More glimpses of the realities of surrogacy in India

J goes to Heeranandani hospital for her routine OB-GYN checkups. I went with her for her very first checkup, and it was an intensely disconcerting experience. There are about maybe 12 surrogates gathering and waiting for anywhere between 1-3 hours. The OB-GYN's assistant shows up, and starts seeing this procession of women. They get a doppler check and their blood pressure and weight read, all while the next 3 patients are queuing up on the other side of the curtain while the first patient is in the bed. My mom likened it to the situation in the poorest, most strapped municipal hospitals, where she worked briefly as an intern

After that first painful experience where I waited over 3 hours for a 15-min cursory check complete with an ancient-looking doppler, I never went again, and instead only go with J to the wonderful, detailed ultrasounds that are run at the Mediscan testing center by the very capable Dr. Bhansal.

This past Wednesday marked 28 weeks, and J went for her checkup at Heeranandani. I contemplated going, but I decided to just trust the system and sent her off with all the reports and expected her to get both the Rhogam shot and much discussed mandatory steroid shot. Too many times where I decide to just trust the system here, it has turned out to be a Bad Idea. But that is a topic for another post.

I talked to J after the appointment and find that no injections were given. I then try to find out what happened. If you go to an agency like Surrogacy India, they have this system where all the reports are scanned and uploaded and are available online for the parents immediately. Here, with the Malpani Clinic, there is no such centralization. I've spent 3 days waiting to find out what exactly was done at that visit. The surrogate handler claims that she gave the report to the receptionist at the clinic, who then claims to have emailed it to me. No such email was received. The handler claims she reminded the receptionist of it again one day later, and that she apparently mailed me. No mail was received. I've asked the doctor what was happening, and have received no word. I am SO very glad that I have to deal with this system only for another 10 or so weeks.

But here is the deal: they don't give the steroid injection at the hospital, they only write the prescription for it, and expect that some local nurse or some local doctor will give it. In the case of the Malpani clinic, the person who gives the shots is no trained nurse, but the handler herself.  A little background on the handler: This is a woman who has gone through surrogacy herself, comes from the same socio-economic class as the surrogate, and is partially literate, but at best studied till high school. In general, these are not people who are professional and impartial: they may not above lying for the surrogate (remember the story I posted about the handler who helped a 42 year old surrogate propagate a lie that she was 28?). 

In this case, the handler will give the shot at her home, which is a shanty of sorts.I have to pray that the she is atleast trained in sterile techniques. I asked my RE about this, but as with most situations, I got resounding silence.

Here is the other thing: J told me that Dr. Malpani thinks that the Rhogam shot at 28 weeks is not necessary. He has not bothered communicating this directly with me, and nor has the OB-Gyn.

The person who did seem to think it necessary is Dr. Bhansal. She is a fetal metal specialist who works with high-risk pregnancies. She is also the go-to person for detecting fetal anemia, and is also the go-to person to give transfusions in the situations where it does develop. I'll have to talk to her about the necessity of this again. I totally hear you guys about the many places that do not give this prophylactically at 28 weeks. The one reason why I'd be more concerned here is because this is a surrogacy, and J may not be as prompt as required if something goes wrong (if she falls, etc).

But, in happier news, we have crossed the 28-week mark. This is the point after which the complication rate falls considerably. I was supposed to go in for an ultrasound tomorrow, but my mother will not be in town. A while ago, my friend M told me to always take my mother with me to the ultrasounds, because she is my lucky charm. I take that advice very seriously: she has come for every appointment, and I'm far too chicken to go in without her now. The next ultrasound should happen in the middle of next week.  

Also, I want to celebrate the surprise (to me anyway, I had NO idea) pregnancies of 2 bloggers who are very close to my heart, who have stopped actively blogging. I think it is rather cool that two such very wise women who I thought were actually quite similar (in their outlook on things and their utter sensibility)  are so synchronized with their pregnancies; they both just crossed 24 weeks. Adele and Arohanui, so very happy for the both of you!

Checking in: 27 weeks

ICLW (IComLeavWe) collided with my vacation in the lovely Maldives. I naively thought I could comment from my phone while I was there (HA), but none of that happened. But anyway, I got away and snorkeled and gazed at insanely blue water to my heart's content. I got back last night and I'm still getting my bearings back.

Tomorrow marks 27 weeks. I have not bought a single thing for the baby yet. Not one bloody thing. Almost all my essentials need to come from the States. I have to figure out how to transport baby bottles (I'm going for stainless steel ones), a gzillion tins of Myenberg Goat's milk powder, and random things like DHA and vitamin drops and probiotics (formulating a very useful post on this one, which will most likely go up on my new blog) and blackstrap molasses. I'm far too terrified to go shopping for cribs and onsies yet. None of this feels real. I wish I could get the gender now---in some funny way, I feel like this would make all this seem a little more concrete.

Next week marks the timepoint to give the steroid shots, and J would also have to get the Rhogam shot or its equivalent. Turns out in India they have a monoclonal IgG shot available that is free of thimerosol, but it comes with its own wrinkles. I'm trying not to overthink and read the literature and decide whether to forgo the 28-week shot or not (there is some mild controversy here) or think of the nebulous risks of giving the shot, or the more easily imaginable repercussions of *not* giving it.I'm so PISSED that this pregnancy has to go through this easily avoidable issue. 

I asked my mother to talk to the NICU chief at the hospital that has the milk bank, and that conversion was again a door clanging shut in my face. No milk (they get super low amounts, apparently); they advised me against a wet nurse because even if you screen for diseases, you miss out on the window period where they could have contracted a disease but do not test positive for it yet.

All in all..hello formula from day 1, goodbye milk. I totally get the desperation of parents to get breast milk to their babies,if only for a few days.  There is a rather poignant/sad yet comical story I heard about a mother who was desperate to get her baby milk after she was born from surrogacy. She paid the surrogate a lot of money to provide the milk on the sly (the doctor had told her it was not in line with their policies), not realizing that the doctor had given the shots that made the surrogate's milk dry up. They apparently tried for
days and nothing happened. I can only imagine the collective frustration of everybody involved.

How important IS breast milk? Apparently, as a baby, I got no breast milk either (and maybe did not suffer at all for it, or mildly did---these things are impossible to judge), and the same will be true of my baby. It is impossible to gauge how your choices hurt or help things along, and I've been determined in theory to not beat myself up for things I cannot help...yet...that stupid urge to nitpick my choices and wonder about what the possible repercussions could be just does not go away. Parenting lesson #1, maybe?   

ICLW #3

Welcome to ICLW! Excuse the typos- I'm typing this post from my phone.

A quick introduction- my story has to strech back to when I was 25, when I decided that if I did not meet the right guy in the next 5 years, I was going to try to have a baby by myself.  To my own shock, I went ahead with this audacious plan the month I turned 30. I tried to get pregnant. I succeeded on my first try. I lost that pregnancy. I tried again two months later. I lost that too. I took a year long break and tried again, only to have the worst pregnancy/loss ever. At this point, I had severe pregnancy PTSD, and the thought of having an ultrasound to see if there was still a beating heartbeat made me sick with anxiety. I returned to my India (the country I grew up in) for the more affordable fertility treatments (including surrogacy)  and the support of my family. My first IVF was an unmitigated disaster. The second (where I designed my protocol myself) resulted in about as good a response as one could hope for, and a surrogate, after rejecting 3 of my high grade day-5 blasts, got pregnant with one of them.

That pregnancy hits 26 weeks tomorrow. It took a lot of superstition squishing to get me to participate in ICLW-- the first time I signed up for this, I discovered a pregnancy loss about 2 days in. I'm trying to recite this mantra from one of my favorite books: Hope strengthens, Fear kills. Well, not literally, but you can miss out on quite a bit just because of your stupid, irrational fears. So here I am, kicking one of my superstitions in the nuts and hoping it does not reciprocate.

My blog is not just a recounting of my story...I'm a scientist and an information junkie, and I'm determined to make this experience as positive as possible by dispersing how much ever information I can. And this I have done, to the point of making your eyes glaze over. If you are so interested, the 'Science of Infertility' page summarizes a good part of it.

So welcome. Thanks for stopping by, and I look forward to reading your stories!

25 weeks...and a shocker

First, thank you all, all the people who "derlurked." I've saved the blog addresses of those who were not on already my reading list, and I look forward to reading your stories.

Apparently, there is an ultrasound every month from this point on. I was pretty darned happy to hear this, and I went back to Mediscan, where I've had all ultrasounds done so far. This is a lab chain that specializes in fetal testing, and the doctor here is one that I absolutely have come to like and respect. Her name is Vandana Bhansal, and I highly recommend this place (and her) for antenatal testing.

The ultrasound was going well. Dr. Bhansal then casually asked J what her blood type was. Both my mother and I were shocked out of our wits when she replied "B negative." Negative?!?! That means she does not express the Rh antigen. I do express it, as does my donor.

Rh- moms need specialized attention when they are carrying an Rh+ baby, because if there is is mixing of fetal and maternal blood, the mother will make antibodies against the fetal Rh antigen. Those antibodies can then cross the placenta and can cause fetal anemia and jaundice. Severe anemia can even result in fetal demise. If the mother is sensitized to the Rh antigen in one pregnancy, then all the later pregnancies are at risk. To prevent this, the mother should be given the Rhogam shot at 2 points: at 28 weeks of pregnancy when the chance of fetal blood mixing is 1%, and at delivery, when it goes up to 10%. If an Rh- mother has a miscarriage or trauma during pregnancy, the Rhogam shot is administered at that point as well.

Now, Rh negativity is sort of rare. It is high in the native American population, and rare amongst Caucasians. I thought it was rare amongst Indians as as well...I found out that it was more common than I thought, coming in at about 10%.

  

I never dreamed that a Rh- surrogate would be selected, especially given the masses of women available for surrogacy in this country that are Rh+. I never got the surrogates initial  screening tests (I had to literally  badger my RE for the initial thyroid testing results); had I seen this, I would have gone with somebody else. I'm shocked that I had to find out by accident, and I am so grateful that I got Dr. Bhansal; had I not, this may have never come to light, and I'm not sure if my RE told the OB specifically about this, or was aware of it. 

So here I am, having to live with this wrinkle as well. We immediately had her tested...as of now, she does not have antibodies against the Rh antigen; she has received one of the two mandated injections (the one given at the time of birth) following all her pregnancies. Not being the sort to take chances, we will have to administer the Rhogam shot during pregnancy as well. Now, Rhogam used to contain thimerosol (ethyl mercury) as a preservative. It was recently removed in the version administered in the US, but I don't know whether the older version is still in use in India. I'm stuck with the headache of ensuring that a thimerosal-free version is given. 

All was well in the ultrasound too: the thing that made me slightly worried is that the head circumference growth is lagging--it went from above the 50th percentile at 19 weeks to the 12th percentile at 25 weeks. The one thing that is absolutely ahead is femur length, coming in at the 84th percentile.

 I'm trying not to think about microcephaly, and I'm trying to remind myself that I have an absolutely tiny skull as well, and was apparently incredibly low birth weight (under 4 pounds at 41 weeks!!), and I turned out to be perfectly healthy. This baby is sort of like how I've been all my life---small head, long legs, so worrying is stupid,right?

Say hello (International Delurking week 2014)

After 3 years of trying to have a baby, I have finally reached “viability.”Today marks 24 weeks (!!). This is a milestone that I did not think I would get to, and when I find myself passing it, I feel like it needs a wee celebration, if only in my own head.

Coming to the topic of this post, Mel announced that this was International Delurking Week. I am a huge fan of that concept.

When I first started blogging, I made an intense effort to connect with other bloggers and find new blogs regularly. Now, I barely find time to post all the things I want to talk about, and when I find a new blog I want to follow, it is quite by accident. This seems like a great opportunity to find many blogs at a single go. If you step out of the shadows, say hi, and share your blog address (if you have one), I would love to follow your journey, just as you follow mine. I will probably be a godawful commenter for the most part, but I will be there silently reading, which is hugely comforting in itself.

If you do not have a blog, step out and say hello anyway.

Finally…we all fall into different camps here. Are any of you single moms by choice? Are any of you Indian? Are any of you an incredibly rare combination of the two, like myself? Are any of you fellow recurrent pregnancy loss warriors?

Please, tell me your stories, and connect with me, and with each other.

No choices, no milk

I had an interesting consult with the OB today. Incidentally, she is the doctor who handles most of the surrogacy cases in Mumbai (apparently), so she is also the person with the most experience in dealing with surrogacy, and that should not be taken lightly.

But what I heard was distinctly disheartening. Remember that choice to waive the steroid shot that I mentioned? She clearly had told me that the first time I talked to her, but today she told me that it is her protocol, and she is going to do it. I could try some things to prevent that, but that would be both counterproductive and foolhardy, so I will just have to go with the flow.

I then asked her whether J could express colostrum and feed the baby (followed by pumping after the first couple of feeds) for as long as she is in the hospital with the baby? She was like...nope. No surrogate can feed the baby. They actually give them shots + pills to dry up their milk as soon as birth occurs, so even if both parties (the birth parents and the surrogates) want to do this, they cannot. She basically told me, this is my protocol, take it or leave it. Unfortunately, I do have to take it, and the sooner I make my peace with all this, the better.

Just FYI for people doing surrogacy in India: Dr Pai in Anand, Gujarat allows/encourages breast feeding.

In the defense of the people in Mumbai, there is a logical reason they shut off the milk supply: if the milk flow is established, and there is no baby to drink it afterwards, there can be breast engorgement that can lead to an abscess. I had already factored it in, and had naively thought that J could go donate at a milk bank (she lives really close to one) and maybe make some money (I hope to god they pay them) and everybody could win, if she was open to this. But nope, her milk supply will be shut off immediately after birth.

AAh....the stuff I wish somebody had told me about, before I signed up for all this.

I also heard a hair raising story about a surrogate, which is an excellent illustration of why one needs to thoroughly investigate the situation before initiating surrogacy in India: A surrogate shows up with insanely, dangerously high blood pressure at a mere 10 weeks of pregnancy. She claimed she was 27 years old. The OB refused to believe her, and on further grilling of the handler, it was revealed that she was 42 (!!!) years old. Her daughter had been kicked out of her home by her own husband (I think) who had told her she had to produce Rs 200,000,  to get back in.

This woman,  in desperation, lied about her age and her medical history and entered a dangerous pregnancy to get that money for her daughter. The surrogate handler propagated the lie, and I have no clue what the RE was doing.

 Everybody was shortchanged here....the poor woman who was the biological parent, the poor baby, and the surrogate, who risked her life for money. Such a situation can only be prevented by investigating the heck of out the surrogate, investigating her previous medical history as thoroughly as possible to ensure that this is not for 5th of 6th or 7th pregnancy...they can lie about this as well.

 Bottom line: based on everything I've heard and my own experience, I''ll say this to anybody who is thinking about surrogacy in India: Ask a LOT of questions before you start. Make sure your doctor has investigated her past pregnancies as well, and has gotten her previous medical records from whereever her last pregnancy was, all of that. I'll come up with a comprehensive list of things to investigate before you start.

A new year, and an interesting quandary (blanket steroid shots!)

Today marks the completion of the 23rd week of pregnancy. I have such hopes for this new year. As I hugged my parents at midnight, each of them whispered to me that they hoped that this turns out to be the year where I finally get what I've been striving so hard to get. I hope so too.

2013 was a lot of things for me, but I hope I can get to remember as the year in which the most important thing in my life came to be.

As for this new year...I hope it brings good things to as many of you as possible.

We did the glucose tolerance testing. In an odd turn of events, I have the 2-hour glucose levels and the glycosylated hemoglobin values, but not the fasting levels yet. The 2-hour glucose level was 94, and the glycosylated hemoglobin came back at 4.8%. Both tell me unequivocally that J does not have to worry about diabetes. YAY!

I have to go talk to the OB tomorrow to discuss one important point, and it is something that will probably make a lot of jaws drop: In India, apparently, every surrogate pregnancy is considered a high risk pregnancy, and what they do is give every surrogate the steroid shot at 28 weeks to induce fetal lung maturation, no matter what the individual situation may be. The first time I heard this, I nearly bit the head off the poor hapless doctor's assistant who informed me about this, because this seemed insane. Even my very restrained mother freaked out when she heard this: a blanket steroid shot?!

The benefit of a steroid shot far outweighs the downsides (it can negatively affect the developing  immune system of the baby; it can aggravate gestational diabetes in the mom, and so on)  in a situation when pretrem delivery is imminent, and this shot has helped improve the health of innumerable babies worldwide.

But to give it in a perfectly normal pregnancy? Obviously, they make the decision to give this based on the statistics. Apparently, most of the surrogates are preterm (At or before 36 weeks), for any number of reasons: a higher incidence of multiples pregnancies, poor nutrition, low vitamin D levels, the strain of having borne many children, etc. Additionally, when they are not under the supervision of a doctor, if things move very quickly say, around 32 weeks, then there may not be time to give the shot: the situation IS different from that of a regular pregnancy.

But a blanket shot when things look fine? This is such a difficult call to make, and I have the choice of refusing this shot. I just don't know what to do. If any of you have any input to offer one way or the other, it would be most welcome.

Also, I have majorly revamped the "Science of Infertility" page, summarizing a lot of what I have discovered/realized in the past year. It is worth a read especially if you are still in the trenches.

On induced lactation

Claire, Michelle, Rebecca, Pam, Josey, Meg, Sloper (OMG, how did I miss out on your second pregnancy?!?!), thank you so much for your inputs.

I started reading up on induced lactation. Reglan is a no-no because it can cross the blood-brain barrier, and has one potential really scary side effect, Tardive dyskinesia.

Domperidone appears to be safer. Still, it can have cardiac effects---it can prolong something called the QT interval, and hence cause arrhythmia, which could potentially cause your heart to stop(!!). Here is a blogpost on the subject on the Skeptical OB blog, though I would say, this post does not seem to be wholly objective. The truth most likely is that this drug is safe in the majority of women, and would be dangerous for a smaller subset. Obviously it is more dangerous if you are mixing it with other medications that also prolong the QT interval, or you have underlying conditions that you are unaware of. The evidence for both intravenous and oral Domperidone causing arrhythmia comes from studies they did in people over 70 years of age.

But what genuinely scares me about this drug is the fact that the baby may get a tiny bit of it through breast milk, and if the baby has any underlying cardiac issues (one unverified source mentioned that 1 in 100 babies born have some sort of cardiac issue), this could be a bad combination. It is probably safe for 99 out of the 100 babies, but what if you are the 100th one?

So...if you are taking it, exercise caution with respect to dosage, be aware of your other medications, and I would suggest talking to your doctor too. I was also a little freaked out by Claire mentioning that her liver enzymes were elevated. So all in all, I'm going to give induced lactation a pass.

Human milk banking exists in Mumbai. However, the milk is pasteurized, which destroys most of the good stuff. I AM going to try to use the milk bank to find a wet nurse though, and if all else fails, supplement the goat milk formula with banked milk.

But all this is a ways away. I want to start doing stuff, but there is no way I will before I get to the "safe zone" of beyond 28 weeks, which I feel I am crawling towards one slow inch at a time. I'm sad to say that I'm not somebody who stops to smell the roses and celebrates what I have today, instead of thinking about tomorrow. I can't celebrate that the J has completed 22 weeks of pregnancy today...all I can think of is how much more time has to pass before we are in the relatively safer zone of 28 weeks and beyond.

But this is folly, because once you decide to have a child, there is no safe zone anymore. After birth, you worry about SIDS and diphtheria and the flu. You worry about Autism. Then one day you worry about your child being bullied at school. You worry about predators----it never ends.  Somebody described parenthood as having your heart walking outside of you, unprotected and vulnerable, for the rest of your life. And here we all are, eagerly signing up for all this.

Merry Christmas everybody. I'm so very happy for everybody who has gotten what they wanted for so long this year. For the ones who are still waiting or have had their hearts badly damaged, all I can say is that I am thinking about you. There are no words to make it better.

Checking in: Week 21

I did some more investigations on surrogacy options in India today, and I'm starting to get a much clearer picture of things. I wish I had acquired all this knowledge months ago, but that is not how it works. Sometimes, even the less than ideal choices we make can lead us someplace good, and sometimes, doing everything correctly and logically will still not garner success.

Still, others will benefit from what I have learnt, and that makes me pretty happy.

One thing I did learn today--finding a human milk source in India will be extremely difficult. Everybody knowledgeable in this area is telling me that getting the surrogate to do this is a bad idea. I atleast want the colostrum, and I hope to god I can get that.  

Now, I have to seriously consider induced lactation. People who started this....what was your timeline? How long were you on the pregnancy hormones and domperidone before you stopped the hormones and the milk production began? I totally want the crash course and not the long drawn out process.

Finally: a question about the final stretch in the 3rd trimester: what gets done in each appointment? From my conversation with the surrogate handler, every checkup, all we can get done is the doppler to hear the heartbeat. That is it. There seems like there should be more, right?

Goat Milk Formula??

As I talked about in my last post, most of the formula choices available today have the capacity to induce food allergies, are nutritionally very far away from human milk, and even the organic choices are riddled with additives that were far from ideal, like the palm oil that forms soaps in the baby's gut and neurotoxic solvent-extracted/synthesized stuff like DHA, lycopene, and lutein.

So here I was, literally wringing my hands. I then remembered a book I had read a long time ago where a monk used goat milk to feed an abandoned baby. Historically, whenever the mother's milk was not available, goats milk was maybe the first choice. Based on that very vague memory, I started to search for goat milk-based formulas.

I was very pleasantly surprised. Goat milk use in baby formulas appears to be a  growing trend. There are two formula brands (Holle's in Germany and  KaniKare in Australia) that manufacture goat milk-based formulas, but both, to different degrees, suffer from the issues mentioned above. Holle's is definitely the better choice of the two though. If I was ever going for a store-bought formula, this would be the safest option.

First, let us talk about goat milk itself:

Protein content: Its protein (and sodium content) is much higher than that of human milk, so if you gave it to your baby straight, you could create kidney problems. You have to dilute it out. But---once you dilute it, it comes pretty close. Goat milk protein apparently forms "softer curds" and is easier to digest than cow's milk. In support  of this, babies who are fed goat's milk have more frequent bowel movements than do babies fed cow's milk. Not obsessed with pooping patterns yet, but I hope that the day will arrive when this becomes one of paramount importance to me.

Fat content: Its essential fatty acid profile seems to be better than that of cow milk, but not as close to that of human milk. This is easily fixed as well.

Allergies: It has extremely low/undetectable levels of alpha-1 casein (the principal culprit behind cow milk allergies).  It does contain another protein (as does cow milk) that can trigger allergy: beta-lactoglobulin. But I'm guessing that is a much less common/severe allergy. But what this means is that a subset of babies allergic to cow's milk could also be allergic to goat's milk.

Nutrients: It has high levels of potassium and selenium. It has seriously low levels of folic acid and Vitamin B-12, so if you feed your baby this formula, you have to add these back.

In a nutshell, if you went with goat's milk formula, you would have to add back a few things and choose your proportions of water and milk powder carefully. This bit is EASY. I'd much rather whip up formula at home than go with the store-bought stuff, given what I have learnt.

This is a great recipe for a homemade goat milk formula.

A good source of powdered goat's milk may be the Meyenberg brand. If you mixed this up with the coconut oil (I read up on this, it seems like a really great idea even for regular cooking), the olive oil, lactose/turbindo sugar, probiotics, and a good vitamin/mineral source (blackstrap molasses or a multivitamin), and it sounds like you would have many bases covered. In theory.

Note that you would have to add all these things back only if you were formula feeding before one year of age. After the one year mark, you could dilute the powder out less, and have to add back less as well.

Overall, what impressed me was how happy *most* parents who tried this formula sounded: read the amazon reviews and the Mt. Capra reviews (though that sounded more mixed). Overall, in most cases, the allergies were fixed, it did not smell like a chemical soup, and most people seemed to report formula guzzling and weight gain and happier babies.

So yeah...this route makes me a lot happier than the organic cow milk formula route, and it seems like something I could live with. If anybody reading tries this, please DO give feedback of how it went. Still want to try to get human milk for as long as possible.

BUT: One advantage that this presents over the human milk route--In India, I cannot eat organic, and neither can whoever acts as the wet nurse. The fruits and veggies and the milk we drink are laden with god knows what. If I went this route, it seems fairly certain that the goats would be consuming less pesticides than I currently do, if you believe Mayenberg. Got to always see the silver linings, right?

Planning all this makes me realize how badly I want to be a mommy and do mommy stuff.  Please god, let it happen.

First parenthood-related research expedition: the search for the best formula

As many of you know by now, I'm an information ferret. My digging for information is not going to end when I have a baby (note I said when, not if!); rather, it is going to intensify.

In my case, I know that unless I get really lucky in my quest for brea.st milk, I will have to start formula feeding from a really early point. My first foray into parenting-related research: finding a decent formula option. Twenty minutes into my research, I was horrified. Everything I was finding had some issue or the other.

• Cow-milk based formulas have the potential to trigger allergy due to the presence of alpha S1-casein, and its nutritional profile makes it much harder for the baby to digest.
• Soy-based formulas are something I would never consider anyway: the nutritional profile of unfermented soy is not ideal, and more importantly, most of the soy available today is genetically modified and has been sprayed that godawful pesticide Roundup
• Wheat-containing formulas have the capacity to trigger gluten allergies. I don't know WHY gluten allergy is so common today, as compared to 50 years ago. Clearly, there is something different with the wheat grown in the world today, or our reaction to it. The why of it will be a post in itself one day.
• Then I considered an elemental formula like Neocate...only to find that instead of lactose, they add corn solids to sweeten the bloody thing.  

Not only are the nutritional profiles of all 4 of these formula choices problematic, even if you go organic, they have some insane additives.

The more you read about the food industry and how fake and profit and lobbying-driven it is, especially in the USA, the more depressed you get. 

DHA supplementation of baby formulas sounds like a good idea right?  Your baby would get this vital fatty acid that it needs for optimal brain development. Except---your baby does not need it. It could make this from other fatty acid precursors. Plus, the DHA in most baby foods is extracted from algae using hexane, a neurotoxic solvent.

Lycopene in tomatoes is great. So if you saw it in your baby's food, you'd be happy. BUT---but the version in organic infant formula is produced synthetically by the chemical manufacturer BASF.  A three-stage process is used to produce synthetic lycopene, and involves the solvent dichloromethane and the solvent toluene.  Toluene is a neurological toxin derived from benzene.

The source for all this information is this FABULOUS article written by the Director of the Cornucopia Institute, which serves as an organic food industry watchdog. 

Basically, even the organic versions of regular formulas for the most part have nutritional profiles that differ from that of human milk, and they could be contaminated with trace quantities of stuff like hexane and toluene, and many contain ridiculous and unnecessary additives like carneegan. This is where you want to grab the food industry people (scientists/executives, etc) and whack them for doing the stuff that they do. Is it all for profit? Do they simply not stop and think? If you read the article above, this woman also talks about the evolution of baby formulas, of how their ingredients could change over time, and this is a key point. The product you see today may not be the one that is there like one year later.

So what is a better, practical alternative? Well I found one, but that deserves a post of its own. Coming soon. 

A glimpse of the realities of surrogacy in India

The 19w1d scan went off wonderfully. My baby is a cheeky monkey...he/she kept alternately yawning and sticking its tongue out at me. No issues were spotted, the bloodflow to the placenta (as measured by the doppler) was great, and the cervix was closed at 3.4 cm. All good news.

Now, J and I have had a rather closer relationship than what is recommended between a surrogate and the mother. Everybody (lawyers, doctors) encourage you to keep a contact to a minimum. The reason behind this is that India's surrogates are women from lower socio-economic strata, and the mothers appear vastly wealthy to them. Hence, the theory is that if they can extract money out of you, they will. This is an extremely ugly equation, and I've tried my best to sidestep it entirely. I don't care if the surrogate takes money from me. I had always planned to give her far more than the amount she had been promised, and indeed, I have been giving money to her every  time I see her. My gynecologist called me a bleeding heart...to her, these are greedy grasping women who see this as a business. 

I don't see it in this way...the way I see it it is these are women who are trying to make a better life for their families, and they have never had the luxury of being honorable and principled. It is hard to be that way when you have so little. So if my surrogate tells me small lies to increase my sympathy for her and get some money out of me, I honestly don't give a damn.

But on the day of the ultrasound, J may have upped her game. She told me that she was being evicted from her home, and was forced to go live with her sister in a place on the outskirts of Mumbai. Bleeding heart me was immediately horrified and I started thinking...how can I fix this? How can I get her housing?

She claimed she needed a hefty deposit for a new place. At this point, even my sort of unworldly mom was like well, she is playing you. The only person who can corroborate whether this is indeed real  is the handler, and she is a woman from the same community...she will lie for her if necessary, and yes, she did claim that J had to move in with her sister the very next day. 

I want to find out if this is true or not, but I have no way of doing so: the handler is not taking my calls, and I have no way of corroborating anything.

I also realized what an uphill struggle everything is when I want something out of the ordinary. J's delivery the last time was at the same hospital, with the same doctor. When I first asked her, she told me she had given birth at full term. Recently I asked her what week it was, and she said 32 weeks.  The way she tells it, she was induced: I was horrified: why would you induce at 32 weeks? She claims the baby was a very high weight (like nearly 8 pounds), which does not add up for a 32-week delivery. Hearing all this, I just wanted to get the medical summary. Easy right? Nope. I ran into one unexpected wall, when the doctor who had managed the last pregnancy told me she could not get this information, because it was medically unethical for me to see it. I then asked, well, can you just get the information and sum up the scenario? She said "nope, ask the surrogate." The surrogate claims she has no paperwork. Trying to get her to access her own medical records from the hospital will be, well, Sisyphean.

Right now, there is no point in pushing. I just have to pray that everything goes well, because the simple things that you can influence in other places cannot be managed here.  If  J turns out to have gestational diabetes (which may explain the induction and the large baby), she is not going to do anything to control it. I have to beg her to take her vitamins, and for the last two ultrasounds, I literally had to bribe her to show up. And despite what it sounds like, she is sort of a decent person...just unmotivated and wants to hang out at home while she gestates the baby, and not be bothered by pesky blood tests because she truly does not get what any of this is all about.

I should add...a lot of what I am going through here may be avoided if you go via an agency like Surrogacy India. They provide housing (for the surrogate and her children apparently), transport, and all in all may do much more. I'll be profiling them, and one other agency.

Writing all this out was cathartic. Everybody around me is telling me to just stop thinking about all this, and that is what I'm going to try to do for a while and see how the cards play out.

Week 19....

First, I had NO idea that Disqus was such a pain, and I'm sorry I subjected you guys to it for so long. It is gone now, never to be reinstated. On comparing blogger commenting and WordPress commenting, there does not seem to be too much of a difference. WP IS nicer in other ways, but when I think of how much else I have to do when I move, I sort of whimper and think it is not worth it. So I'll *probably* stay here. So commenting is easier, and as a favor to you all (I hate it when I have to do it on other sites), I've turned off the word verification thing. Hope I am not immediately bombarded by spambots or whatever else that mysterious feature protects against.

Pregnancy news: J will be 19 weeks along tomorrow. She apparently went for an hospital visit last Thursday and everything was fine. She is not having an easy time of it though: while her hemoglobin levels are just below the the lower edge of normal, which is apparently good for a pregnant person, she tells me that this pregnancy has been much rougher on her than her last pregnancies, with constant dizziness as well as nausea.  One reason could be the crazy high beta HCG levels...the levels in almost all my pregnancies has been really high: one clue about how high came in the dual marker scan at 12 weeks; they express the levels as "multiples of the population mean" or MoM. So if you have a beta-HCG MoM value of 1, your levels are at the population mean. In this pregnancy, the beta-HCG MoM was 2.15, which may be the reason she is feeling so crummy. I hope it is nothing more sinister than very high pregnancy hormone levels.

The one thing that I've been freaking out slightly about is the placental grade. Classically, you are supposed to start with a grade of 0 in the first trimester, move to 1 in the second trimester, stay as 2 in the second trimester and most of the third trimester, and hit 3 only just before you deliver. The placenta was grade 1 in the first trimester, and grade 2 already by 17 weeks. I expressed my concerns to the fetal medicine specialist, and she told me not to worry, that the grading system is obsolete; now what counts is the placental blood flow as measured by the doppler. And that, apparently, was normal. We go in for another scan this week, as recommended by the fetal medicine specialist.

I now have to start thinking about feeding this baby, and how to come up with breastmilk from a safe, tested source. I'm also starting to weigh the pros and cons of induced lactation. Every time I start to think about planning for when the baby comes, I'm paralyzed with fear: what if I start doing stuff and something goes wrong? But as the weeks pass, I do have to put that behind me.

In other news, I found this excellent Fertility Authority article on multiple embryo transfer that I thought was worth sharing. What they said about the shortsightedness of American insurance companies in refusing to cover IVF and thus pushing people to transfer multiple embryos and then having to pay for the staggering medical costs arising from complications in twin/triplet pregnancies was spot on...talk about penny wise and pound foolish! I wish they at least covered transfers as a compromise.

Considering a move (updated)

I'm currently considering the WordPress plunge...I've exported most of the contents of this blog to a new blog there (the easy bit), and I'm still feeling it out and seeing how I like it.

If I do like the fit of it, I'll complete the move. This process has been initiated  for two reasons: a) that newspaper article and b) It is *so* much easier to comment on WordPress, especially from a mobile device. Question: Just how difficult do people find Disqus? Have you ever felt like commenting but have given up because of how painful the process is? I've had a few people mention this to me in passing, and I want to get an idea of whether this is a real issue

If I do move, people could get the new address from Mel's website, or you could email me for it. I should reiterate, I'm just trying this out. There is a lot to do while trying to move a behemoth of a blog from one site to another, and I may just throw my hands up and stay here if  I feel the easier commenting is not worth the hassle.

Update: I decided to first try the path of lesser resistance: Disqus has been deleted. The only reason I will miss it is because it allows you to directly respond to a particular comment, which the commenting options on Blogger do not seem to allow. Does its removal make commenting easier? Would people prefer WordPress to Blogger commenting? If you can, please let me know, because it will help me decide whether to stay here or move.

Time it is a-crawlin

Somebody asked me when I'll be able to share everything I've learned about surrogacy, and I answered, only after this process is done for me. And I'm praying it does not get done for atleast 3 and a half  more months.That is so far away, and time, it seems to be crawling forward.

I have such a long way to go before making it into the safe zone. Even at the the best Indian NICUs, 24 weeks is probably considerably less promising than it is in the western world, where it is not very hopeful to start with. At 28 weeks, you possibly start to have some chance of making it. At some point, I think I'm going to put together a list of studies of what exactly are the realities faced by a baby born at 28 weeks. It is definitely something people should think about before deciding how many embryos they want to transfer.

Yesterday, the risks of pregnancy sort of struck close to home. One family employee's wife is, from the sounds of it, facing intrauterine growth restriction and pregnancy complications with a twin pregnancy. Here is a girl who was not infertile and really young, and should have had no issues with pregnancy. Her doctors told her that had she been carrying a singleton, her chances would be better  She is 28 weeks along, but the thing is she probably wont get to be at the hospitals with a good NICU..apparently her doctors told them that things did not look good. Hoping things end well. Gave her husband a Vitamin D sachet, for what little it its worth, because with a twin pregnancy with no supplementation, she was bound to have been badly deficient.

At my end, the only think I need to worry about continues to be Vitamin D. J cannot take the 2000 IU Vitamin D pills (she claims they make her throw up, but says she can down calcium and iron, which I find rather contradictory). I don't want to keep continuously giving her sachets, and the key is taking it regularly. So now I'm trying to have Vitamin D oil drops sent from America. As things continue to progress (you note that I have gone from saying "if" to "as," which represents a huge leap of faith for me), I will need about a gzillion things off Amazon, which I will somehow have to have sent to India. God I miss Amazon prime.

Once we make it past the 20 week mark (2 weeks away), I'll have to start thinking about fun stuff like telling people at work and how to arrange to feed my baby. At least the latter should make for an interesting post!

16w6d: Detailed anatomy scan mostly done!

I got us in today instead of having to wait, and OMG, the relief is indescribable.

My biggest concern was addressed: her cervix is closed at 3.2 cms, as determined by a transvaginal scan.

We did the detailed anatomy scan, and everything seems fine. I kept trying to cheat to see the baby's gender, the doctor laughed and told me that I had no chance of figuring it out. I am going to try again at the 19-20 week scan when we measure femur length. Am not too optimistic of my chances.

It is both a blessing and  a misery that I am not carrying this pregnancy. I'm saying it is a blessing because I probably would have implanted the 4 embryos that 2 surrogates did not implant, and unless we greatly lucked out, we would not have transferred the embryo with the mojo first. Its a blessing because my stress levels would have been through the roof through the entire process. It *may* be a blessing in that I am an untried entity when it comes to carrying a pregnancy longterm, while J is a proven deal.

It is a misery because my baby is nearly 17 weeks along and I have not felt him/her yet. Its a misery because trying to get J to take her vitamins is well...challenging. Nobody else is making sure she eats well...I've been giving her bags and bags of dry fruits (nuts, dates, stuff like that) to make sure she gets some bio available micro-nutrients into her. I have to beg her to eat meat because her B-12 levels are low. Getting her to this ultrasound took 3 scheduling attempts, and a little strategic bribing.

Based on my experience of surrogacy in India, few people are this hands on;they assume everything would be managed the same way they would manage their own pregnancies, and show up 9 months later to get the baby. This is what the medical establishment here advises as well.

I'm incapable of doing that...one of the reasons I moved back to India was to make sure that if I went this route, I could try to monitor the situation. I don't know if that will make any difference, or help at all, but I could not have done it any other way.

I want to meet this baby so badly, but definitely don't want that to happen for atleast the next 18 weeks. I keep counting down the time left once a day.

Taking the sensible approach to treat infertility

This post was prompted by two things:  Another blogger's accounting of her painful response to lupron during a FET, and yet another multiples (triplet that transformed to twin) pregnancy that may just end in the unthinkable

All in all,  I am struck by how often  doctors just follow a set protocol without being thoughtful about the situation, the patients problem, the patient's comfort, and the  long term safety, of both the mother and the child. If the doctors can't think about all these things, then the patient should think about them, because ultimately, they are the ones facing it all. 

There are many roads to infertility. All we can do is identify the problem and treat it intelligently. When I say treat it intelligently, I mean choose a path that minimizes the number of injections you have to take, the hormonal overload you face, the number of FETs you have to do and importantly, choose a path that allows single embryo transfers so you do not have to face the higher risks associated with a twin/triplet/quad pregnancy.

Here are some practical examples:

• If you have a high-ish antral follicle count and a normal-ish cycle, choose the antagonist protocol over the long agonist protocol: The antagonist protocol is infinitely more "natural" than the agonist. Overall, most studies fail to show any benefit of one over the other.  The antagonist protocol is infinitely kinder to patients: you have to take a far fewer number of injections (Doctors, yes, this DOES matter). You can skip lupron. You have a reduced risk of OHSS. Knowing all this though, many doctors prefer the long protocol to the short protocol simply because it has been around longer.
• If you can identify a relative date of ovulation, even with +/-3 days of variation, choose to do a natural FET over a medicated FET. That way, you don''t have to start your pregnancy already having been on lupron followed by estrogen followed by progesterone injections, you simply start with Beta-HCG (RMA-NJ has a trial on this) followed by progesterone, and transfer 3 days or 5 days after ovulation. Many doctors are now going with a natural FET now. Incidentally, this study found better results with a natural cycle as opposed to a medicated cycle. This does not surprise me, because mother nature is the best architect, and giving somebody 3 hormones to mimic the complex natural process should be the inferior approach. I don't know why REs prefer a medicated FET.  One fertility center basically said that some doctors like the medicated cycle better because it is less of a hassle with respect to scheduling. Needless to say, I don't respect doctors who would pick medicated FETs for solely this reason. 
• If you end up with a large number of embryos, then do your best to pick the best one in the bunch from the getgo, so you do not have to do 5-10 transfers to find your two good ones.  There are two things you can do for this: let your embryos grow till day 5 (most of which arrest are shown to be chromosomally abnormal) and test the rest. This part is up to your doctor. The embryoscope has some utility in this weeding out process to allow you to transfer your best embryo first. But it is not a conclusive/fool proof test by any means.  To really know which of your embryos is okay, you need to find a doctor who has the technology to offer a trophectoderm biopsy with CGH microarray testing. Note that a day 3 biopsy and FISH testing are useless. Day 3 biopsies are bad for two reasons: Most embryos are actually chromosomally abnormal at day 3, and if you test at this point, you may throw out a good embryo (the doctor at RMA-NJ told me that a lot of the embryos that they had discarded as "abnormal" through day 3 testing/FISH turned out to be normal when tested at day 5 with CGH microarray...they had been "rescued"). The second reason is that the biopsy itself can damage the embryo, given that you are pulling out 1 cell out of 8. 
• Avoid transferring multiple embryos: To do this, you have to let the embryo grow in the lab till day 5. This is where the patients may balk:If a low number of eggs are obtained, then most patients are reluctant to even grow their embryos to blasts. They don't want to see their embryos arrest in the lab, and somehow feel that if it goes into them, it may have a better chance. Here is the problem with that idea: right now there is little to no evidence to show that the womb poses any advantage over the petri dish. And if you transfer all 3 of your day 3 embryos or two blasts at one go, you may win the battle but lose the war. I've lost count of the number of people on the blogsphere I've seen this happen to.  I've seen some people pull through through the skin of their teeth, after being on bedrest for months, and enduring unbelievable stress. Compared to that, a failed IVF cycle is a walk in the park.  If you can...grow your embryos to blasts, biopsy them on day 5, find out which one is chromosmally normal, and transfer that (pregnancy rate: rate 66.4%) Failing that, transfer one blast at a time without biopsying (pregnancy rate: 47.9%). 

 The first two things I've talked about here, picking a more natural IVF, choosing strategies that minimize the number of injections you have to take (it is really easy), and picking a  natural FET is doable for many, and most people would have no issues with these things if they fit the necessary patient profile.

The third thing is a comfortable place to be in: If you have twelve day 3 embryos, you can easily make the decision to grow them further, and most people do. The testing is up to your doctor anyway. On the day of transfer, you have to make the harder decision of transferring one or two. Remember, a day 5 blast has about a 50% chance of implanting.

The fourth choice is the hardest. What if you get only 3 fertilized eggs? Making the decision to wait and grow those in the lab for 5 days, knowing that all of them may arrest at day 3 or 4,  and facing the reality of going home empty handed from your IVF is the hardest decision to make.  But therein is the gamble. You could transfer all three embryos on day 3, be ecstatic when you have a positive pregnancy test, and 20 odd weeks later, lose two or three babies. It has happened SO many times, and I'm writing this post because I am very, very tired of seeing it happen. Everybody thinks that this could not possibly happen to them, or they choose not to think of it at all when going for embryo transfer, but really, they should. Not all doctors have a single embryo transfer policy, and they should. Because gambling like this is not acceptable.

Despite my preaching, and my knowing all this, I gambled too. I wanted to transfer only one blastocyst at a time, but my doctor froze my embryos in pairs even after I specified that I wanted an elective single embryo transfer. I could have then done two things to address the situation: gotten two surrogates, or refrozen one of the embryos. I did neither...I okayed the transfer of two embryos to one surrogate, and prayed only one would implant, and I got lucky. My OB-GYN, who regularly sees surrogates, told me that she considered all surrogates high-risk. My mouth fell open then, and I asked...even the ones carrying singletons? She said yes, She said they were high risk for many reasons, not all of which that I bought completely.   As we move into the second half of pregnancy, I am terrified of pre-term birth. And that is with a singleton. If there were twins now, my stress levels would be much higher, and my fears would be perfectly valid. Tomorrow is an ultrasound, and we will be at 16w5d. Praying her cervix is holding nice and tight and long, and all is well. And I'm also giving fervent thanks that there is only one in there.

Reassurances and (good) news

I've been rather surprised by the responses to the last post. First, I just want to say that even if I do move, I'll make sure all the legit people who want to find me would be able to. My new blog would be listed through Mel's website, and even if I wiped this website clean of everything, I'd still leave a post with my email address so people could get in touch with me to get the new address.

Also, I'd like to reiterate a big part of why I blog: to make information available to people. To this end, I made this blog Google-searchable a long time ago, and many people have found this site that way.

 I'm also not just invested in making sure the "regulars" find me (that was a thoughtless choice of words). Even if you came across my blog just now and would like to keep reading, you will be able to.

What WOULD suffer through the move would be the information itself. I'd like to still have a Google blog (not ruling out Wordpress though). If I stay with Google, I am not sure if the all my posts could be moved (anybody who knows about this, please tell me if it is possible, and how). Also, it would take a while for search engine optimization to kick in at the new site.

Taking stock, based on the lack of random visitors, I think I am mostly safe. But all it would take would be like one untoward visitor/comment. I still feel violated that I was dragged out there like that. The journalist kept telling me that well, she was given my information, and I kept pointing out that my RE had absolutely no bloody business to do so...but less said about that, the better.

I did get an incredibly nice email from somebody in need who found me through that article, and I want to say that I am really glad he did. But overall, people, I'd rather you found me through a Google search, and not the front page of a newspaper.

Anyway, moving on to pregnancy-related stuff....I got the results back for the Verify non-invasive fetal DNA test....and it was all negative! That conclusively rules out Trisomy 21, and almost certainly rules out Trisomy 13 and 18 and Turners syndrome.

It really, really SUCKS that I cannot find out gender: this test could provide me that information...they have it in a little file somewhere, but because I live in India, I have no access to it. Every medical professional is forbidden from revealing gender in this country. And for somebody like me, not knowing something so momentous is like smearing me with honey and letting ants crawl all over me. Seriously.

Finally, the only fly in the ointment continues to be J's Vitamin D deficiency. She swears she took two 60,000 IU sachets (she said she thew up a lot). I checked her levels again, and they were exactly the same as the last time....14 ng/mL. Deficient. Didn't know what the heck she was doing when she said she was supplementing.

So last week, I met her and watched her have one entire sachet. There are many reasons I'm so vehement about decent levels in pregnancy. One is if you are deficient, your child's risk for stuff like diabetes and other things definitely goes up. Second, Vitamin D deficiency in the second part of pregnancy conclusively and definitively increases the risk for all sorts of stuff  (gestational diabetes, bacterial vaginosis, other infections) that can contribute to second/third trimester complications, including preterm labor. As an important distinction, Vitamin D deficiency early in pregnancy can contribute to preeclampsia. There is so little you can do to even try to protect yourself from stuff like that. All you can do is avoid  pregnancies with multiples, have vitamin D, and check for infection regularly through urine tests. None of these are foolproof shields, but they're all we CAN do, and they may go some way in protecting you.

If things continue to go well... one ultrasound at 16 weeks for my own peace of mind), followed by the detailed anatomy scan at 19-20 weeks, and I cross the 30 week mark 10 weeks later, I may start to really believe that all will end well. Till then, in my too cynical, burned-too-many-times form, I remain deeply suspicious of the Universe's intentions.

I'm back!

My doctor gave the bare bones of my story and the address of my blog to a reporter, without asking me about it first (!). That reporter visited this blog and wrote to me asking me a bunch of questions, which I did not get around to answering for a few days. I finally wrote to her Saturday night asking her if she still wanted my response.

I woke up the next day to find the bare bones of my story, as well as my bloody blog address (!!!!!), published in a story featured on the first page of the biggest newspaper in India. I log in here and find random people visiting from like everywhere in India. I panic and shut down the blog, and go try to get the reporter to get my address off atleast the mobile version of the story. I succeeded after a few hours, and am going briefly online again to test the waters.

I can't believe this happened----I've always tried to stay as anonymous as possible, and I've lost track of how many reporters I've rebuffed. Let us hope damage control has been sufficient. I want this blog to be found by people who come looking for information on it, or who are part of the the ALI community, and not random gawkers who happened to read about me in the papers.

Worst case scenario: I think I may end up moving.  If I do....the regulars...you will know where to find me.

14 weeks today

I went for the first antenatal visit today; No ultrasound, but I did get to hear the baby's heartbeat very briefly through a rather ancient looking Doppler...it was definitely not as satisfying as getting to see the baby moving around, and the rather suspicious/easily freaked-out parts of me wanted a little bit more proof than a few wooshy sounds that I listened to for like 10 seconds,  but looks like the little one is doing okay. It is 14 weeks exactly and my baby is still alive!!!! YAY!

Sometime ago, somebody impressed upon me that the ultrasound cannot be fun for the baby, because of the ultrasound waves, which apparently sound like "a train entering a subway station." So I guess not being observed via ultrasound constituted a good day for the baby, so I should not complain.

After I saw the doctor's assistant, I waited a really long time (a few hours) so I could see the OB. The wait was very totally worth it, and it was a very useful conversation; I'm not going to talk about what I learned, today, except to say that, based on initial impressions, I like this OB and think I'm in decent hands. It was also tremendously useful because only the assistants see the surrogate, and the doctor gets a report, but in this case, because I waited and talked to her, she got to know me, and because she did, it added the personal touch, which can make a tremendous difference. Sort of a game changer with respect to pregnancy management, in this case.

In other news, I'm happy to see that I crossed the 300,000 mark for page views today. So many people, from all over the world read this blog, and I'm really happy about the amount of information I am able to disseminate through it. Thank you for reading, and I'm glad you are all here.

We need a resource to vent and release pressure, so we can sound all normal and chilled out in our day-to-day lives. On that note, there is SUCH a difference between TTC-me and me-me. When I'm not going crazy talking about science and worrying about baby making, I'm kooky and irreverent with a complete gutter-brain that I am rather proud of. I wish that part of me could come through here, but sadly, you people will only get the earnest, human encyclopedia version of me that yammers on about Vitamin D and genetic testing and insulin resistance and all that other fun stuff.