Conceivability_What I Learned Exploring the Frontiers of Fertility

by Elizabeth L. Katkin

  In contrast, in most developed countries, surrogacy is regulated by national governments, with legislation ranging from outright bans to clear requirements.3 In the United Kingdom, Ireland, Denmark, and Belgium, for example, surrogacy is permitted but commercial (paid) surrogacy is not; in Israel, while restricted to those who meet certain criteria (i.e., heterosexual couples only, the intended parents and surrogate must practice the same religion, the surrogate must be single, the semen must be that of the husband and not a donor), gestational surrogacy is funded in totality by the state, and the birth mother does not have any legal status with respect to the baby. France, Germany, Italy, Spain, and Portugal, among others, forbid all forms of surrogacy. It is essential for a third-party parent-to-be to get fully educated on the legal ramifications of undergoing a treatment in a particular jurisdiction.

  In the United States, the laws vary wildly by state, and not always along the lines you might expect. California, Arkansas, Illinois, and Tennessee are among the best jurisdictions for gestational surrogacy, while New York, Arizona, Nebraska, Michigan, Louisiana, and Washington, DC, are among the worst. In Michigan, for instance, individuals who enter into surrogacy contracts can be fined up to $50,000 and imprisoned for up to five years; Washington, DC, similarly, imposes fines of up to $10,000, a prison sentence of up to one year, or both.4 New York forbids paid gestational surrogacy, although New York State senator Brad Hoylman, father of a child born through a surrogate, is cosponsor of a bill called the Child-Parent Security Act, a proposed law that would overturn the current law and make compensated surrogacy legal in New York State.5 Neighboring New Jersey permits it (although the courts will not necessarily enforce surrogacy contracts). So, naturally, there is a burgeoning business of would-be parents being treated at clinics in New York crossing the Hudson on the day of embryo transfer (particularly if the surrogate does not live in New Jersey), as we did in our failed attempt with Brenda, or traveling to nearby Connecticut or Pennsylvania, where they pay yet another clinic to transfer their embryos into a surrogate.

  More confusing still, most states have no clear laws on the books. In Alaska, Colorado, Connecticut, Georgia, Hawaii, and nearly two dozen other states, in the absence of explicit laws, courts are often favorable to intended parents, although there is no guarantee—a large risk to take with respect to custody of your child. Legal expert Melissa Brisman believes it is in the best interests of all involved for states to enact clear laws specifying that intended parents are legally responsible for the children that they create. Responding to the fact that most people are worried about what happens if a surrogate wants to keep a baby, Brisman points out the flip side of that coin. “What if the baby is born with a defect, and the intended parents decide they don’t want to take responsibility? You have the surrogate, who gave this wonderful gift, and now she’s stuck with parental rights and responsibilities.”6 Sean Tipton, chief advocacy, policy, and development officer of the American Society for Reproductive Medicine (ASRM), does not disagree, claiming that fertility specialists would welcome thoughtful attempts to clarify parentage laws, “making it clear what parental rights and obligations are, and how to obtain or relinquish them.”7

  * * *

  Despite the challenges, increasing numbers of hopeful parents are turning to surrogacy to build their families. And while not every surrogate birth goes as smoothly as Alexandra’s—reflective to some extent of the fact that not all births go as well, and not all hospitals as indulgent—virtually everyone with whom I spoke who became a parent via surrogacy had an extremely positive, albeit sometimes stressful, surrogate experience.

  When Robert and Jeffrey, a same-sex couple who are both medical professionals in DC, decided to have a baby with a surrogate and egg donor, they desired professional guidance and support, and went straight to an established agency. In choosing their surrogate, they were concerned primarily with health and a good fit for their family rather than proximity. They didn’t mind that she lived in Ohio and they would not see her regularly, although they did travel to be with her for all the milestones. Their surrogate pregnancies went extremely smoothly, and they felt tremendous joy and gratitude at the birth of their daughter, and later twin boys, born of the same surrogate, who remains a special family friend.

  Paula, to the contrary, wanted a surrogate nearby, close enough to be able to participate in the appointments. Convinced after her fifth miscarriage and further diagnoses that she could not carry a child, Paula, like me, was determined to find her own surrogate. When her first two choices didn’t work out for various reasons, she eventually turned to an agency in her hometown and happily found a surrogate not too far away. Their proximity proved fortuitous, as Paula and Derrick were awakened one night at 3:00 a.m. and rushed to the hospital upon learning that their surrogate, Amy, was in labor at only twenty-six weeks and four days. In addition to their overwhelming fear for the health of their twin babies, who were each born weighing less than two pounds and were immediately rushed into incubators, they worried about Amy and the impact on her husband and her son, struggling with the guilt of knowing that Amy had put her health and her family at risk for them. Paula and Derrick felt tremendous relief when they learned that Amy was OK—though the guilt persisted. Paula felt that she should have been experiencing the difficulty and pain instead of their surrogate.

  Similarly, Pietro and Peter, professional dancers living in Houston, experienced the full gamut of emotions. From gratitude and wonder to disappointment, guilt, and helplessness. From the outset, they felt strongly about working with an agency and surrogate who were local so they could participate in every aspect of the pregnancy. Their relationship with their first surrogate fell apart because she decided she no longer felt comfortable working with a gay couple. Her withdrawal left Pietro and Peter so shattered that it made them take a step back and reconsider the whole process. “We weren’t feeling as confident,” Pietro, who is from Italy, explained. They felt let down by both the surrogate and the agency, who had assured them that she was happy to work with them.

  Longing for a child, they eventually found the strength to try again. Working with a different, more experienced agency, they quickly narrowed their search to two potential surrogates. After meeting the surrogates in person, they felt a good connection with one: twenty-one years old and with one daughter, she was inspired by seeing two of her good friends serve as surrogates for others, and quickly agreed to work with them. Although she didn’t struggle at all emotionally, as is often a concern for intended parents, she had a very hard time physically. She didn’t feel well from the time she started the hormone shots and continued to feel poorly throughout the pregnancy. She started spotting at fifteen weeks, and after a very stressful few weeks, sadly lost the baby in the eighteenth week. She eventually had a D&C, and Peter and Pietro learned, to their great surprise, that the fetus was fine, with the normal complement of chromosomes.

  Devastated by the loss, they didn’t discuss it for a year, until a call from the embryo bank regarding its storage fee reopened the conversation. Soon after, their agency found a new surrogate for them—an American woman married to an Italian with whom she shared two daughters. From the moment they met Cindy, they knew they had found the all-important perfect fit. The IVF went smoothly, and Cindy became pregnant with twins. At fifteen weeks, the heartbeat of one stopped, causing them to relive the trauma of their first loss. Pietro had upsetting dreams in which he saw his dead baby lying next to his live baby. As they mourned, Cindy, still pregnant with the other twin, was a great source of optimism and stability. Later in the pregnancy, the baby’s placenta stuck to Cindy’s uterine wall, causing bleeding and putting her health at risk. Cindy went in for a necessary C-section six weeks early and gave birth to a beautiful baby girl, but the placenta had burrowed too far into her uterus, causing her to have an unplanned hysterectomy (thankfully covered by insurance they had purchased), which Pietro regrets to this day.

  Naturally, sometimes, as with all pregnan
cies, surrogates miscarry, which is crushing for all involved. After seven miscarriages, Jessica and Ethan had turned to surrogacy as their last hope. Jessica found her own surrogate, who had successfully given birth to three babies, and they began the process at the clinic she had grown to hate; she was willing to try just about anything to have the baby they longed for. Emma, their surrogate, conceived on the first try, and both the pregnancy and their relationship progressed beautifully. In her second trimester, Emma miscarried. Their “sure thing” had failed them. Jessica’s words at the time so eloquently convey the depth of her devastation: “I hurt. Not in a scary way, not in a can’t-get-out-of-bed way. But in a can’t-stop-crying way. I imagine my heart dripping down into my stomach and slipping out of my body in a sea of tears. If my heart melted away, maybe I would hurt less. I have come to love and hate hope. I want to disown hope, that horrible tease of an emotion, so I can just be peacefully numb for a bit. A welcome reprieve.”

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  When it works, surrogacy can be a win-win for all, not only enabling the birth of a much-desired child, but often, in the process, creating unexpected, sometimes lifelong bonds. Sitting in Robert and Jeffrey’s kitchen on a rainy Sunday morning in DC, drinking coffee with their surrogate, Jo, and her friend, who were visiting from Ohio, I was struck by both the beauty and the normalcy of the scene. Three happy, giggling children playing in the background, while their two dads and surrogate who carried them chatted with me about their unconventional family. Jo was so moved by the experience, she switched careers and began working for the surrogate agency that had connected them. While accustomed to hearing parents rave about the surrogates who carried their children, it was Jo’s response about their surrogacy journey that stayed with me verbatim: “It was a privilege and a joy.”

  Alone we can do so little; together we can do so much.

  Helen Keller

  10

  When It Takes a Village

  Surrogacy and Egg Donation

  Twenty months on, Alexandra’s birth still seemed like a miracle. She was walking (sort of) and talking (often in words only I could understand). Yet it was harder to give up on trying for Number Two than I expected. We had been trying to have a baby for more than six years, and it had become part of my daily life. After the failure of the agreed-upon “last IVF cycle ever,” my acquiescence to finally getting off the IVF treadmill was helped along by our big international move. Richard had accepted a job in Dubai and had been commuting there from London for six months, partly because I insisted he make sure that he liked it before we uprooted our small family and left a city we loved, but also so that I could continue my fertility treatments. With the latter constraint now sadly out of the picture, and Richard enjoying his job and Dubai, I arranged—not without difficulty and drama, of course—to transfer to my law firm’s new Abu Dhabi office. It sounded logistically easy to me at the time, as Abu Dhabi, the capital of the United Arab Emirates, was just sixty-odd miles away from Dubai. Maps don’t let you know that the route between the two cities is a death-defying road across a desert, where car pileups reach into double and triple digits.

  Richard and I set off for the Emirates with Alexandra; our cat, Sesame; and, for the first time in years, no goal of family expansion. We would enjoy our daughter and our time in the sun, taking some time to process what we had been through. Maybe we would adopt in the future. Maybe we would be “one and done.”

  It didn’t take very long to adjust to life in what felt like an episode of The Jetsons. We met new friends from all over the world and experienced the incredible buzz that was Dubai before the financial crash. It was far enough removed from our everyday lives that shots and IVF and PGS receded quickly into the past—until my phone started to ring. My friend Andrea had a friend Alice, in London, who had cancer and needed some advice on egg and embryo freezing and surrogacy, and my friend Olga had a friend Michelle, from New Zealand, who lived in Moscow and was desperate to talk to me about IVF protocols. Sarah, a college friend now living in New York, had a friend who needed advice as well. Friends and acquaintances of my mother began to call, all desperate to help their fertility-challenged daughters or daughters-in-law.

  I spoke to Michelle, the New Zealander in Moscow, at length about IVF and miscarriage. She asked me why I hadn’t considered treatment in Russia or Ukraine, particularly since I had worked and lived in Moscow on and off while trying to conceive. Russia or Ukraine? They were not on my radar screen. But Michelle told me that Russia and Ukraine, along with Israel, had among the highest success rates in the world. She gave me the names of the clinics she was considering and sent me all the information she had assembled. The numbers were unbelievable—I mean really unbelievable. It couldn’t be true. Nearly a 70 percent live birth rate at her top two choices—in contrast with an average of approximately 30 percent in the United States and 25 percent in the United Kingdom across all age groups in 2011. She went for an appointment at the AltraVita clinic in Moscow and was impressed. Then forty-three years old, Michelle had somehow endured thirteen miscarriages and was focusing on adoption. Yet after her visit to the clinic, she decided to try IVF one more time. Her protocol was totally different from those I had seen before—partly because many of the hormones had different brand names, but also because the dosages and duration were shorter, and there were a number of items on the list that I had never heard of. She became pregnant with twins. Everyone she met going through the cycle at that clinic also became pregnant. She urged me to go see her doctor.

  I was torn. We had a wonderful daughter and had put much of our pain and anguish behind us. We had had our hopes raised and crushed so many times. I didn’t want to put either of us through that emotional turmoil again. But I also kept thinking about a conversation with my cousin Caryn at our farewell gathering in New York as we were embarking on our move to Dubai. A sister and a mother of three, she had taken me aside and urged me not to give up on trying to get a sibling for Alexandra. And I couldn’t imagine my own life without my brother.

  Fortuitously, a business trip to Moscow came up. I convinced myself it was fate. I called the Moscow clinic and begged for an appointment during my two-day visit. After several back-and-forths, the English speaker at the other end of the phone finally scheduled a consultation for me during one of the doctor’s lunch breaks. Richard agreed to the consultation, but he was not willing to commit to anything else. Although we had quietly, and somewhat uneasily, discussed the option of IVF with an egg donor, for the most part it had remained on the back burner as Richard had simply had enough of the fertility drama.

  Other than our good friends Jeff and Olga, who kindly put us up during our treatment visits, we didn’t tell anyone—including my mother—about that first trip. Or any of the trips that followed. Having now turned forty, even I knew that it looked like I had finally lost my marbles.

  I went straight to the clinic from the airport, with my carry-on bag and a healthy dose of skepticism measured by a touch of new hope. Dr. Oxana sat in front of me with my file on her desk, her inscrutable face skimming her Russian notes for what seemed like a very long time. She finally spoke, through the translator. “OK, first you do tests, next we decide how we proceed.”

  I turned to look at the translator. “But I have a number of questions before I decide if I even want to proceed.”

  “What questions?”

  “Does the doctor really think it makes sense,” I asked, “for me to try again? Would I need an egg donor? I don’t seem to have any good eggs.”

  The translator spoke, and the doctor smiled as she replied, her warm brown eyes softening. “You wouldn’t know if you had any good eggs. The high level of drugs would have ruined them. You may have several.”

  Dr. Oxana explained her plan. First, I would follow a homeopathic detox regime to help rid my body of the hormones I had pumped into myself during my multiple IVF treatments in New York and London; she insisted that the damaging levels of hormones in my body were compromising my egg q
uality. Then, once I was detoxed, I would begin IVF, on a short protocol, at a very low level of drugs. When I started to express my concern that there wouldn’t be any eggs to retrieve at those dosages, she became frustrated. Either I accepted the clinic’s philosophy or I didn’t, she explained. It was very simple.

  Accept her philosophy? Whoever heard of an IVF philosophy? Dr. Oxana told me with little fanfare (through her translator) that the doctors in Russia had a different philosophy from those in the United States. In the West, she explained, most doctors believe that the chromosomal health of a woman’s eggs is essentially determined at birth and degrades with age, and that it is the job of the fertility specialist to coax out the highest number of eggs to find the “healthy” ones, i.e., the proverbial needle-in-the-haystack approach. In contrast, in Russia (and Ukraine and certain clinics in Israel, Japan, and Western Europe, among others), she explained, many fertility specialists believe that the environment in the body, and in the outside world, greatly affects the health of the eggs and thus the embryos produced; that diet, toxins, chemicals, hormones—especially of high dosage as in the very IVF protocols I had been following—potentially harmed the eggs I was so desperately trying to harvest. Rather than stimulating the production of as many eggs as possible in an assumption that it would increase the chances of finding at least one good one, Dr. Oxana was seeking to gently stimulate the production of only a handful of eggs, hoping to find one or two good ones.

  She and her colleagues also believe, radically, that egg quality can be improved. Not only is egg quality not static, it can go up as well as down. “At six hundred units of Puregon [the amount taken during my last cycle in New York], all your eggs would be damaged,” Dr. Oxana said. “I will use one hundred and fifty to two hundred and fifty units. We will probably have only four eggs, but half should be normal. That is all you need.”