Surrogacy 101

Tips: Working with your clinic

 

 

Below is a short list of documents and tips that you and your clinic will need to facilitate your ART case. 

 

1. Your clinic will need to have the contract signature page at the very least (they may require the entire contract) on file or an affidavit from the contractual attorney, indicating that the contract is complete and has been signed by all parties.

 

2. The medical information forms need to have been signed by all parties and given to your clinic for their files.

 

3. The Surrogate Mother/Carrier is the patient. Information on medication, transfer, and follow up must be conveyed to her through the clinic and not the Intended Parents although they should be informed as well.

 

4. The Intended Parents need to make sure that they have a credit card on file with the clinic for all medication and procedures that involve the Surrogate Mother/Carrier and/or Egg Donor.

 

5. The Surrogate Mother/Carrier or Egg Donor should receive NO BILLS. She is not responsible for any payment of bills and this is usually stated in the contract between the Intended Parents and Surrogate/Egg Donor.

 

6. IVF costs should not be attempted to be billed through the Surrogate Mother/Carrier's insurance. (Blood tests, pap smears, OB appointments etc. are usually ok.) Remember the Surrogate Mother/Carrier is not the infertile woman and billing her for IVF costs can cost her the insurance policy and possibly pose insurance fraud accusations. Medicaid should not be used under any circumstance.

Polycystic Ovaries by Dr. Barry Jacobs

Polycystic Ovaries

 

 

One of the most common findings when a couple enters a practice with the complaint of difficulty achieving a pregnancy is polycystic ovaries, or PCO.  Sometimes the condition is referred to as PCOS or PCOD, adding either syndrome or diseases after PCO.  I am not sure we can truly classify the problem as a single entity by declaring it a disease or syndrome.  We know of at least 2 causes of the problem.

The majority of women with PCO are insulin resistant.  By that, I mean that their cells do not respond adequately to insulin, so they must make extra insulin to keep blood sugar normal.  No, that does not mean they are diabetic.  However, people who are insulin resistant are at greater risk to become diabetic.  They are also at greater risk for heart attack and stroke.

On of the things insulin does very well, even in people who are insulin resistant is to convert the carbohydrate they eat into fat for storage.  The more fat they have stored, the worse their insulin resistance; the higher their insulin levels rise in response to a carbohydrate load, and the faster they convert carbohydrate to fat.  It’s s vicious circle.  We have to break the circle.  I strongly recommend my insulin resistant patients drastically cut their carbohydrate consumption to 30 grams a day. 

In addition to carbohydrate restriction, I prescribe a medication called Glucophage (metformin).  It will decrease carbohydrate absorption from the intestine and increase the response of her cells to insulin.  We also know that women with PCO have a lesser risk of miscarriage if they are taking Glucophage, and women who are insulin resistant have a lesser risk of developing gestational diabetes, if they are taking Glucophage. 

The side effects of the medication are related to the inhibition of carbohydrate absorption from the intestine.  The carbohydrate remaining in the intestine draws water into the intestine and the bacteria in the intestine make gas, when they eat the carbohydrate.  The result is diarrhea, cramping and gas.  Carbohydrate restriction decreases the symptoms.  The other side effect, if patients really follow the protocol, is weight loss.  Most of my patients like that side effect.

The other known cause of PCO is a deficiency of an enzyme in the adrenal gland.  The enzyme involved is called 21-hydroxylase.  It is part of the pathway to create cortisone.  There are 2 known molecular variants of the enzyme abnormality.  One is relatively mild, and the other more severe.  It requires 2 copies of the gene to make the enzyme – one from each parent.  If a woman has 2 abnormal copies of the gene, and one is a mild version, she will have a condition which will be clinically described as PCO.  Adding a low dose of steroid at bed time will help.  If one gene is a severe variant, and her pregnancy inherits that one and a severe abnormal copy from her husband, the child will have a condition called adrenogenetal syndrome.  If it is a girl, she will have ambiguous genetalia.  Both boys and girls are at risk to be salt wasters and have severe disorders of blood chemistry.  Diagnosis is critical.  These gene abnormalities are among the most common known, and are present, in at least a carrier state, in at least 5% of some ethnic groups.

Ovulation induction to help achieve a pregnancy for women with PCO can be assisted using treatments such as Glucophage or steroids, if indicated, but alone, neither is usually adequate.  There are specific medications available for ovulation induction.  The oldest, and to my thinking the worst, is Clomid.  Far better is the group of products that are pituitary hormones which cause development of the ovarian follicles which contain eggs.  The use of these medications is safest if done by a Reproductive Endocrinologist.    

 

Dr. Jacobs is a Reproductive Endocrinologist, practicing in Carrollton, Texas, a northern suburb of Dallas.  He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become its first fellow once Baylor achieved accreditation for an advanced training program in Reproductive Endocrinology and Infertility.  Dr. Jacobs has served on the faculty of several medical schools and was director of Reproductive Endocrinology at Texas Tech Health Science Center in Amarillo.  Currently, in addition to his clinical activities caring for infertile patients and those with recurrent pregnancy loss, he is Chairman of the IVF committee at Baylor Medical Center in Carrollton.  

Barry Jacobs, M.D., 4323 M. Josey Lane, Suite #201, Carrollton, TX 75010 www.texasfertility.com
Phone: 972-394-9590 Fax: 972-394-9597

What to Expect from a Psychological Evaluation By Dr. Barbara Feinburg

 

You may be asked to meet with a psychologist for a “psychological evaluation”.  A psychologist is different from a psychiatrist.  A psychiatrist has a medical degree (M.D.), and they primarily prescribe medication, although some also conduct psychotherapy.  A psychologist has a doctorate in psychology (a Ph.D. or Psy.D.), and they provide evaluations and conduct psychotherapy.   

If you are interested in serving as an egg donor or traditional surrogate, the aim of the psychologist is twofold.  The psychologist would like to gather as much information as possible so the recipient couple is prepared.  For example, should there be a family history for learning disabilities, the recipient couple can learn about possible warning signs.  Consequently, should their child develop academic difficulties, the recipient couple could then proceed with appropriate treatment.  It is important to remember that psychologists know there is no perfect person and that it is extremely rare for a person to have a family history devoid of any psychological problems.

The psychologist is trained to remain neutral, and is interested in providing acceptance and support.  A well-seasoned psychologist knows it is more credible if a person has had a bump or two along the road and/or if a donor/surrogate speaks of at least one relative who has experienced some sort of psychological problem.  It is best to be honest.  It is far better to honestly portray yourself and your family than to cover up what you fear could disqualify you.  It is likely you will be disqualified if you are inconsistent in your responses.

The psychologist is also interested in determining your stability.  Couples who seek out an egg donor or surrogate are very serious about wanting a successful outcome.  Some couples have tried to have children for five or even ten years, by the time they reach this step.  It is imperative you are certain you can and want to take this journey to completion.  The psychologist will try to determine whether or not you will follow through by not only asking you about your feelings about serving as an egg donor/surrogate, but also by looking for patterns of stability in your past. 

The psychologist will also spend time discussing with you the psychological ramifications of serving as an egg donor/surrogate.  This portion of the interview is for your benefit.  Regardless as to your motivation, helping a couple have children is a wonderful gift.  Your desire to be a part of the miracle of life puts you in a very special, cherished category.  You deserve to understand how this experience might affect you.  It is also important you learn enough about this process in order to make the right decision for you.  Should you have any questions, please ask them.  Serving as an egg donor/surrogate is a decision that will affect you for the entirety of your life.  It will most likely be comforting for you to receive answers to any questions you might have. 

 If you are interested in serving as a gestational surrogate, it is likely you will be asked to meet with a psychologist.  Many of the same questions will be asked.  Although your genetic history will not come into play, the psychologist will want to get to know you, so s/he can describe you to the intended parents.  Additionally, the psychologist will be interested in determining if you will be able to provide a safe environment, both physically and environmentally, while you carry a couple’s baby.  The psychologist will also want to prepare you in many different ways.  Not only are there many issues to consider during your pregnancy, but it is of utmost importance to prepare you for what you might feel when you release a child to the intended parents.  This is one of the most selfless and beautiful gifts you can give to others.  At the same time, it can leave a tremendous void.  The psychologist will want to prepare you and your partner to make sure that as you think through your decision, you can determine what is best for you.

You may be asked to take a personality test.  Most often, the Minnesota Multiphasic Personality Inventory, 2^nd Edition (MMPI-2) is administered.  This is a long inventory that consists of approximately 500 true-false questions.  The test is sensitive to test-taking style.  Oftentimes, potential donors/surrogates feel nervous and at some level, feel they must be close to perfect. It is not true that you have to be nearly perfect to be chosen.  Nevertheless, this mindset sometimes leads people to “fake good”, or present themselves in an overly favorable light.  “Validity scales” will reveal this test-taking style, and you could invalidate your results.  This could disqualify you.  It is good to know that the inventory allows for “normal” stress, occasional sadness and anxiety, and for human frailties.  Besides the “validity scales”, the inventory also yields “clinical scales”, which group together to form a “profile”.  The profile describes your characteristic ways of interacting with the world.  If you respond in a manner that is open and honest, it is likely your profile will yield interesting information for you.  Many psychologists are willing to discuss your results with you, should you ask.

Recipient couples, also known as intended parents, are sometimes asked to attend an interview with a psychologist.  They are sometimes asked to take an MMPI-2.   For those of you who are considering using an egg donor, the interview with a psychologist is to make sure you have considered what it might feel like in the future, to have a child who is not fully genetically related to you.  Additionally, the psychologist may ask questions to determine your financial and emotional stability.  This is not done in a judgmental or critical manner.  Rather, this would be to help you plan well for yourselves, especially if you have never had children.

If you are considering using a surrogate, the clinical interview for the intended parents is designed to prepare you for the emotional and financial issues that may come up.  There are many things to consider when using a surrogate, such as whether or not you will provide health insurance, life insurance, or home support in case your surrogate becomes bedridden with a pregnancy. Additionally, it is wise to think ahead with regards to how you might handle a poorly formed fetus, or multiples that jeopardize the life of the mother and/or the babies.  Lastly, it is a good idea to discuss what expectations you have with regards to a relationship with the surrogate both during and after a pregnancy.  A trained psychologist can guide you through this dialogue, and inform you so you can make the best decisions for this very important and life-altering event.

 

Dr. Barbara Feinberg is a licensed psychologist.  She received her doctorate in clinical psychology from Florida Institute of Technology in 1985.  Dr. Feinberg has been practicing psychology in Tampa, Florida for over twenty-two years.  Dr. Feinberg works with adults and children.  Areas of treatment include infertility support, as well as coping with depression, anxiety, panic attacks, marital concerns, divorce and behavioral problems.  Dr. Feinberg also provides gifted and learning disabilities evaluations.  Additionally, she has specialized in reproductive issues for over ten years.  She has spoken around the state of Florida on psychological and emotional issues that pertain to infertility. Dr. Feinberg provides psychological evaluations for egg donors, traditional and gestational surrogates, and intended parents.  She works in conjunction with several egg donor agencies, surrogacy agencies and attorneys around the United States.  You may contact Dr. Feinberg at 15961 North Florida Avenue, Suite A, Lutz, FL   33549, or [email protected]. 

Foods to Help You Feel Better By Elaine Magee, MPH, RD

Are you feeling down in the dumps? Are you irritated at how often you’ve been irritable?

Perhaps it’s time to look at the foods and drinks you consume to see if they are trashing your mood. Nutrition experts say that the foods you eat can help you feel better -- or feel worse -- in the short-term and the long-term. 

• Meal-to-meal and day-to-day, keeping your blood sugars steady and your gastrointestinal (GI) tract running smoothly will help you feel good and energetic. If your blood sugars are on a roller-coaster ride -- hitting highs and lows from too much sugar and refined flour – you are more likely to feel out of sorts. This is also true if your gastrointestinal system is distressed due to intense hunger from a fad diet or constipation because you aren’t getting enough fiber and water.  

• Week-to-week and month-to-month, keeping your body healthy and disease-free makes good moods more likely. For example, key nutrients you get in certain foods can influence the levels of feel-good hormones such as serotonin. Other nutrients can help prevent inflammation so blood circulates well to all of your organs.

“Eating a heart healthy diet -- high in fiber and low in saturated fat -- is a great place to start to boost your mood. There isn’t any question about it, says Diane M. Becker MPH, ScD, director of the Center for Health Promotion at the Johns Hopkins School of Medicine.

Conversely, “a high-fat, high-glycemic load meal can make you physically feel dysfunction in your body. People who eat this type of meal tend to feel bad and sleepy afterwards,” she says.

6 Tips for Foods and Beverages That Help You Feel Good

1. Seek out foods rich in vitamin B12 and folic acid (folate).

What’s special about chili made with kidney beans and lean beef? Or a light chicken Caesar salad made with skinless chicken breast and romaine lettuce? Or grilled salmon with a side of broccoli?

All these dishes feature one food that is rich in folic acid (folate) and another that is rich in vitamin B12. These two vitamins appear to help prevent disorders of the central nervous system, mood disorders, and dementias, says Edward Reynolds, MD, at the Institute of Epileptology, King’s College, London.

The link between higher food intakes of folate and a lower prevalence of depressive symptoms crosses cultures, too. A recent study confirmed this association in Japanese men. 

Folic acid is usually found in beans and greens. Vitamin B12 is found in meats, fish, poultry, and dairy.

Other dishes that feature B-12 and folic acid-rich foods include:

• A burrito or enchilada made with black beans plus beef, chicken, or pork

• A spinach salad topped with crab or salmon

• An egg white or egg substitute omelet filled with sauteed spinach and reduced-fat cheese

2. Enjoy fruits and vegetables in a big way.

Fruits and vegetables are packed with key nutrients and antioxidant phytochemicals, which directly contribute to your health and health-related quality of life.

In a one study, eating two more servings of fruits and vegetables a day was associated with an 11% higher likelihood of good functional health. People who ate the highest amount of fruits and vegetables felt better about their health.

3. Eat selenium-rich foods every day.

Selenium is a mineral that acts like an antioxidant in the body. What do antioxidants have to do with feeling better and minimizing bad moods? Research suggests that the presence of oxidative stress in the brain is associated with some cases of mild to moderate depression in the elderly population. 

One study evaluated the depression scores of elderly people whose daily diet was either supplemented with 200 micrograms of selenium a day or a placebo. Although more research is needed to confirm the findings, the group taking selenium had higher amounts of selenium circulating in their blood and significant decreases in their depression symptoms.

Try to get at least the recommended daily allowance for selenium: 55 micrograms a day for men and women.

Whole grains are an excellent source of selenium. By eating several servings a day of whole grains such as oatmeal, whole-grain bread, and brown rice, you can easily get 70 micrograms of selenium. Other foods rich in selenium include:

• Beans and legumes

• Lean meat (lean pork or beef, skinless chicken or turkey)

• Low-fat dairy foods

• Nuts and seeds (especially Brazil nuts)

• Seafood (oysters, clams, crab, sardines, and fish)

4. Eat fish several times a week.

Several recent studies have suggested that men and women have a lower risk of having symptoms of depression if they eat a lot of fish, particularly fatty fish like salmon, which is high in omega-3 fatty acids.

Omega-3s from fish seem to have positive effects on clinically defined mood swings such as postpartum depression, says Jay Whelan, PhD, head of the department of nutrition at the University of Tennessee.

Good sources of omega-3 fatty acids include:

• Herring

• Rainbow trout

• Salmon

• Sardines

• Tuna  

5. Get a daily dose of vitamin D.

Does a little time in the sun seem to make you feel better? The sun’s rays allow our bodies to synthesize and regulate vitamin D. 

Four recent studies showed an association between low serum levels of vitamin D and higher incidences of four mood disorders: PMS, seasonal affective disorder, nonspecified mood disorder, and major depressive disorder.

Researcher Pamela K. Murphy, PhD, at the Medical University of South Carolina says people can help manage their moods by getting at least 1,000 to 2,000 IU of vitamin D a day.

That’s significantly more than the Institute of Medicine’s Recommended Dietary Allowance for vitamin D, which is 600 IU daily for ages 1 to 70, and 800 IU for people over 70.

Very few foods naturally contain vitamin D. So she recommends we get vitamin D from a variety of sources: short periods of sun exposure, vitamin D supplements, and foods.

Vitamin D can be found in:

• Fatty fish such as salmon, tuna, and mackerel

• Beef liver

• Cheese

• Egg yolks

But our primary source of dietary vitamin D is fortified foods, such as breakfast cereals, breads, juices, and milk.

6. Treat Yourself to 1 oz of Chocolate

“Small amounts of dark chocolate can be a physical upper,” says Becker at Johns Hopkins. “Dark chocolate has an effect on the levels of brain endorphins,” those feel-good chemicals that our bodies produce. Not only that, but dark chocolate also seems to have a heart-healthy anti-clogging effect in our blood vessels.

In one study from the Netherlands, Dutch men who ate 1/3 of a chocolate bar each day had lower levels of blood pressure and lower rates of heart disease. The chocolate also boosted their general sense of well-being.

How Foods and Beverages May Make You Feel Bad

Just as some foods can help you feel better, others can make you feel down. Here are ways to reduce the harmful effects of three foods that can drag you down.  

1. Reduce foods high in saturated fat.

Saturated fat is well known for its role in promoting heart disease and some types of cancer. Now researchers suspect saturated fat also plays a role in depression.

The link was found in a study called the Coronary Health Improvement Project, which followed 348 people between the 24 and 81. A decrease in saturated fat over a six-week period was associated with a decrease in depression.  

2. Limit alcohol carefully.

That “feel-good” drink, alcohol, is actually a depressant. In small doses, alcohol can produce a temporary feeling of euphoria. But the truth is that alcohol is a chemical depressant to the human brain and affects all nerve cells.

Depending on the amount of alcohol consumed, people can go quickly from feeling relaxed to experiencing exaggerated emotions and impaired coordination.

It’s no coincidence that depressive disorders often co-occur with substance abuse, and one of the main forms of substance abuse in this country is alcohol.

3. Don’t go crazy with caffeine.

Caffeine can increase irritability a couple of ways.

• If the caffeine you consume later in the day disrupts your nighttime sleeping, you are likely to be cranky and exhausted until you get a good night’s rest.

• Caffeine can also bring on a burst or two of energy, often ending with a spiral into fatigue.

Some people are more sensitive than others to the troublesome effects of caffeine. If you are sensitive to caffeine, decrease the amount of coffee, tea, and sodas you drink to see if this helps uplift your mood and energy level, particularly in the latter part of the day.