole story and being balanced. Recent isolated cases of DNA tests not matching the intended parents are indeed very concerning, but still isolated and could conceivably happen in other countries as well. Some other "gone wrong" cases have more to do with a couple going to a clinic without making sure they were established and well reputed, or not being careful about legal conflicts (and the laws of the home country were the problem instead of India to my recollection). I don't think rare and extreme examples should be the basis of a decision like this. You can find a horror story about any potential infertility solution, so take them with a grain of salt and use reasonable precautions. Nothing is guaranteed, especially when it comes to infertility.

While India could use some better regulation on surrogacy, I hope they never become over-regulated to the point places like England are where it becomes nigh on impossible to do surrogacy. See: http://oneinsix.com/  I find that the biggest roadblock to surrogacy is not only the cost, but the lack of legal recognition that it is a legitimate path to parenthood in so called "developed" countries. India was our land of opportunity partly because the regulations were not overbearing.

There are plenty of pros and cons to any solution to infertility, and surrogacy in India surely as any has a unique set. I hope that my blog and online presence has helped to educate others in their decisions. But the bottom line: I would do it all over again and recommend it to others. But you must DO YOUR RESEARCH and prepare yourself. Above all find a reputable clinic. Clinics and surrogates have been deceptive and taken advantage in many countries, and regulation can't always keep you safe. Be prepared for what could go wrong. But also be prepared to finally have your dream come true and become a parent 9 months later! (Our in our case 6 months!) I will try to give a brief summary, insomuch as someone like me can ever be brief!

Pros:
1. The baby: You could finally become a parent! Finally having a child outweighs all the other pros by a mile, but you can't let it cloud your decision so that you don't do proper research and preparation or examine other reasonable/affordable alternatives for your unique situation.
2. The cost: A lot closer to $30K than the $100K+ you would pay in America. It takes 2.5 tries on average before successful implantation, so the cost for attempts is something to take into consideration.
3. The chances of success: If you are looking into surrogacy in India, you have likely looked at and tried other options but they have either failed, have low odds of success, or have cons that you are uncomfortable with. A proven gestational carrier combined with modern fertility medicine and the best prenatal care give you odds of success that other options may not have offered you. You could have equal chances of success for surrogacy elsewhere, so likely you are looking to India for the cost.
4. The betterment of many lives: The impact you will have on the surrogate and her family is beyond measure. The surrogate, her children, and her children's children will live a totally different life than they would have otherwise, with a home and education and life lifted out of poverty. Our clinic offered financial counseling and set up a trust in the surrogate's name to help them make sure to manage their windfall well for long term benefit.
5. Having the full experience: As a general pro to surrogacy anywhere, you get to to participate in a pregnancy, though in a limited sense when it is in India.  A big reason I chose surrogacy was that you get a child from their first day of life and experience infancy and all stages of development. Low cost adoption of older or challenged children, fostering to adopt where you can lose the child, or international adoption of an older infant or toddler were the only affordable options for us. While we intend to do that someday, each had an understandable downside with a process and paperwork that in my perception is a lot more intensive than surrogacy in India. If you can be a genetic donor, then you can also have the experience of a child that you are related to. It is not selfish to want that, anymore than it is selfish to want a healthy newborn that is lower risk for medical, developmental, and attachment problems.
6. Return on investment: While you can have failed attempts, you will be out a lot less money than you could potentially be from a failed adoption from what I understand. From my research I've seen more horror stories about failed adoptions and tremendous emotional pain and  loss of investment than I was comfortable with. I know an adoptive mother whose birth mother changed her mind in the several day waiting period after birth, and devastating does not even begin to describe it. An Indian surrogate not only does not want the baby, but they bear no relation or right to it. As long as your home country's regulations are also on board and you do the proper contract through a reputed clinic, this is YOUR child and it cannot be taken away from you.
7. Prenatal care: In India they will most likely choose to stay at communal surrogate housing, and you can choose that as a condition for your surrogate, though it could limit your selection. Some folks look at pics and see a room of cots and make negative judgements, but they have clearly never been to India. Trust me...a surrogate house is Shangri-la compared to other alternatives or where they have been living. Healthy food is prepared and educational classes are offered. There is air conditioning and on site medical care and close prenatal monitoring. They don't have to work and clean and endure the strain of caring for their own children during the pregnancy, though their families can visit frequently. These surrogates are not only happy about how their life and their family's lives are changing for the better and their comfortable accommodations, but many of them say the lifelong friendships they formed with other surrogates are the best part and lead them to do it again.
8. You have a greater chance of having twins. It's risky, but it is also AWESOME! This is a pro for surrogacy in general, and not exclusive to India.

Cons:
1. Culture shock: If you haven't traveled, been to a third world country, and aren't familiar with Indian culture you are in for a shock. But if you open up your mind and prepare yourself it can be an amazing trip and a wonderfully life changing experience. I married into an Indian family and had spent a month there 8 years before we tried surrogacy so it was a lot easier for me and I knew what to expect. If you are borderline OCD and like everything antiseptically clean and hate crowds and traffic, India may not be for you. In my personal opinion things are much cleaner than they appear, but Westerners are used to everything being new and bright and shiny.
2. Communication: The language barrier, cultural differences, and time zone will pose definite challenges. As someone who has suffered from the pain of infertility, you are likely to have some control freakishness going on so the lack of clear communication will be hard to handle but can be well worth the frustration when the baby is finally in your arms.
3. Emotional connection: There will not be much of one, either with the surrogate or your baby. You are having a baby by email, and it may not feel like this is actually happening until there is a screaming infant being handed to you. You may connect with the surrogate, but since you don't have ether lifestyle or language in common it isn't likely. You will have the baby in common, and that is enough. It is primarily a business arrangement, and there is really nothing wrong with that. It's great if you can have a local surrogate in your home country and ya'll become besties and can share in every moment of the pregnancy, but it's not somehow morally wrong if that isn't your reality.
4. Medical standards: They do a great job at Indian NICU's. Don't get me wrong. But having experienced both I can confidently say that they cannot compete with American medical care, even if it is simply because of the available technology and not the doctor's skill level. Availability of experienced specialists is more limited. You have to hope you won't wind up in this boat, but you can do everything right and it can't always be prevented. They may be able to treat the symptoms pretty well but not give a solid diagnosis, and advanced therapies may not be available.  I've felt guilty that my daughter needed more medical care and expertise than was available, but the fact is my guilt is misguided because I would have done surrogacy in America if I could have afforded it and I've done everything in my power to give her the best care I can possibly provide.
5. Baby born premature or with medical problems: This can happen anywhere, even if you have a well screened egg or sperm donor and your surrogate does everything right and has no complications. But since this baby is in another country where you don't live, you could be in for a long and expensive ride. Your insurance may not cover out of country care or put up a fight about coverage, even though it is far less expensive there. You might have to live in India for many months, or wait to join your baby until they are discharged from the NICU. You may have to medivac your child out. (Check out the Rasta Less Traveled blog for what this can be like). This part of the journey did indeed suck, but we made it through to the other side and have two beautiful babies and have our happily ever after.
6. Death of the surrogate: Though not a risk exclusive to India it bears mentioning. I only know of this happening once, and it couldn't have been prevented or anticipated. It was an educated risk the surrogate or any woman takes on in a pregnancy, so your clinic should offer life insurance. In the case I know of the family was paid several times what she would have earned, and the baby did survive.
7. Surrogate risking their reputation: Education and scientific understanding is lacking in India, so many folks can't understand how surrogacy works without infidelity or genetic links to the offspring to the surrogate. This is one reason why surrogates travel from smaller villages and often choose to isolate themselves in communal surrogate housing, though often it is for the comfort and camaraderie. They just tell people it was for a job opportunity, which is very common and an easily believable ruse .An Indian woman takes on this risk, though they do it in part because they understand far better than most women in the world the pain and stigma of infertility because of how it is viewed in their culture. Our clinic helped local women at lower costs, and helped fake a pregnancy so the family will never judge the woman for not being able to bear a child.
8. You have a greater chance of having twins. It's awesome, but it is also risky no matter where you do surrogacy. You may have to do a reduction procedure if more than two implant. You stand a greater chance of loss of the pregnancy or one twin, complications, or prematurity. It will be more expensive to have twins in any country, but if done in India while you live elsewhere you could find yourself paying for double the extended NICU and exit fees like we did.
9. You won't know gender: It's annoying because gender neutral clothing is a myth in my experience. But if you really care about this so much then you probably shouldn't be having a child in the first place.

Myths:
Please read my previous posts to see the many misconceptions about surrogacy in India. http://www.10milesuphillinthesnow.blogspot.com/2012/06/ignorance.html  and  http://www.10milesuphillinthesnow.blogspot.com/2012/05/surrogacy-faq.html.  
A couple of things I'd like to re-emphasize.

1. Indian surrogates are being exploited: Why is it assumed that they won't understand what they are doing but an American surrogate will? Do you have to have money in order to make a responsible decision for yourself? You don't have to be educated to be smart, and the tough lives these women have lived make me seem ignorant in comparison. They are perfectly capable adults who are counseled and aware of what they are doing, and selective reduction if necessary is done to ensure the health of the surrogate.  They have all been pregnant before, so that understanding of what it entails is a given.  Yes...being poor sucks in many ways. But it doesn't automatically make you less of a human being or less capable of making good decisions for yourself. And it doesn't mean that two women reaching across the world to help each other are engaging in exploitation just because one of them lives by what the other defines as poverty. Why is it that if you do it in America it is okay, but if you do it in a poorer country it is exploitation?

2. Isn’t there a risk of wealthy Americans ‘outsourcing’ pregnancy and birth to the third world to avoid stretch marks?”

Fears like this are extrapolated using a logical fallacy call the slippery slope. The pundits latch on to this one because sensationalism sells. It’s like saying that by allowing gays to legally marry pretty soon we’ll wind up allowing people to marry their dogs or inanimate objects. Sigh. Anyone who has been through the process could never imagine someone doing this as an “easy solution” because it is anything but. Having been through it, I cannot fathom any way where someone foolish enough to try this could even get through a beginning phase of the process.  It would be far costlier, but much easier to abuse surrogacy in the U.S. than to go overseas in my personal opinion.

Day 68: Certifiable

Great news today!

Vinnie picked them up at the embassy today along with the CRBA certificates that state our children are United States citizens.

We also made a long trip across town this evening to an ROP surgeon and all is clear so far. Vivek is out of the woods and Tara will need one more checkup in two weeks, but by then we'll be back in the US.

Vinnie leaves in the early AM hours Monday, and Monday morning at 9:30 I'll be at the FFRO applying for the babies VISAS! It normally takes 1-3 days, so barring any problems we could be out of here by the end of this coming week!!!



500 Babies....and counting!

So just this past week Dr. Patel and the Akanksha clinic celebrated the 500th baby born through surrogacy! Technically it was twins, so they are at 501.  Video below. Wish I could understand the language!

Media links below:

http://www.dnaindia.com/india/report_anand-clinic-celebrates-birth-of-500th-test-tube-baby_1702932
It was twin celebration for Anand’s Akanksha clinic when a surrogate mother delivered twin babies three days ago. The delivery not only brought incomparable joy to a childless couple, but also marked the 500th birth of a surrogate baby for the clinic.

The clinic wanting to share their happiness held a small ceremony which was joined by not only the recently born twins but also many other surrogate mothers and their families on Friday afternoon.

Doctors at the clinic say that childless couples from around 29 countries including India, USA, UK, and Pakistan turn to Anand seeking help of surrogate mothers to give birth to their babies. According to them, babies born through In-Vitro Fertilisation (IVF) have shown a ratio of 253 boys and 247 girls at the clinic.

“It is a good feeling. After a long struggle and controversies we have been able to spread happiness to 500 childless homes,” said Dr Nayna Patel, who is considered to be one of the pioneers in IVF surrogacy.


http://todayhealth.today.msnbc.msn.com/_news/2012/05/28/11883566-a-baby-made-in-india-a-couples-dream-comes-true?lite
This second one is a good article, but does address some of the need for regulation and the recruiting done in Mumbai slums.


I found a few more articles today, but they are poorly written and full of misinformation and logical fallacies so I'm not posting links because I don't want to contribute to fear and ignorance. Heavy on the slippery slope arguements and short on actual facts or research. People make a lot of statements and they are not backed up, and from what I can tell they are based on fears or isolated cases rather than reality. It just reminds me that modern day journalism lacks the ethics or integrity to put out well written factual articles, and I feel sorry for people who read the garbage they write and can't tell the difference.

Interpreting scan results & updates

We got an update today! I think the only reason we got it earlier than the predicted schedule of 23-24 weeks is because I sent Dr. Patel an email asking for a signed copy of our surrogacy agreement and to verify if our package of sarees and pictures and thank you letter to Manju was recieved. So excited, and today happens to be our eight year anniversary. I showed my husband the blog and he loved it!

So we are at 21 weeks along, though I say that because we are 20 weeks and 2 days, so that to me means in the beginning of week 21 right? Who the heck knows. I've seen all sorts of online calculators but I enter the same info and they give me different calculations on due dates and such, and with twins they are full term at week 37 anyway. I'm not really sure what week begins or ends a trimester because apparently there are 3 different ways to calculate it, though around 27 week mark seems about right:

by Development:

This uses actual developmental stages to divide up a pregnancy. From LMP to 12 weeks the embryo develops all the major organs and becomes a fetus. From 12 weeks to 27 weeks the fetus continues developing and reaches viability. From 27 weeks on the fetus finishes development and prepares for delivery. Here the second trimester begins at 12w 0d and the third at 27w 0d.

by Gestation:

With this method you take the 40 weeks of gestation and divide into three equal stages. Here the second trimester begins at 13w 3d and the third at 26w 6d.

by Conception:

This method is where you take the 38 weeks of post conception development, divide by three, into the three equal trimesters. Here the second trimester begins at 14w 5d and the third at 27w 3d.
What is the length of the first, second and third trimesters?
The length of the trimesters is often a source of confusion. The word trimester means 'three months'. Three periods of three months each, gives pregnancy a beginning, a middle and an end period.
These periods match the developmental stages to divide up a pregnancy.

• Beginning: From LMP (last menstrual period) to 12 weeks the embryo develops all the major organs, becomes a fetus, and the placenta takes over control.


• Middle: From 12 weeks to 27 weeks the fetus continues developing and reaches viability.


• End: From 27 weeks on the fetus finishes development and prepares for delivery.

As a side note, 28 weeks seems to be the magic number where a baby has a very high chance of survival with little to no chance of developmental delays. My brother's twins were born at 28 1/2 weeks and they are both fantastic with no problems, though it did take another full 3 months in the NICU before they could go home.

So when you get these scans from Dr. Patel, what are you supposed to do with them? Other than trying to figure out what part of the baby you are looking at, of course... I am not sure on most of them what I'm seeing if it isn't the head, and lately they seem to get even blurrier and harder to tell instead of easy like the first ones were. Maybe they are doing more close ups. Dunno, but this latest scan is the first time we have gotten shots that appear to the be fancier 3D Doppler kind. It says on the report "2D Echo" so that is probably what refers to these two shots.  Check them out! The 2nd one I don't have much of an issue telling what I'm looking at on the left side, but the 1st one I have no idea what is in front of my the baby on the right. Is that the other baby's feet or something?:
 
 


















I'm not going to pay out of pocket for a local radiologist to look them over when Dr. Shah (Anand radiologist on report) and Dr. Patel already have and say everything is fine. That would be going overboard. Okay, okay...so I did have my Dad call in a favor and forward the last two to a radiologist friend just to see if he could determine gender. He isn't sure cause they are scanned in with big fax stripes and so blurry by the time we get them by email, but he agrees we may have at least one girl. But I can scarcely see the A or B mark on each pic that tells you which pic is for which baby, so unless you have a double gender shot with both babies in it (highly unlikely) or see a boy and a girl clearly, you won't know which twin you are looking at in each photo and could think you have two boys when you are looking at the same boy for example. Plus they don't tend to take shots from the right angle since they aren't really trying to detect gender. I don't honestly care because I just want them healthy, but it would make packing clothes so much easier because gender neutral stuff is harder than I thought to find.  I can tell you that when you see a split screen pic with two images in it that it seems to be of the same baby every time.

So what does all of it mean beyond the pictures? I just go to the very bottom and look for the sentences first, since it is easiest to understand and seems to sum it all up. I'll put what I've been able to decipher from Googling, but I'm just a layperson and NOT a doctor or radiologist so I could be very wrong. I know a bunch about physiology and anatomy from taking two college courses for fun on the subject and getting my Emergency Medical Technician in 1995, but that hardly makes me an expert so take everything below with a grain of salt. I assume if there is a real problem Dr. Patel would email you and tell you. It says stuff like:

• DCDA twin pregnancy-Dichorionic/diamniotic twins. It means they are fraternal and don't share an amniotic sac. This is good because there is no risk of twin-to-twin transfusion syndrome. If it was monochorionic (MA) they would be identical twins. The chorionic part is actually referring to the placenta, and sharing a placenta means the syndrome above is a possibility. Identical twins are the only kind that can share an amniotic sac, and there is a high survival rate but there is an added risk of cord entanglement or compression.
• Variable presentation. That seems to simply mean the baby moves around and doesn't stay stuck in one spot. From what I understand, that is a good thing.
• Posterior high placenta. That means the placenta is in the back of the uterus. This is good, and I think where Dr. Patel tries to get the embryos to implant on purpose since both of our twins implanted there. A low lying placenta is the only place I know that is definitely bad, but I'm not sure what medical term that would be. That means there is a chance of "placenta previa" and the baby will have to be born by C section. Google it. So when you see "no previa" on a report that is a good thing.
• Fetal growth 7 AF normal. Sounds good to me. I think AF is amniotic fluid. Not sure what the 7 is for. I found AFI charts online to show normal fluid levels, but I can't  interpret it that in depth and it is probably different in twins.

• Fetal heart normal. Awesome!
• Low resistance flow in both uterine artery--PIH least likely. PIH means Pregnancy Induced Hypertension, so least likely is a good thing. That means low resistance flow in the uterine arteries are a good thing too.
• No fetal malformation. Definitely good.
• No growth discordance. This is good. It means one is not growing significantly faster than the other.
• EFW-Estimated fetal weight. Ours is in grams, but it shows the conversion to lbs too.
• Note* In the measurements section there appears to be a column for "last" measurements to measure growth. Ours is always the same number as the most current measurements on every report, so I think he doesn't re-enter old data in the new reports for whatever reason. So don't freak out and think your baby hasn't grown.
• LMP-Last Menstrual Period: This is a way of calculating the gestational age.
• GA-Gestational age: This column is next to all the measurements from the fetal biometry section I describe below. You want this to be close to
• EDD-Estimated date of delivery. I think in the first column it is calculating it based on the LMP and the other based on GA, which makes sense because I've seen that there are several ways of calculating due date and these are two ways.  This never seems to change more than a day or two for us and reflects the 40 week date. With twins 37 weeks is full term though, and delivery can depend on other factors and 35 weeks is frequent with Dr. Patel and twins.  
• HR-Heart rate. It starts off in the very early weeks the same as the mother's, then by week 9 rises to 175 BPM (beats per minute). In the middle of the pregnancy it is often 120-180 BPM.
• NT-Nuchal Translucency. Ours says normal at the very bottom, which is good. See more about this below.
• NB visible. I think this means nasal bone. I take it that it should be visible, so woo hoo! This was right next to "nasal triangle normal" so that makes sense.
• Fetal biometry is basically the section where they take various measurements of your baby in order to determine the fetal growth is normal. On some scans they have done a side by side comparison in a separate section to establish any growth discordancy.  This linke shows charts of what is normal percentiles if you want to totally obsess about it: http://www.centrus.com.br/DiplomaFMF/SeriesFMF/18-23-weeks/appendix-03/normal_fetal_biometry/appendix-03.htm   Abbreviations from this section as follows:
• BPD - biparietal diameter: Transverse diameter of the head between the protuberances of the two parietal bones of the skull
• OFD- occipito-frontal diameter:  The diameter of the fetal head from the external occipital protuberance to the most prominent point of the frontal bone in the midline.
• HC-head circumference.
• AC-abdominal circumference
• FL-Femur length (thigh bone)
• HUM-I think this is humerus length, but not sure.
• The names Hadlock, Jeanty, Hansmann are all referring to which growth table the doctor is using on that particular measurement on the scanner.
• Fetal cranium: This section is all about measurements of the head, including the left ventricle, the cisterna magna (CM), and cerebellum (CEREB).
• Ratio section: These have the previous mesurements in a ratio format. It takes these ratios and compares them to a normal growth chart, and the percentages on the right show you what is normal for how many weeks along your baby is. You want it to be somewhere in that percentage range.
• 2d Echo section: ASC AO stands for ascending aorta and MPA diam stands for main pulmonary artery. These kinds of scans I think are designed to check for good blood flow on major arteries, so that makes sense because it doesn't get more major than these two arteries in the human body. This section also has measurements on the uterine artery flow, which admittedly is way too hard to interpret. But the summary section at the last page will say what it did on ours hopefully that I referred to above, which tells you all is okay. We had another report that had similar abbreviations and a section for "Ductous Venousus," (DV) which appears to be an important fetal vein that shunts approximately half of the blood flow of the umbilical vein directly to the inferior vena cava.
• PI Pulsatility index
  RI Resistance index, Pourcelot’s index
  S/D ratio Systolic/diastolic ratio
  Vmax Velocity maximum (same as PSV and MPSV)
  MDV Minimum diastolic velocity
  PPI Peak to peak pulsatility index
  PSV Peak systolic velocity (same as MPSV and Vmax)
  MPSV Maximum peak systolic velocity (same as PSV and Vmax)
  TAMV Time averaged maximum velocity (same as TAMX and TAPV)
  TAMX Time averaged maximum velocity (same as TAMV and TAPV)
  TAPV Time averaged peak velocity (same as TAMV and TAMX)

When you get the first trimester screening report around week 11-14, it is written in mostly plain English. A few points for interpretation:

• Cord-3 vessels is what you want and is normal. 2 can still result in a live birth but poses more risks.
• The Nuchal translucency test is the portion of the ultrasound which tells you an estimated risk of certain genetic disorders. It screens for Down syndrome (trisomy 21, meaning an extra copy of chromosome 21) and other disorders that are caused by extra copies of chromosomes (trisomy 13, trisomy 18), as well as congenital heart defects. Fetuses who have an extra chromosome may have more fluid at the base of their necks — a spot known as the nuchal fold — and this can make their necks larger. This fluid can be measured on a sonogram during weeks 11 to 14 when the base of the neck is still transparent. I think the results are easy to understand and self explanatory. Here is a screenshot of that portion on our report.

I found online this list of abbreviations for ultrasound reports, so if your reports have different stuff than mine maybe this will help:

ABO - May be seen in reference to blood test to check what your blood group is

AC - Abdominal circumference

AF - Artificial feed i.e. bottle fed

AFP - Alpha fetal protein (test offered at 16weeks to assess risk of problems with babe such as Downs syndrome)

ANC - Ante natal clinic

APH - Ante partum haemorrhage. Bleed whilst pregnant

BF - Breast fed

BO - Bowels opened

BNO - Bowels not opened

BPD - Bi parietal diameter. One side of the head to the other (ear to ear direction)

BP - blood pressure

Br - Breech

CEPH - Cephalic (head), in regards to presentation means head down

CRL - Crown to rump length i.e. Top of head to baby.s bum

C/S - Caesarian section

CTG - Cardio toco graph. The machine that they use on delivery suite to measure contractions and baby.s heart rate over a period of time
Cx - Cervix
= d - Usually in relation to fundal height (uterus size) means is right for dates

EBM - Expressed breast milk

EDD - Estimated date of delivery
ELSCS - Emergency lower segment caesarean section
Eng - Engaged
EPU - Early pregnancy unit
FAU - Fetal assessment unit
FBC - Full blood count
FBS - Fetal blood sample OR fasting blood sugar
FL - Femoral length (thigh bone)
FMF - Fetal movements felt
FHHR - fetal heart heard regularly (sometimes seen as FHH)

GTT - Glucose tolerance test

G2 P1 - Gravida 2 (2nd pregnancy) Para 1 (1 child living)
GA - General anaesthetic
Hb - Haemoglobin i.e. Iron levels
HC - Head circumference
IM - Intra muscular
IUGR - Intra uterine growth retardation i.e. Small baby for dates
IV - Intra venous (going into vein)
IVI - Intra venous infusion i.e. a drip
LA - Local anaesthetic
LMP - Last menstrual period
LOA - Left occiput anterior i.e. the back of baby.s head is to the front left side of your abdomen (where you want it to be)
LOP - Left occiput posterior i.e. back of baby.s head is to the back left side of your abdomen (where you don.t want it to be really)
LUSCS - lower uterine segment caesarean section (sometimes seen without the U )
Mec - Meconium (babies early poo)
Multip - Has 1 or more living child
MSSU - mid stream specimen of urine
NAD - Nothing abnormal detected
N/Eng - Not engaged
NNU - Neonatal unit

NICU - Neonatal intensive care unit

NPU - Not passed urine
OC - Oral contraception
OP - Occiput posterior
OA - Occiput anterior
Palp - Palpable i.e. what can be felt
PIH - Pregnancy induced hypertension (high bp)
PMH - Past medical history
PPH - Post partum haemorrhage. Bleed after baby is born
PR - Via rectum
PU - Passed urine
PV - Via vagina
Primip - First pregnancy
Reg - Registrar

Rh - Rhesus

SCBU - Special care baby unit
SHO - Senior house officer
SPD - symphisis pubis dysfunction i.e. loosening of cartilage at front of pubic bone (v. rough definition)

TOS - Trial of scar

Tr - Transverse ie Lying sideways
U&E - Blood test checking urea and electrolyte levels
USS - ultrasound scan
VBAC - Vaginal birth after a caesarean section
+ve - Positive
-ve - Negative

VE - Vaginal examination

Vx - Vertex, used in relation to presenting part/position. Means head down.

IVF at Akanksha Infertility Clinic

I go inside my lovely hotel, the Rama Residency. Sure there are nicer and more expensive ones around for those folks that care about amenities and a westernized feel, but this is plenty nice and is within a 1 minute walk to the Akanksha IVF Clinic/Dr. Patel and also to the NICU. Why stay anywhere else when you are going there on a daily basis one or more times?  http://www.hotelramaresidency.com/ 

The hotel is nice and the BEST place to meet other patients of Dr. Patel and pump them for info and stare at their babies with longing. The AC in your room turns on when you insert your key into a device in the wall, so you can't leave it on when you leave. 

Rama decorated for Diwali--the biggest Holiday in India




Cafeteria with great daily breakfasts

 



Our room looked just like this. Seating area at right off camera.

  After I check in I don't even bother to get unpacked and I go right across the street to Dr. Patel's clinic. I have no problems getting there thanks to Hammock Guy that posted YouTube videos of how to get from Point A to Point B all over Anand. http://www.youtube.com/user/hammockguy66

He is the super awesome creator of the forum of Dr. Patel's patients where you can find loads of info and some posts from me. Anything I write here I'll try to make additional to that and not repeat to save myself time.
http://dr-patel-surrogacy.com.

So I get to the clinic and Dr. Hitesh can see how tired I am and greets me and tells me to go back to the hotel and get some rest, then come back later in the afternoon for my first IVF shot.  There are lots of men and rickshaws waiting around the area, and the waiting room is full of folks. They always smile at the foreigners, or maybe just me because I wear a saree and follow the custom to remove my shoes and leave them outside even though they don't expect me to. I sign in up front with my name and contact info, and they write down and give me a patient # that I will use for reference during my trip. They don't seem to be expecting me or know this is my first day, and this alarms me a bit.  They immediately direct me to Dr. Hitesh's office outside.

Dr Hitesh's English is great, and I'm used to Indian accents so no problems understanding anything he is telling me. He gives me a map (copy found on blog) of the area and where to eat, and says we can take care of business details later. I follow orders and get some sleep. I find out later I am on their schedule for surrogacy and they are expecting me, but Dr. Patel has that info and Dr. Hitesh and the front desk don't have immediate access to scheduling and so it seems a little more disorganized than it is. Dr. Patel has a lot of people assisting her, medical or otherwise, and I see her pass by in a flurry of activity as I depart to take a long overdue nap.

When I go back in the late afternoon the clinic that was previously a hustle and bustle of activity, it is almost abandoned. Now let me say if you are used to American medical clinics that are perfectly sterile, then India will be a shock for you. Having been there before and finding the USA to be a little overboard with sterile conditions I had no problems whatsoever, save the one occurence on this one day. Even my American physician said that somewhere between the US and India is probably the happy medium on sterile conditions, and the US takes it a little overboard. The equipment is not brand new but everything is clean enough and they take new needles out of the package everytime. The "Vampire" guy that takes your blood doesn't wear gloves. But the man is good...this is all he does. But the only thing that bothered me regarding conditions was on this day, because the sharps container is just a bucket. This late in the day it was overflowing and there were needles on the floor. Remember that I was barefoot, so I tread carefully. But other than that, I felt perfectly safe. I get my first shot in my belly, and that's it. This was my first time doing IVF since we were hoping to use my eggs.

Having never done IVF before I didn't know what to expect, so that made my anxiety level higher than most. Also, my husband was not with me. He speaks some Hindi and so having him there helps, though they mostly speak Gujarati there and Hindi is of little use. I was lonely without him, and Dr. Hitesh commented on how much more I smiled when he arrived. But ultimately here is what it is like:

1. You go in and get a shot almost every day. You get blood taken and trans-vaginal sonogram seen above every few days. It will hurt cause she has to poke towards the ovaries where you are already swollen, but it ain't that bad. There is a curtain in front of that area, but lots of folks coming or going, but all female. This curtained area is directly behind Dr. Patel's desk in her office full of assitants rushing about. The only bills I received in addition to what I was told beforehand was for bloodwork, and it was minimal.

2. Your time with Dr. Patel will be brief and to the point. She will give you updates on how many eggs are growing and such. You can ask questions. However, I recommend letting the doctor be the doctor and not try to control everything, and if you are very experienced with IVF and into all the details that may be challenging for you. Communication here is not what you would expect in the US, but some of that is a cultural difference that I knew to expect. She will make the decisions and inform you after, to include how many eggs she implants.

3. Unless you've never been to India and want to do the tourist/shopping thing, there is not much to do in Anand. All the places to eat and shop are on Dr. Hitesh's map and in the blog link above. I was bored, and so nauseated I barely left the room. It was a little too hot for me to go out in that state in the middle of the day in October, but I ventured out a few times. Thank goodness for wireless internet and TV, with I think 2-3 channels in English that were playing a Schwarzzenager movie marathon unfortunately. I saw True Lies 5 times. I mostly went out to Big Bazaar for foods that didn't make me want to puke. I hated buying westernized food when I love to eat local fare, but I have never been so consistently nauseated and bloated in my life. For this reason I won't comment on the food at Rama Residency, because it may have been much better than it tasted to me at the time. I did drink the milk and eat fruit with peels, but as long as you stay away from the non-bottled water or unheated water you should be fine in my opinion.

Kellogg's & Cadbury are the few recognizable brands you'll see

 I did realize that computer where all emails are recieved and responded to is right next to Dr. Patel's desk. There is an assistant on it all the time. I think most emails, of which they recieve TONS from everyone from current clients to prospective ones who want to know every last detail, are answered by an assistant. Sometimes she must copy and paste some FAQ, other times it is personalized. But I realized that the reason my email responses were stilted and brief and sometimes didn't answer all I asked was for this reason. They are VERY busy. It seems they get a lot of folks who want to know about and control every last detail. I am low maintenance in comparison, and if I wasn't I think that alone would drive me nuts. 

They do track payments but aren't really demanding or communicative about due dates, so when I asked about the first payment transfer I found out that I did need to get the money transferred. Below is a chart I made of what it costs for those who are curious about doing it themselves. This is only what I came up with and not something they gave me, and doesn't include initial travel costs like airfare and lodging and food, etc. Some stuff I  won't be sure on until we actually pick up the babies. I'm told the NICU fees are about $40 per day per baby, and with twins 1.5-2 wks in the NICU is common and she tends to delivery by C-section at 35 weeks. We'll see how true that is come September!

I did get to meet the surrogate, and it was a tad awkward and while Dr. Hitesh was available to translate....I didn't have much to ask beyond basic chit chat. I got a very good vibe off of her and she seemed like a confident and strong young woman who was determined to do this for her family.. Dr. Hitesh offered to take a pic with her so I did. I no longer have it because I deleted it when our attempt did not work. Anyway, she was cute as a button and got married at 15 years old to a farmer, and had been married 10yrs. She looked healthy and was shorter and smaller than me, and had very demure mannerisms.  He asked if there was anything I wanted to say to her after I read the very basic profile of her he had handed me. I just said directly to her "Ghano ghano dhanyavad" which means thank you very much in her language. I got choked up when I said it to her, and that was the first time she smiled. I realized that was all I needed to say.

I did meet some couples who were suprised at the surrogate selected for them as they were older or very skinny, however ours was young and very healthy looking. I think the more slender body type is common here. You don't have control over who your surrogate is, but they will be married with at least one child. They will select one whose cycle is synced up with yours or the egg donor's. I trust Dr. Patel and I trust her selection process. I'm sad that it didn't work out with our first surrogate. I haven't met our second surrogate because we used donor eggs and a frozen sample, but I can't wait to meet her. I sent her a package with sarees, photos of us, and a personalized letter of thanks that I had translated into Gujarati below.

We thank you so very much for what you are doing for us.  My husband and I are finally so happy!  You are making our dreams come true. We know that carrying two babies will be difficult and you are sacrificing much time with your family. Your help in creating our family is giving us the happiness we have hoped for over eight long years of waiting. We hope that the money you receive for this incredible gift will help to make your dreams come true also.

I have not been able to carry a baby for more than a few months before it would die, so I have grieved for so many years. But you have made hope possible again. My husband and I and our entire family pray for you and your family every day. All of our parents are older and in failing health, but now they all have new life because they will get to meet their grandchildren. My husband and I married in 2004, and we have wished for children since then.

In 2003 before my husband and I were married we traveled to New Delhi India so he could introduce me to his family. We did not think then that we would get married, but a wise old man who was dying read our palms on our hands and told us our future. He said that we should be married as soon as possible, and our marriage would be very long and successful. He had never met us and knew things there was no possible way he could know. He told us that one day we would have two children, and then someday adopt a little girl. For so many years I thought he did not speak the truth, but now I know he was sent from God to give us hope...just like you were.

We will give both babies a wonderful home in the United States in the state of Texas. They will always be loved and well taken care of. We have sent you some pictures of us and our family from our wedding. Later when we finish the room for the babies we will send you pictures of our house. Please also accept these gifts of sarees. I hope you like them and wear them, but if you do not wear them I’m sure you can give them to someone who will be able to use them. Even though I am not from India I have always loved and worn sarees, so we hope you will like these.

Thank you and God bless you

Mumbai to Anand

So I finally get to Mumbai after my all to brief layover in London, and have to wait for a bus for 45 minutes after waiting in several lines hoping I'm in the right one. I think it's cool that the customs agent recognizes my last name as and Indian surname and asks me about it. No one in America does, but here I'll see family businesses that say "Grover Auto Mufflers" so I know it must be semi-common. Without sharing a language, I seem to befriend and sit next to an elderly woman who is also headed to Ahmedabad and is worried she is in the right place.

The bus turns out to take us to another terminal, which is one big room with a few shops that are closed. Did I mention it is after midnight and my flight to Ahmedabad leaves at 6am and I'm exhausted? So I have to wait overnight in this room with uncomfortable chairs, but fortunately there is a snack bar. I learn a few things going through customs:

1. Your original boarding pass issued from your first flight is not good there. You need to exchange it for an Indian boarding pass at the flight counters before passing through the final security check for the waiting room.

2. They like to stamp stuff in India.... a lot! So when they repeatedly offer luggage tags for each and every item you have as carry on take the hint and attach it. They use these to stamp that something has passed through okay. Expect more than one person to stamp and screen you at every point in the airport along your trip to Anand.

3. I don't have my saree folded quite to their liking. I am good at folding Punjabi style, but this is my first time folding Gujarati style with the pallau in front. Females are examined by other females and go into a separate line. My security agent speaks broken English and is having a good time asking me about my visit, and is very charmed by my saree and how much I like to wear them. In the space of a few minutes I have three female security agents gathered around me re-dressing and folding and pinning my saree. It was hilarious and they are having a grand time. 

When I finally am released into the waiting area I realize something. I am the only white person aside from one guy. The problem is that there is a room of 100 men staring at me boldly. Really staring. Not even trying to hide it. I don't know if it is that some folks seem to think I look like this one Bollywood star or it's the saree or what, but if you've never had a hundred men stare at you at once it is truly disconcerting. I will encounter a lot of staring on my trip, but this was the most bothersome. i walk around a lot to ease my nerves and when the shops finally open I check them out.  It is all touristy stuff I've seen before and I'm here to make babies, not shop. I make this odd vow that I'll shop when I come back to pick up my baby, but have this strange feeling that I'll jinx myself if I shop like I'm not coming back in 9 months. I'm not here to be a tourist this time.  I do take a picture of the Playskool Saudi Arabian Melody. Woo hoo for multiculturalism, but she can't be all that much fun to play with because the whole point of Barbies is to dress them up in cute clothes.

Saudi Arabian Melody

I finally get on the long awaited bus that takes you directly to the plane on the tarmac to fly to Ahmedabad.  Unfortunately I realize I've left my packet with all my printed out info as well as pics of us for our surrogate in the waiting area! It even has bank transfer codes on some of the emails. I am proud to say that someone turned it into the security agents, who look through it and call the hotel listed in the papers to let them know they have it. I tried to send my husband to pick it up but by the time he is in Mumbai it has been over a week and they disposed of it at the ticket counter. Fortunately I have one photo elsewhere for our surrogate.

After a short flight to Ahmedabad I watch the sun rise over India with excitement. I notice on the flight that of all the music and Bollywood songs they could select from, they have "When a Man Loves a Woman" muzak  playing overhead. Wierd. We touch down at the cutest airport I've ever seen in Ahmedabad.  I find it hilarious that we get on a bus that drives us a whopping 25 yards to the entrance to the airport. I could have walked there in less time. I get my baggage, and the driver Indrajeet that Dr. Hitesh (Dr. Patel's husband who takes care of the business end of things) had arranged is waiting for me with a sign. I've always wanted to have someone greet me at the airport with my name on a sign!

As I drive through the streets of India right into oncoming traffic for the hour or so drive to Anand, all the memories rush back and it finally hits me that I really am back in India.  Some pics are from Anand, but a few are actually in Delhi at the tail end of our trip when I got touristy for a day and shot a few photos of the local flavor to show what it is like and what you'll see. They look the same, but Anand is much smaller and less developed, and you see more trash and burning in the streets and things are more run down.



Pimped out auto-rickshaw (Tuk-tuk)



Shops along street (this was actually Delhi)





Fascinating how much they fit on carts here!



Exported Rejected Doormats. Poor doormats.



 

Camels are common in Gujarat. And they're big!

 



Lots of men did double takes on their motorcycles at the white woman in a saree. Two almost had wrecks...it was funny!






Cows Cows Everywhere!



Surrogacy FAQ

So I'll digress again and post about the top questions we have gotten since we've started our surrogacy journey. This addresses the most common questions we've been asked as well as some of the controversy surrounding surrogacy.

1. “So do you know what you are having?”

This is a popular question, for obvious reasons! However, in India it is illegal to detect or reveal gender. There are some cultural reasons that boys are preferred. The darker side of this is that is in many cases people have aborted girls or even refused to take a girl home from the hospital, which led to the law being created. Some girls have been given a name that means “unwanted” and there was a huge renaming ceremony held recently because of this in Mumbai. http://www.msnbc.msn.com/id/44998378/ns/world_news-wonderful_world/t/name-changers-indian-girls-no-longer-unwanted/

Some reasons for this are that girls require an expensive dowry when they are married, and they typically live with the husband’s family and take care of them in their old age. That means boys will bring home a large dowry and a homemaker/caregiver. Because of this gender preference issue, Indian law is strict about revealing the baby’s sex.

We do get some sonogram pictures emailed to us but will not get videos, so it is pure luck if bits and pieces happen to be at the right angle. The pictures have a huge fax stripe across them and have been scanned into a poor quality scanner before being emailed to us. At the bottom of every page there is a disclaimer stating that the sonogropher has not “detected or revealed” gender. We’ll take a good look at every scan we get and show a few of our doctor friends, but it looks like we are in for a wonderful surprise in October!

2. "So is it...like...your eggs, and umm...Vinnie's...ya know...stuff?"

(Below is the ddiplomatic answer I gave to acquaintances)

We understand the curiosity factor and why this is the most common question we've been asked so far, but this question is a little personal. We'll let everyone have the fun of guessing, but the important thing is that we'll always be open and honest with our children when they are old enough to understand about how others have helped us on our fertility journey. If it doesn't matter to us, it certainly shouldn't matter to anyone else. We firmly believe that we each are the captain of our own ships and genetics don’t govern our destiny, so we look forward to seeing who our children become regardless of the impact of nature as well as our nurturing over the course of their lifetime.

3. “Why India?”

India is where Vinnie’s family is from, and we have enjoyed their tremendous hospitality in Delhi several times. I’ve been there twice and Vinnie five times, and he does speak some Hindi. We are both familiar with the country and culture, and have much support there and from our Indian community here in the US. We began our life together there when we were first dating before we became a family, and now we return to make our family complete.  It is truly wonderful how it has come full circle and India has become the land of opportunity for us.  Despite tremendous growth and progress as well as embracing developing technologies and becoming a rising economic power, India is still a country afflicted by much poverty. This means the money we are spending will go so much further and will without a doubt change the lives of the surrogate and her family in a truly significant way.

The most simple answer however is cost. Surrogacy in America is easily at least three times the cost in India, and fraught with far greater legal and financial risks from what I’ve read. As we’ve spent 8 years living through the hell of infertility and extreme expenses that go along with it, we don’t have over $100,000 to spare. Insurance covers nothing when it comes to common infertility treatments in our case, not to mention surrogacy. Only 3 companies in the US cover surrogacy when I last researched, and the cost was so high it would be cheaper to pay all medical expenses out of pocket and hope all goes well. That is hardly responsible. To try to cover a surrogate anyway without disclosure to the insurance company would be committing felony insurance fraud, and would likely be discovered during the delivery or after attempts to get the birth certificate altered to the biological parents ($7,000 legal fees for that alone). This made us very sad because at one point we did have a wonderful woman volunteer as a surrogate for us without asking anything in return, but due to insurance and legal costs alone there was no way we could responsibly afford it.

4. "So how does that work with the surrogate?"

This question has come up a lot and it sounds like people are really asking about the surrogate selection process and how they avoid forming an attachment to the baby (or in our case babies!) they are carrying for nine months. In order to qualify as a surrogate she has to be married with at least one child, whom she carried to full term with no complications. The egg implanted in the surrogate is not her own, which in addition to the selection and counseling process provided assures that she does not form an unhealthy level of attachment.

There are legal documents that protect both parties in the agreement, and the contracts clearly put the health of the surrogate as the top priority.  We have found this comforting, and it helps us to trust that our clinic has their priorities and ethics straight. International law can get complicated, so choosing a clinic like Akanksha with a superior reputation ensures that all parties are treated fairly and things will go smoothly.

It will certainly be difficult to let go after nine months of bonding, but this is a decision she and her family have not made lightly and have been well prepared for. I’m sad that I’ll never be able to understand what she has been through to deliver these babies to us, but I am certainly more grateful than she’ll ever be able to understand.  She is doing this not simply as a human kindness, but because her family lives on a few dollars a day and she can now provide support them far better than she could have otherwise. We have no problems with her seeing or visiting the babies after birth if she chooses, and will be offering to pay her to produce breast milk for two weeks if she wants to. After that though, the clinic has told us it is best for everyone to not continue contact.

We did not have the opportunity to meet this surrogate beforehand unfortunately, so we only know her name and that she must be an amazing woman to make this sacrifice and help us in such a profound way. We did get to meet our first surrogate, but the attempt failed so it took a second try with frozen samples that occurred while we were back in the states. Thus we’ll just have to look forward to meeting Manju in October. We are mailing her gifts and pictures of our family and home as well as a heartfelt letter we had translated into her native language. We do plan to pay for the modified baby shower they offer as an option for the surrogates to keep her spirits up during the difficult late stages of pregnancy.

5 “Are the surrogates well cared for?”

One of our greatest comforts, especially with twins, is that she has the sole task of relaxing and focusing on taking care of herself and the babies for the duration of the pregnancy. That along with her history of uncomplicated pregnancy helps us to hope that all will progress well.  Most of them choose to stay in the two “Surrogate Houses,” that are host to about 70 active surrogates. Medical care and exams are provided on site on a weekly basis. Does anyone in the US have their doctor and specialists make home visits weekly?  Organic, healthy food is provided daily along with nutritional counseling.

Family members can visit once a week. Many of them travel from great distances to become a surrogate, so the money provided will allow their family to visit for the 9 months duration. In addition they will now have some spending money typically well beyond their normal income to support their family in the meantime.  Keep in mind many married women are used to their husbands working in a large city while they live in village and only see their spouses a few select times throughout the year.

The surrogates mostly rest and commune, but also benefit from classes to include English lessons, which can provide gainful employment in the future that they would not otherwise have enjoyed. They do often keep their surrogacy a secret, because so many people in the community do not understand the scientific sophistication of fertility medicine, and not everyone understands how they can be pregnant with someone else’s child without having extramarital relations. Their confidentiality is well protected, as is ours to prevent any attempts at seeking additional compensation beyond what has been agreed upon.

6. “But isn’t this taking advantage of poor, uneducated women in the third world who have no idea what they are getting into?”

As much as there has been media coverage sensationalizing the risk of taking advantage of poor women in the third world, we are confident that our clinic and the physician couple who are running are doing things the right way. We initially learned about Dr. Nayana Patel’s clinic from her interview on Oprah.  She has a signed head shot in her office. J  You can see multiple interviews of Dr. Patel on You Tube, and I think you will like her style as much as I did when it comes to how she handles the questions and unwarranted criticisms.  It took us three years to be accepted into the surrogacy program because there was a wait list. She was focused on being careful not to overextend herself and reduce the quality of care to the surrogates when the demand rose because of the publicity that Oprah brings.

Documentaries like "Google Baby" that focus on the questionable ethics of one clinic in particular, raise valid questions, but do not present the whole picture of surrogacy in India. We are confident that our surrogate has entered this process with an educated understanding of the risks and consequences, as well as the benefits. Her husband must have full consent and support her in this decision and sign the contract beside her.  I see her as a very strong as well as smart woman, who has chosen to make huge sacrifices for over nine months of her life. She knows exactly what pregnancy entails from having done it at least once before. Even if she has not had the benefit of a full secondary education she has lived a life that has made her tougher and in many ways smarter than the rest of us. Many of them have experienced a   hard life with living on a few dollars a day, which I argue is an education beyond what someone as privileged as I have been could ever understand.

In return she will gain an amount of money that is a salary of many years of what could have been hard labor.  Most commonly  the money is used to purchase a home and a put her own children through college, raising her own standard of living to an entirely new level and giving her children a better life than she could have imagined for herself. If someone has not personally visited a third world country, it is unlikely that they can even imagine how profoundly such a sum of money can impact the destiny of an entire family. We feel blessed that in exchange for creating our family and granting us happiness more profound that we ever dared to dream, in exchange we are making as profound of a difference in the life of another family on the other side of the world and granting one or more children a far better life.

7. “Isn’t there a risk of wealthy Americans ‘outsourcing’ pregnancy and birth to the third world to avoid stretch marks?”

Fears like this are extrapolated using a logical fallacy call the slippery slope. The pundits latch on to this one because sensationalism sells. It’s like saying that by allowing gays to legally marry pretty soon we’ll wind up allowing people to marry their dogs or inanimate objects. Sigh.

Anyone who has been through the process could never imagine someone doing this as an “easy solution” because it is anything but. Having been through it, I cannot fathom any way where someone foolish enough to try this could even get through a beginning phase of the process.  It would be far costlier, but much easier to abuse surrogacy in the U.S. than to go overseas in my personal opinion.

But Dr. Patel handles her critics below better than I ever could. My favorite part is how she questions the fact that if you do surrogacy in the U.S. no one is using the word exploitation, but once you do the same thing in the third world it is assumed as such.  I'm so glad that she sees the truth around her in the joy she brings to so many, and is strong enough to ignore the criticisms of those looking for headlines.