Sunday 21 February 2016

Talking about fertility again, part 2

Here is part 2 of the contemplation I started a few days ago regarding possible ways of expanding our family. Apparently I ended that post on a cliffhanger. As I said in one comment, these questions have been rattling around in my head for so long I kind of forget everyone doesn't already know about them.

I recently had a few standard medical tests (hormone levels, pelvic ultrasound, and bone density scan) to check on how my POF is affecting my fertility and general health. I should have the results of those in a week or two. Meanwhile, we've started a conversation about what exactly we will consider to have a second child.

We may or may not be able to get pregnant again without intervention. Will the tests I just had, or hypothetical future tests, answer that question definitively? Who knows!  We thought two years ago we had a definitive answer, and then the unexpected happened. Pondering the chances of another conception without intervention feels like wandering around in a fog that sometimes recedes, then thickens and blocks everything from view. The next question feels like an amorphous shape looming in the fog, a stranger that I'm not sure I should approach or not.

If donor egg IVF (DEIVF) is our only chance to have another child, do we want to go for it?

Or, re-phrased as a negative: If DEIVF is our only chance to have another child, are we OK with not doing it?

Back when we were deciding what treatments we were willing to pursue, Mr. Turtle and I did an analysis of our priorities using the 8 factors listed in in the chapter "Planning Your Itinerary" in Melissa Ford's book Navigating the Land of IF.  I love this book! As Mel says "This chapter will provide you with the practical tools you need to be as strategic as possible in making decisions during your stay in the land of IF." Just reading the words "strategy" and "practical tools" I can feel the anxiety ebbing out of me like a big receding wave.

Here are the eight factors:

  • cost
  • certainty of reaching parenthood
  • sureness of leaving infertility
  • possibility of a genetic link
  • possibility of a biological link
  • amount of control over prenatal health
  • average speed of resolving infertility
  • importance of maternal age
Mel suggests that parents each rank these factors based on importance to them, and then compare their priorities, so that is what we did in 2013. We had the same top two priorities: Certainty of reaching parenthood, and amount of control over prenatal health. On number three we were different but subtly similar: Mr. Turtles's 3rd top factor was possibility of a genetic link, and mine was importance of maternal age.

Based on our top priorities of control over prenatal health, and certainty of reaching parenthood, we preferred DEIVF (or embryo adoption) over adoption as a Plan B (plan A being conception of a child with our genetic material).

So, what if anything has changed now?

Control over prenatal health is still a priority. If it's me that's pregnant, I know I can do everything in my power to provide for a healthy pregnancy.

Importance of a genetic link, this is a tough one. Before AJ's birth I didn't rank this too highly. It certainly was more important to me that I got to be pregnant and give birth to the baby than to be genetically related. Also, the narrative seemed straightforward enough: we want a child, my eggs don't work, so we use a donor. Insofar as these things are in any way straightforward. But now that we have a child genetically related to both of is, it feels more complicated.

I'm not exactly worried about feeling that a child conceived via donor isn't "mine." It's the subtler things.  See, AJ is not just my genetically related child, she's (TRIGGER WARNING: SMUG PARENT) such a perfectly perfect awesome child. She's healthy, beautiful, smart, sociable, affectionate, easy-going, eats well, teethes well and she (mostly) sleeps well. She's on the late side of normal for her gross motor development, but who cares. It's not just us; all our extended family and friends adore her and rave about how perfect and special she is. I know, I know: we'll have to cool it at some point so AJ doesn't become an entitled little narcissistic brat. Or maybe she will make it easy for us by turning into a terror at her next developmental stage. 

But for now, I wonder: Suppose we have another child with an egg donor, and he/she is colicky, or anxious, or aggressive, or stays up all night, or has a developmental issue, or _______ (fill in the blank). As I stumble about in a haze of parental self-doubt, will I start to compare them, thinking thoughts like "I wonder if it's because _______ has somebody else's genes." Not that I think I have such amazing genes that I'm guaranteed to have perfect children every time. But will I credit the donor gamete part for differences or challenges, and start perhaps unconsciously to treat the children differently?

Then there's extended family. Since we would definitely choose to be open about using a donor, would our extended family treat the child differently? Would AJ be perceived as more.....special, more "one of us?" I really hope not, but the thought makes me cringe. On the other hand, I would hope that most thinking people understand that genetics are not the basis of relationship. Probably the best example of this is Nana, one of AJ's 3 grandmothers. Nana is my father-in-law's second wife, so she is not a blood relation to AJ. But she is in no way less of a grandmother than my mom or Mr. Turtle's mom. I actually saw her handle the matter of relatedness beautifully on one occasion. We were visiting her store, and one of her friends made a comment on how AJ resembles her. "Isn't it great how these things work out even when there's no genetic connection," she said, without a trace of discomfort or judgment in her voice. I hope I have her cool and presence of mind one day.

Then there's the whole matter of sibling relationship. Mr. Turtle and I have good sibling relationships, so again we'd like to assume that our children would too, but there's no way to know. Again, would the matter of genetics become something that divides them? I would like to think no, if we handle the matter responsibly as parents. And who knows, perhaps in their daily lives they will meet other children who have a similar family story, and it won't be that unusual or uncomfortable at all. But for now I wonder if I have a right to introduce that kind of complexity into AJ's life and the life of a hypothetical sibling, or more bluntly, if it's simply a bad idea.

Mr. Turtle interestingly did not seem to have the same misgivings about a donor gamete situation that I have. One might think that's because he would maintain his genetic link, but then he reminded me that we might even have to use donor sperm. He acknowledged that my concerns are real, and his comment was that if I think something is likely to happen, then I increase its likelihood of happening. If I think "I can be on an plane to a warm tropical beach" then it instantly becomes more likely that I will be on a plane to a warm tropical beach in the future. (Note to self: put that theory to the test.) But less happily, if I think: I will treat my children differently because of their genes, then it's more likely to happen.  He also noted that he's seen how doubts about paternity (different situations, obviously) can be very corrosive in a family, and lead even on a sub-conscious level, to fathers treating children differently. And the relationship problems continue even if paternity is proven. The basic theme of his comments was: If you start a pattern of behaviour in a family, for whatever reason, it can be very difficult to change. Overall, however, Mr. Turtle said he would be happy to have a child via gamete donation.

But following that theme, Mr. Turtle also said that he would not want to adopt a child, because he did not feel that he could show the same level of affection to an adopted child as he does to AJ. This surprised me a little, partly because we have never seriously discussed adoption, but also because in my mind adoption is in a completely different category from fertility treatment. I would need a very different mindset to adopt and build a relationship with an adopted child than I have to give birth to a child, by whatever process. I actually think I worry less about comparing a hypothetical adopted child to AJ, because the way that each child came into our lives would be so different, that there wouldn't be the same temptation to compare and contrast. It goes to show how subjective these matters are, but paradoxically how real in the way they could manifest in the way family members treat each other. 

Finally, I'm not sure how much of this is the anxiety that any parent might feel about adding a sibling to the family, even if the process didn't involve fertility treatment or differences in genetic inheritance. It seems not uncommon for parents to worry that a sibling with negatively impact the first child, or that they couldn't possibly love the second child as much, etc. But from what I can tell, in reasonably happy and functional families these things mostly work out.

Apart from the concerns about sibling relatedness and family dynamics, there are other issues complicating my feelings about DEIVF.

Cost: This wasn't a huge concern to Mr. Turtle and I before AJ's birth.  Faced with big bills for fertility treatments, our attitude was, "We only live once," and the possibility of a child was absolutely worth a major investment. But now that we have a child to support, I see things differently. We have respectable savings, seniority at work, and our public sector jobs in the supposedly essential fields of health and education seem secure. But there's always a "but." Our generally prosperous province is experiencing an economic downturn. People are being laid off all around us. Businesses are struggling. Our recently elected leftist government is nominally on the side of the public service, but that's not much help if they bankrupt the province or make our professional lives living hell with some ill-conceived restructuring scheme.

Faced with uncertainty (the in-your-face kind, as opposed to the kind that is always there), or even just contemplating our responsibilities to AJ, I feel much less easy about spending thousands of dollars on something that may or may not work. That money is also our child's future, her security. AJ can grow up without tons of material possessions (I did), but there are things I feel we absolutely must give her: quality life experiences, healthy family relationships, and high quality education, including post secondary. Money can't buy all those things, but some of them it can, and mom and dad should have sound financial plans so they avoid quarreling about money, as much as possible.

On the other hand, we do only live once. And maybe The Fertility Clinic is also feeling a bit of the economic crunch and will feel just that little bit more obligated to give us great service.

Lastly, if we do DEIVF there's always the chance that we will complete our family and still have embryos left over. The question of unused embryos sitting in storage (or disposed of via other means) was always the part of IVF that made me the most uncomfortable. Due to the POF, it was always extremely unlikely we would have surplus embryos if we did IVF with our own gametes, so as we moved through the process I didn't worry much about potential unused embryos. As it turned out of course, we didn't make any embryos with IVF. But with donor eggs, maybe we'd get a lot. How would I feel in that situation? I can be cynical and calculating about a great many things, but about embryos that are potential babies? Paying cash for a service is one thing; paying with a piece of a tiny soul is something else again.

So here we go again.

If donor egg IVF (DEIVF) is our only chance to have another child, do we want to go for it?

If DEIVF is our only chance to have another child, are we OK with not doing it?

I'm not sure.

Thursday 18 February 2016

Talking about fertility again, part 1

For the past two years I've know that at some point I would be talking about fertility again. I've never stopped thinking about it, other than perhaps the anxiety-ridden weeks of early pregnancy, and labour, and the first month of AJ's life.  During those particular points in time there was no room in my mind for thoughts about future fertility / sub-fertility / infertility. But most of the time, there's a dialogue about it in the back of my mind, and anything that happens in my life, or that I read in the news, or on another blog, or in a conversation, or __________ (fill in the blank) becomes part of the commentary.

Of course, there have been plenty of reasons to silence or ignore this commentary for the past couple of years. And I have. But in the last few months it's become harder to ignore, and finally I'm relieved to put the questions and the thought process out there. One way or another, we have to move forward. So here goes.

It all comes down to a couple of questions, basically: How important is a second child to our family, and what are we willing to do to bring that child into our family?

Mr. Turtle and I both agree that we would like a second child. We seem to be doing alright with the child we have, and in our innocent visions pre-IF diagnosis we always thought we'd have two or even three.  At the same time, we can both envision a happy family with one child, i.e. A.J. After all, we are a happy family now! It does not feel like a great burden to simply go on being a happy family. Of course, for me, stopping at once child means accepting that I will never be pregnant again, never give birth, hold a newborn, breastfeed, etc. etc. This is hard to do. I could write a half dozen blog entries about why, but I'll just leave it at that for now.

So, we want to try for a second child. We offer our will and wish against.............whatever in nature opposes it.  But what exactly are we willing to try?

Our ideal scenario: We get pregnant again without intervention. It happened once, after all. Or at least, I got pregnant after a failed intervention. I'm not sure that's quite the same as you know, natural-naturey-naturally-O, but I doubt we can exactly replicate the conditions of that conception (shudder).

The challenges here? Mainly premature ovarian failure. POF.

Here's the dirt. We've been sexually active more or less regularly for about a year.  Factor in parenting a young child, a parade of infectious illnesses, death in the family stress, work stress, graduate school stress, etc. etc. and it's certainly not been optimal conditions all the time. But still, we show up for our dates of reproductive roulette.

My period returned last April. My cycle lengths since then: 30, 23, 21, 44, 20, 21, 24, 25, 67 (I almost lost track with that one!), 19, 21.

I ended up going to see my doctor during the really long cycle because it was unusual even by my standards. Except my doctor was on holidays, and the one that saw me looked about 22 years old. Sigh. But actually he was able to call female reproductive parts by their full names without smirking, and that's better than I've sometimes experienced. We went over my reproductive history, including several letters from The Fertility Clinic. When we (mainly I) was undergoing testing in 2013, Dr. Cotter kept my family doctor informed by sending him letters describing the results. I had never seen these letters as Dr. Cotter would meet with us in person. She wasn't one to mince words, but somehow the letters seemed even harsher than the meetings I remember. My POF is "severe." There is little to no chance of unassisted conception. And so on. It felt very cold.

The conclusion of Not-My-Doctor was that my very irregular cycles are consistent with the POF diagnosis, and that I can expect more of the same, followed by early menopause. He did not think more testing was necessary, but I said I would prefer to be pro-active about my health. So he requisitioned a few blood tests, an ultrasound to look at the ovaries and fibroids, and, on second thought, a bone density scan since low estrogen can lead to osteoporosis. I go for the ultrasound/x-ray tomorrow, and the plan is to schedule another meeting to discuss the results with my real doctor (Dr. Gnomish on the blog).

I'm expecting that the bloodwork and ultrasound will show similar results to my 2013 tests, and can only hope that things have not gotten much worse, but it wouldn't surprise me to learn they have. I'm not too concerned about the bone density scan, because I don't have symptoms of low estrogen. But we'll see. I also discussed the long-term health implications of POF with Not-My-Doctor. The main concern with early menopause is low bone density. Hormone replacement therapy addresses this issue, but also causes infertility. Not just almost-infertility, but complete infertility. Hormone replacement also leads to a slight increase in the chance of uterine cancer, although that can be addressed by the proper balance of hormones. It slightly decreases the chance of breast cancer. It also can improve "lifestyle" by regulating the irregular or heavy periods associated with POF.

Unless these tests show something really unexpected, I am not interested in pursuing hormone replacement therapy, and I don't think I'd even consider it until I'm completely in menopause. But still, it's part of the discussion.

So, in summary, it's not a very optimistic picture, and then add to that Mr. Turtle's sperm problems.  On the other hand, we have a cuddly, adorable, and very real counter-argument in the shape of AJ. Should that give us hope? I don't know.

Back in 2014, Dr. Cotter told us that we should pursue donor egg IVF, that anything else was a waste of time. And if we go back to The Fertility Clinic, I don't expect to hear any different. It would be nice if there was a reproductive specialist who could analyze how I fell pregnant in the first place, and come up with some personalized treatment to help that happen again, but I doubt it. I have no reason to believe Dr. Cotter was dishonest with us, but The Fertility Clinic is a business and they will steer people toward whatever process is a money-earner and will hopefully look good on their statistics.  There's no money in or research into people who become pregnant after a failed IVF cycle.  I don't think so anyway.

That leaves, most likely, DEIVF. We were on track to do DEIVF in 2014, and we were completely OK with it then. Obviously since we didn't end up doing it we didn't fully process all the emotions. But we didn't have any ethical issues with DEIVF. And I think DEIVF is an amazing option for many families.

Now, however, with AJ in the picture, things are a bit more complicated. Since this entry is already getting long, however, I think I'll save that discussion for another entry. For now a big fat novel is calling me.

Jump to Part 2 of this contemplation

Sunday 7 February 2016

Don't look over your shoulder, the sunset's at your back

....and we're movin' on, dn-dn-dn......movin' on..... (I'm hoping at least Gypsy Mama and Aramis can sing along.)

Movin' on. Last evening I moved the boob pillow out of the nursery into the basement. It was a hit with AJ in the new setting, as she has recently discovered the sensory pleasure of soft fluffy things.

I'm not totally ready to say she's weaned, but I haven't boob fed since last Monday and everything is good. No problems falling asleep. AJ hadn't been falling asleep at the boob in a long time anyway. The truth is, it was probably Mommy who most wanted that last snuggle and suckle of the day. I had no timeline for weaning her off the breast; I figured AJ would make it clear when she was ready and she has.

I find the best way to handle AJ's milestones is to not make a big deal out of them. Still the end of breastfeeding is a little harder to accept. It means letting go in a very tangible way of the things that made her an adored infant. At the same time my strongest emotion by far is gratitude for AJ's development and increasing skills. She ate successfully at the breast from the beginning. And then that she transitioned well to solid food. She can feed herself some foods with a spoon now. Everything has gone the way it is supposed to. It's been an easy transition, but still a transition, with many emotions. (It seems impossible to even write this paragraph without overusing the words "but" and "still.") I am still lactating, which makes me kind of sad; I wish the milk would just disappear so I don't have to think about it not being used. But so far at least I haven't been uncomfortable. I haven't read anything on how to go about this; I figure I'll let nature take its course. I hope that's not a dumb idea but I really don't want to prevaricate on it.

I've known since about November that AJ wasn't  relying on the breast for eating. It was a comfort thing, but she's learned other ways to seek comfort (like biting her blanket before she goes to sleep). We still have lots of cuddles before bedtime, and I love when she goes to sleep in my arms. (I know, that's not how you're supposed to "sleep train," but generally AJ sleeps through the night and naps about 2 hours at home and daycare: I don't begrudge her the cuddles! On the other hand sometimes she doesn't want to be cuddled to sleep. She'd rather do this thing where she half gets up, and then flops down in the crib. And up, and flop. Until she's too tired and stays down. Also freaking adorable.)

Oh, and because there's always room for Rankin Family nostalgia on torthúil: here is the music video  for "Movin' On" released in 1998.  The Rankins were still in their 30s here. It was barely a year before Raylene retired from the band to spend more time with her infant son and only child (born after repeated miscarriages). Two years before John Morris died in a car accident, leaving two young children. Fourteen years before Raylene passed away from breast cancer. Yeah, I think a lot about death lately. I don't know if the remaining siblings will ever perform as a collective again, but on a more cheerful note: Jimmy (married and two kids) has a successful solo career; Heather is releasing her first album; John Morris's daughter is experiencing success with her indie rock band Alvvays; and I assume Cookie is happily married to her music producer husband (no kids).

Moving on can be sad, but as I like to say when I'm in a cheerful mood: The good times today have to come to an end so we can get to the good times in the future.