When You're Not Expecting Part 7

"When my therapist asked me what was the hardest part of discontinuing treatment, I said that I just hadn't found a way to put my dream child, Debbie, to rest. I still could picture her, and I still cherished her in my dreams, although I'd stopped talking to her in my imagination. My therapist suggested that we create a small ceremony where I could put Debbie to rest. So that's what we did. We decided to have the ceremony in a nearby meadow where we have taken so many walks and talked about our hopes of getting pregnant. We invited our parents and a few very close friends. We read some poetry, then Stan and I read the letters we each had composed to our dream baby, then we attached the letters to a helium balloon and launched it off into 195the sky. I think, for us, this was the ideal way to bring closure so we could move on."

Moving On As you give up the dream of a birth child, you also are giving up the entire future that was a.s.sociated with the birth of your baby. It can feel as if you have a gaping hole where before there had been hopes and dreams. So one challenge is how to make new dreams.

Another challenge is how to come to terms with what infertility now means in your life. There is an ident.i.ty in trying to conceive, and without that preoccupation you may feel empty.

Previously your infertility had been a rallying cry to health professionals, to sympathetic loved ones, to people in Internet chat rooms, members of support groups, and counselors. But now that you are no longer pursuing medical treatment, some people will a.s.sume that you have put your infertility behind you. Your challenge will be how to integrate infertility into who you are becoming in the months and years ahead as you attempt to move on: "It's a funny thing. When I decided to end treatment, I thought that I would feel relief at not needing to subject myself to the disruptions, the side effects, and the discouraging test results. But as I was saying my goodbyes and offering thanks to the clinic staff and to the doctor who has seen us through three years of unsuccessful treatment, I also was struck with how much I would miss their caring, their encouragement, and their concern. These were special relationships. I know they wanted very much for me to leave the clinic with a pregnancy and to return with a baby for them to fuss over."

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Ending Treatment: When Enough Is Enough When Enough Is Enough "My therapist and I are still discussing whether we have work to do. Even though she offered support and insight as I brought closure to my dreams of being a birth mother, and even though she was integral to helping Joe and me process the pros and cons of adoption, I'm not sure I want to continue in therapy now that we've decided to adopt. Ending therapy and pursuing adoption are my ways of a.s.serting that we are moving down a new path with more hope and less grief than the infertility treatments. I think I'd like to try it on my own, but it's good to know that she will be there if I need her support."

"When I told the members of my support group that Kelly and I had decided to withdraw from treatment, I was really touched with the warmth of responses that they offered. Several of them who are pursuing adoption offered to share their materials with us if we decided to adopt. Others said that they would be glad for us to stay in the support group as long as we needed to. That was a real comfort, because they know me so well, and they can understand what this decision represents for me after five years of treatment. These folks are dear friends, and I didn't want to lose their friendship at the very time I was struggling with giving up one of my life dreams."

However you come to the decision to discontinue infertility treatment, you will also need to come to terms with your own future and the role that a child can play in it. Has adoption become more attractive? Have you decided to weigh the risks of having a surrogate bear your child? Does child-free living seem more possible now? In the next chapter I will examine the various options that many people consider after ending infertility treatment.

197.Therapeutic Tips As you read this chapter, you are likely to realize that you have been preparing yourself for these issues for some time. As efforts to become pregnant have consumed more and more time, energy, money, and stamina, questions have crept into your mind; "Will I spend my life trying to have a baby?" and "What if nothing works?" and "How much longer can I keep my life on hold?" are just a few. Now, as you contemplate what it will mean to close this door, here are some tips to help you in this part of your journey: * Take a gradual approach to your decision to end treatment.

Since it is very likely that you and your partner are not on the same psychological page, one goal is to come closer together in discussing the factors that influence your decisions. You can begin this process by making a list of the factors identified in this chapter and weighing with your partner whether or how much longer to continue treatment.

* Have a straightforward discussion with your infertility specialist about the pros and cons of continuing treatment.

Remember, however, that this physician is weighing your information from a medical perspective, and you need to consider carefully the other factors in your life that are affected by continuing treatment.

* Consider setting some limits for yourselves: 1) a date in the future when you will end treatment if you have not become pregnant; 2) a bank account balance below which you will not withdraw money for treatment; and 3) a date by which another important decision (grad school, new job application, down payment on a home) must be made that conflicts with your capacity to continue treatment, and validates your wish to move forward with your lives.

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Ending Treatment: When Enough Is Enough When Enough Is Enough * Gather information from others in your support group who are deciding whether to end treatment, from adoptive parents, or from child-free individuals and couples about the process they used to reach their decisions about ending treatment and moving forward. Ask if they would do anything differently if they had it to do over again. Ask if they had support in making their decision, and ask who supported them. This will ease you a little closer to the reality of ending treatment while opening doors to new information and to choices that are still available to you.

* Consider seeking the a.s.sistance of a counselor who can help you weigh alternatives and make decisions. Although the decision you reach is is a significant turning point in your hopes of becoming a parent, the way in which you get to that point is a a significant turning point in your hopes of becoming a parent, the way in which you get to that point is a process process, which requires time, discussion, and careful consideration. Since this process may cause tension in your relationship with your partner, it can be very helpful to have a counselor on board to attend to the feelings generated, as well as to provide input to the concrete decisions you are weighing.

Although you ultimately will see ending treatment as closing a door, remember that being in treatment has taught you and your partner some things about yourselves, your resilience, your priorities, and your relationship. This knowledge will hopefully serve as a good foundation upon which you can move forward with future discussions and decisions. Keep in mind the potential importance of having support in this process, whether from loved ones, professionals, or other people who, like yourselves, have decided to open different doors on the journey to parenthood or to child-free living.

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Eleven.

Different Dreams: Opening New Doors to Life Individuals and couples who decide to discontinue infertility treatment have a range of new emotional and practical directions to pursue. Ending treatment is itself a monumental decision, one that plunges you into a mora.s.s of uncertainty and a wellspring of possibilities. And those possibilities will be influenced by everything from your finances and your age to the reactions of your extended family and the supportiveness of your community. In this chapter you will hear from couples who are weighing the options that are available once they discontinue their efforts to become pregnant: adoption, surrogacy, or living child free. (At the end of this book is a list of resources that you may want to consult for more information about these options.) Adoption Adoption, the preferred next step for infertile couples, has changed dramatically over the past 50 years. One major change has been a result of the availability of birth control and abortion.Not only have the rates of unplanned pregnancies declined in Canada and the US, but also the pool of infants available for adoption has changed. Now, with relatively small numbers of healthy Caucasian infants being placed with adoptive parents, prospective parents are identifying larger numbers of non-Caucasian babies, older children, sibling groups, and children with special needs.

In the past three decades there has been a surge of international adoptions from Asia, Latin America, Africa, and eastern Europe. The number of children adopted internationally by US citizens has increased 20-fold over 30 years. This poses the challenge for many parents of how to help their child feel connected to the culture of his or her ethnicity or country of birth, about which the parents themselves may know relatively little. It poses the additional consideration of the extent to which the parents' community offers a hospitable environment for children of color, children with special needs, and adopted children in general. Fees for international adoption are comparable to a domestic placement, generally in the range of $15,000$40,000. When children with special needs are adopted, there may be public agency funds available to cover the costs of counseling, academic a.s.sistance, and medical help.

International waiting times vary, ranging from six months to two years, a time period that is shorter than for a domestic agency adoption.

There also has been a shift in how individuals and couples with infertility find potential children. Those interested in adopting foster children or children with special needs are most likely to begin with the public agency in their community responsible for such placements. Others place advertis.e.m.e.nts in newspapers (particularly in university communities) in the hope that a young pregnant woman may consider an offer to adopt her baby; some 202 Different Dreams: Opening New Doors to Life Opening New Doors to Life work with lawyers specializing in adoption to get advice about the most efficient way to locate a potential birth mother; and some look for adoption information using the Internet. work with lawyers specializing in adoption to get advice about the most efficient way to locate a potential birth mother; and some look for adoption information using the Internet.

In fact, the Internet has opened up a range of opportunities for prospective adoptive parents: partic.i.p.ating in online bulletin boards or chat rooms can provide information, answer questions, help to refine decisions, and offer a receptive audience for hopes, dreams, joys, and frustrations. Adoption agencies also use the Internet to post information on families who have completed their home studies and are now hoping to locate a pregnant woman or new mother who is considering making a plan for her baby's adoption.

Individuals who have used the Internet during their months and years of infertility may consider it a useful resource; however, beginning anew in the area of adoption can easily lead to information overload. In addition, some of the information posted on Web sites is outdated, inaccurate, misleading, or fraudulent, and some of the people who offer themselves online as adoption facilitators use pressure tactics that play upon the desperation of prospective adoptive parents. So while browsing the Web, be an educated consumer and steer clear of those sites that promise quick results with minimum cost or involvement.

The best Web sites are those that offer information on how to think about and prepare for adoption, adoption laws, precautions to take, and resources on adoption from beginning to end.

(You will find helpful information in the Resources section at the end of this book, where I list Web sites on general adoption, international adoption, interracial adoption, and special needs adoption.) Before you decide whether adoption is the way to pursue your dream of becoming a parent, it is important to confront some of the myths about adoption: 203.* Once you adopt, you'll relax and become pregnant. Once you adopt, you'll relax and become pregnant. Wrong! Wrong!

Adoption is not a cure for infertility. In fact, it is healthy to have resolved your dreams for a birth child before embarking on the search for a child to adopt so that you can devote your full emotional energy to this new challenge. In truth, about 5 percent of women who discontinue infertility treatment become pregnant, whether or not they have pursued adoption.

* Adoption is an event, rather than a process. Adoption is an event, rather than a process. Wrong! Although the event of the adoption itself is a time for celebration, most adoptive parents find that over time the unique ident.i.ty of their adopted child requires special concern and consideration at different stages of the adoption process. Wrong! Although the event of the adoption itself is a time for celebration, most adoptive parents find that over time the unique ident.i.ty of their adopted child requires special concern and consideration at different stages of the adoption process.

* If you're a good parent to your adopted child, he or she will have no If you're a good parent to your adopted child, he or she will have no interest in learning about his or her birth family. interest in learning about his or her birth family. Wrong! In fact, many adopted children will be curious and interested in learning more about their birth families. Adolescence and young adulthood are stages when this need may feel most compelling (and national resources are available to a.s.sist them in their search). A search for the birth parents doesn't mean that the adopted child is rejecting her adoptive family or feeling unloved by them; it is an expression of the adoptee's need to know where she came from, and perhaps why a plan was made for her adoption in the first place. Wrong! In fact, many adopted children will be curious and interested in learning more about their birth families. Adolescence and young adulthood are stages when this need may feel most compelling (and national resources are available to a.s.sist them in their search). A search for the birth parents doesn't mean that the adopted child is rejecting her adoptive family or feeling unloved by them; it is an expression of the adoptee's need to know where she came from, and perhaps why a plan was made for her adoption in the first place.

Next, you will want to examine the many choices that exist for prospective adoptive parents. Some of these choices involve the following factors: * Resources: Resources: your financial position, possible time out of the country if you are pursuing an international adoption, the amount of time you are prepared to invest in the adoption; 204 your financial position, possible time out of the country if you are pursuing an international adoption, the amount of time you are prepared to invest in the adoption; 204 Different Dreams: Opening New Doors to Life Opening New Doors to Life * Risks: Risks: possibility that the birth mother may change her mind or that the birth father may want custody, the concern about prenatal care or nutrition of the birth mother during her pregnancy, the impact on the child of months or years spent in an orphanage or in foster care, the lack of trustworthy medical records on the child's growth and development; possibility that the birth mother may change her mind or that the birth father may want custody, the concern about prenatal care or nutrition of the birth mother during her pregnancy, the impact on the child of months or years spent in an orphanage or in foster care, the lack of trustworthy medical records on the child's growth and development; * Type of child or children: Type of child or children: infant, toddler, older child, child with special needs, sibling group; infant, toddler, older child, child with special needs, sibling group; * Geography: Geography: country you are considering (where prospective adoptive parents may be told they are ineligible if, for example, they are over a certain age, have specific health problems, are in a same s.e.x relationship, or have had more than one marriage), the laws of certain states (declaring it illegal for unmarried or same s.e.x couples in the US to be adoptive parents), comfort level adopting a child from outside North America or from a different racial or ethnic group; and country you are considering (where prospective adoptive parents may be told they are ineligible if, for example, they are over a certain age, have specific health problems, are in a same s.e.x relationship, or have had more than one marriage), the laws of certain states (declaring it illegal for unmarried or same s.e.x couples in the US to be adoptive parents), comfort level adopting a child from outside North America or from a different racial or ethnic group; and * Privacy: Privacy: open or closed adoption. open or closed adoption.

These choices are challenging at many levels. They require that you confront your biases, examine what kind of child you could love, accept a certain loss of control, decide how open you want family boundaries to be, and imagine how much your own family will need to change to give your new child a welcoming and supportive home. Depending upon your answers, you may decide that you need to give more thought to adoption, that adoption is right for you, or that the risks or difficulties are too much and you will not pursue adoption: "Although our friends and relatives have been urging us to consider adoption for months now, we realize they mostly want us to move on with our lives after being treated for infertility 205for so many years. When Ed and I began to discuss what we wanted in our lives if we couldn't have a birth child, we realized that adoption didn't fill either of us with hope. Both of us have been so invested in how our baby would look like us, how it will carry on the family genes through the next generation, and how important pregnancy and nursing are to me.

Frankly, neither of us can see ourselves becoming emotionally attached as parents to a child of a different race or ethnicity. And I also know we would worry about whether a birth mother had eaten well during her pregnancy and received the best prenatal care. I guess we are pretty clear that having a birth child is the only way that we want to become parents.

So since that isn't an option, and adoption just doesn't feel right, we're going to need to do some hard thinking about next steps in our lives."

"We live in a pretty small rural community where a few couples have adopted their children. All of these have been international adoptions, so these children stand out in our mostly Caucasian town. I wondered how the adoptive parents have handled this issue with their children, so I decided to talk with a few of the mothers who go to our church about my interest in adopting.

All of the mothers were very welcoming - that's the bond that infertility can provide, I guess. All of them were glad they had pursued international adoptions, partly because they moved relatively quickly and partly because they worked with organizations that had helped them cut through all the red tape. But all of them said that their children spoke of feeling 'different.'

The kids get a lot of questions from their cla.s.smates, and all mothers spoke of questions they initially heard from curious people in the grocery store or on the playground. The mothers are pretty philosophical about this, but John and I are really 206 Different Dreams: Opening New Doors to Life Opening New Doors to Life not sure that we want to bring a child into our community who will be made to feel different because of facial features or skin color. This is where both of us grew up, and we don't want to move away, but it is not a community that I believe would support us as an adoptive family. The hard truth is that I think we will need to find a Caucasian baby or to find another way to involve children in our lives." not sure that we want to bring a child into our community who will be made to feel different because of facial features or skin color. This is where both of us grew up, and we don't want to move away, but it is not a community that I believe would support us as an adoptive family. The hard truth is that I think we will need to find a Caucasian baby or to find another way to involve children in our lives."

"When I think about adoption, one of the things that worries me most is we may find a pregnant woman who is willing for us to pay her medical bills during her pregnancy, but who changes her mind once she gives birth. I just don't believe that after my own three miscarriages I could possibly endure losing another baby."

"When I mentioned the possibility of adoption to my parents, it was clear they were less than thrilled. They have provided emotional and financial support to us during our infertility treatments, and they very much want me to be pregnant with their grandchild. A few weeks after our initial conversation, I asked my mother what she had against adoption. She said that she and my father didn't think they could love an adopted baby as much as 'a grandbaby of our own,' and she was worried that Sam and I might be making a serious mistake by considering adoption.

I asked whether she believed Sam and I would be happy if we couldn't be parents. That stopped her cold, and I realized that she and my father believe that if we just keep on trying I will get pregnant. So Sam and I sat down with both of them and reviewed what our doctors had concluded - namely that my chances of having a healthy pregnancy are slim and that I'm not getting any younger (and my eggs aren't getting any healthier).

We told them that we're not going to rush into this, but that 207we'd like to share with them the books and articles we can find on adoption. It was a lot to say all at once, but they seem to be more willing to talk about adoption now."

"Adoption has always seemed 'second best' to me. The few adopted kids I knew as a child were not very happy kids, and I guess that has always made me wonder if there would be a cloud hanging over the head of any child we might adopt. Since several members of our infertility support group have adopted, Jay and I decided to talk with them about how they decided it was right for them. I think it is fair to say that all of the couples were enthusiastic about their decision to adopt. They all spoke of how they have talked with their kids from an early age about their adoptions, and several of the parents have encountered insensitive remarks from other adults, but on the whole these parents are real advocates of adoption. They encouraged Jay and me to go to a regional infertility conference where there will be a panel of adoptive parents, so that's next on our list of trying to learn from people who have been in our shoes and who have chosen adoption after infertility."

"Fred and I initially did not believe we could consider adopting a child. Having a pregnancy was so important to me that we only focused on how to accomplish that. Gradually, as it became clearer and clearer that I couldn't get pregnant, we began to talk about adoption. We didn't know any couples our age who had adopted, so we had no one who could relate to our ambivalence.

Finally, I said to Fred that we should set a date and if I weren't pregnant by then, we would begin to look into what would be involved with adoption. That date was several months ago.

Although we agreed to continue at the clinic for a few more cycles, now our energy is going into reading everything we 208 Different Dreams: Opening New Doors to Life Opening New Doors to Life can get our hands on about adoption. It's kind of scary, but it also seems as if we're much more willing to consider it than we were even a year ago." can get our hands on about adoption. It's kind of scary, but it also seems as if we're much more willing to consider it than we were even a year ago."

"As lesbians, my partner and I are constantly confronting discrimination. We were both very open to adoption, so that's where we turned our energy after ending infertility treatment. Since we have many gay and lesbian friends who are adoptive parents, we actually were unprepared to learn that certain countries would not consider us as applicants for international adoption. For a while I even considered presenting myself as a single straight woman, but our lawyer friends told us that could seriously jeopardize the success of an adoption if anyone discovered that I were lying. So, with some help from our friends, we have found an agency that is comfortable working with gays and lesbians. I am still feeling apprehensive at the prospect of the home study, which I know will feel intrusive, but we want so much to be parents that I know I'll keep that as my main focus."

"Once Ron and I decided we would pursue adoption, we found ourselves intrigued by the possibility of an open adoption. I'm someone who is more concerned with my baby feeling loved than I am with my baby believing that she just has one mother and I'm that person. The idea that we could keep the lines of communication open with the birth mother made me feel as if we would be doing the right thing for her, for the baby, and for us. Of course, Ron and I felt as if this will only work with a birth mother who is mature enough to have her own support system and her own life apart from being a parent. So right now that is where we're headed. I'm looking forward to meeting other adoptive parents who have pursued open adoption so I can learn its pitfalls and rewards."

209."In retrospect, I realize that in spite of my months of infertility treatment, I actually want to have a baby more than to give birth to a baby. The idea of morning sickness and stretch marks never appealed to me, and I know I would have chosen not to nurse a baby after it was born. So when Barry and I were discussing how much longer to pursue medical treatment, we both realized that adoption was a really viable alternative for us. Both of us traveled extensively to developing countries in our early twenties, and we have a real love for several South American countries where we lived. I would be thrilled to adopt from any one of those countries and to share with the child our fascination with the culture and the hospitality we experienced.

Adopting internationally could open up opportunities to renew our early explorations of our baby's birth country."

"When I stop to consider the number of babies languishing in orphanages around the world, and when I consider how much Joe and I have to give a baby, both emotionally and materially, it makes complete sense to open our hearts and adopt. I know I'm apprehensive about the health of a baby whose mother may not have received good nutrition during pregnancy, and who may not have received much stimulation in an orphanage. But I also know that babies can be resilient. And since one of my siblings had several physical disabilities, I understand the adjustments required on the part of parents. Joe and I have so much love to give each other that I just know we would find a way of adapting even if the child we adopt has special needs."

"We have an adopted daughter who is now three years old. In the past year, Jeff and I have been exploring adopting a second baby. To our utter amazement, we learned last week that I am pregnant! Instead of being filled with joy, I found myself fearful 210 Different Dreams: Opening New Doors to Life Opening New Doors to Life that our daughter, Teresa, would wonder whether we love her sibling more because that baby is our birth child. For about a day I actually contemplated terminating the pregnancy and proceeding with our second adoption. Jeff and I immediately booked an appointment with the therapist we had seen years ago before we adopted Teresa. Fortunately she knows us well from our years of infertility, so she was able to help us sort out issues of expectable sibling rivalry, worries about the viability of the pregnancy, how to help Teresa feel important as the 'big sister,' and how to stretch our lives to make time for two children. So, for me, adoption would have been emotionally easier, but now I have a better perspective on how to keep my anxieties in check." that our daughter, Teresa, would wonder whether we love her sibling more because that baby is our birth child. For about a day I actually contemplated terminating the pregnancy and proceeding with our second adoption. Jeff and I immediately booked an appointment with the therapist we had seen years ago before we adopted Teresa. Fortunately she knows us well from our years of infertility, so she was able to help us sort out issues of expectable sibling rivalry, worries about the viability of the pregnancy, how to help Teresa feel important as the 'big sister,' and how to stretch our lives to make time for two children. So, for me, adoption would have been emotionally easier, but now I have a better perspective on how to keep my anxieties in check."

"For many years I believed that I would meet someone with whom I would share my life. When that never happened, I decided not to give up on my dream of being a parent. Having experienced premature menopause, I saw adoption as a real opportunity to share my life with a child. In the midst of all the paperwork, I realized that this baby deserved to have more people in its life than one enthusiastic mother, so I began a careful inventory of my siblings, friends, neighbors, and relatives to see who I could call upon to become involved with me in parenting my baby and in supporting me. Around Christmas I sent out a holiday letter to a handful of people who care about me, telling them of my plans to adopt. I decided that those people who responded with enthusiasm would be the ones I would invite to become more involved with me as I raised my child. To my delight, the very people I care most about have responded with excitement and enthusiasm as I've proposed how we can make a strong network of love for this baby."

"Imagine my surprise when my parents were the ones to initiate the first conversation about adoption. They said that they knew 211how caught up we have become in our medical treatments, but that they worry about how focused we have become on a birth child as the only way to begin our family. Both of them know many couples who have adopted, and they were quick to say that some of their children had experienced difficulties growing up. But they reminded us that many families have at least one child who faces problems of one kind or another, and that is a challenge for all parents, not just those who adopt. They reminded us that the doctors seem no closer to diagnosing the cause of our infertility than they were three years ago when we began our workup, and they asked if we had set a time frame for how long we would continue treatment. It really set Matt and me to thinking, since month after month we had only envisioned more medical treatments. My parents encouraged us to open a new chapter in our quest for parenthood, and I'm really glad they did."

"For me adoption was a legal formality that I both welcomed and dreaded. Since my partner and I are lesbians and she is the one who carried our pregnancy, I would not have had any legal rights as a parent unless I formally adopted our baby. I'd be less than honest if I said that the home study was anything other than an intrusion and a reminder that society hasn't figured out how lesbian mothers can coparent without legal intrusions. But it is clear that adoption protects our baby and us in case anything happened to my partner or me."

Surrogacy Before 1993, when in vitro fertilization (IVF) became widely used, traditional surrogacy traditional surrogacy was the only surrogacy option available to infertile couples who wanted some genetic tie to their 212 was the only surrogacy option available to infertile couples who wanted some genetic tie to their 212 Different Dreams: Opening New Doors to Life Opening New Doors to Life baby. For those couples, the woman carrying the fetus provided her eggs and was inseminated with sperm from the donor father. baby. For those couples, the woman carrying the fetus provided her eggs and was inseminated with sperm from the donor father. Gestational surrogacy Gestational surrogacy, far more common now than traditional surrogacy, occurs when the surrogate mother is carrying a child genetically unrelated to her. In gestational surrogacy, the intended mother or an egg donor provides the eggs, and the intended father or a sperm donor provides the sperm. The resulting fertilized embryos are implanted through a catheter directly into the uterus of the gestational carrier, who has no genetic connection to the fetus.

There are differences in how countries regulate surrogacy.

In Canada, the use of commercial surrogacy is banned.

However, altruistic surrogacy is permitted, in which a "known surrogate" is involved who does not accept payment for her services. The same is true in Canada when donor eggs are used to attempt a pregnancy; the eggs must come from a "goodwill donor" who is known to the woman with infertility and who will not accept payment for her eggs. In the US, surrogacy is unregulated, and laws vary from state to state. Some states prohibit surrogacy and others require that the intended parents (who often are also the genetic parents) adopt their child after its birth from the gestational carrier.

These legal variations by state emphasize the importance of working with a lawyer who is experienced in gestational surrogacy cases.

Surrogates are used in a wide range of circ.u.mstances, including when the cause of infertility is the absence, malformation, or inadequate functioning of a uterus; when treatment for cancer has damaged the woman's reproductive organs or eggs; when a pregnancy would threaten the life or health of the prospective mother; when chronic health conditions or necessary medications are incompatible with a pregnancy; when multiple 213pregnancy losses or IVF failures have occurred; or when premature ovarian failure has occurred.

Although an infertile woman will have ended her medical efforts to become pregnant by the time she decides to use a surrogate, she may still be very involved in a.s.sisted reproductive technologies a.s.sisted reproductive technologies (ART) if she decides to donate her eggs to be fertilized (by her partner's sperm or by donor sperm) and to have the resulting embryos transferred to the surrogate. In this circ.u.mstance, her involvement in ART is for the purpose of harvesting her eggs, but the focus of attention then shifts to whether or not the surrogate can achieve a healthy pregnancy. (ART) if she decides to donate her eggs to be fertilized (by her partner's sperm or by donor sperm) and to have the resulting embryos transferred to the surrogate. In this circ.u.mstance, her involvement in ART is for the purpose of harvesting her eggs, but the focus of attention then shifts to whether or not the surrogate can achieve a healthy pregnancy.

The genetic mother may choose to freeze any embryos that are not transferred, or she may donate fresh eggs with each cycle of embryo transfer. As long as the intended mother is donating her eggs, she will experience many of the disruptions, to her life and to her emotions, caused by the careful timing of the ART procedures and the emotional side effects of the hormones she is taking.

Surrogacy is a choice couples make who value genetic ties or who want to have more control than adoption affords. One or both of them may be genetically related to the baby, and they can select a healthy surrogate who they have confidence will seek good prenatal care. In the US, if donor eggs or donor sperm are used, the couple can select the donors. They can select the clinic in which the a.s.sisted reproductive efforts are conducted.

In concert with a lawyer, the surrogate and the intended parents can agree on the terms of a gestational agreement, which can serve as a guide for ongoing and future behavior and communication. For example, intended parents and their surrogate should decide in advance how they would handle medical issues that can arise, such as amniocentesis, multiple gestation, and potential medical risks to the surrogate or the fetus.

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Different Dreams: Opening New Doors to Life Opening New Doors to Life However, with this control come some tradeoffs. Adoption (especially internationally) is somewhat predictable in terms of the time it will take to locate a child. Contracting with a surrogate guarantees neither a pregnancy nor the birth of a healthy baby, and the surrogate may be willing to continue for only a limited number of cycles. The costs of surrogacy are likely to exceed those of adoption; and if donor eggs or donor sperm are used, there is likely to be only minimal information about the donors. As with IVF, there will need to be decisions made regarding how many embryos to implant, how long to store frozen embryos, and what to do with any unused frozen embryos. During her pregnancy, the surrogate has full power to choose how many fetuses to carry to term, who will be involved in the delivery, and what medical interventions are acceptable. However, with this control come some tradeoffs. Adoption (especially internationally) is somewhat predictable in terms of the time it will take to locate a child. Contracting with a surrogate guarantees neither a pregnancy nor the birth of a healthy baby, and the surrogate may be willing to continue for only a limited number of cycles. The costs of surrogacy are likely to exceed those of adoption; and if donor eggs or donor sperm are used, there is likely to be only minimal information about the donors. As with IVF, there will need to be decisions made regarding how many embryos to implant, how long to store frozen embryos, and what to do with any unused frozen embryos. During her pregnancy, the surrogate has full power to choose how many fetuses to carry to term, who will be involved in the delivery, and what medical interventions are acceptable.

The financial costs of using a surrogate in the US can range between $35,000 and $100,000, depending on the number of IVF cycles required. Costs will include medical expenses, agency costs, legal expenses, and payment to the surrogate (including the surrogate fee, expenses, medical costs not covered by the surrogate's insurance, and travel expenses).

So, just as adoption may be the best choice for many infertile couples, the use of a surrogate may be the best choice for other couples. Here are both the concerns and the antic.i.p.ations of women who investigated whether gestational surrogacy was a viable option: "Much as I would like to think of surrogacy as something we could pursue, I just know that we could not afford it if it took more than one or two cycles. It would break my heart to go to all the effort of identifying a compatible surrogate and then not to have enough money to pay for all the expenses involved."

215."I've spent months and years of infertility treatments and pregnancy losses. Since using a surrogate offers no guarantees that we would have a baby after more months of hoping and waiting, I can't see myself choosing such an uncertain option. Frankly, I need something besides loss and grief to fill my days."

"After the chemotherapy for my cancer, my main focus was on getting healthy again. Now that Jon and I are feeling more positive and hopeful about my health, we want to get on with our lives, and that includes thinking about ourselves as parents. The possibility of working with a surrogate appeals to me because at least we could know that Jon would have genetic ties with the baby. After the shock of my cancer, I think that both of us need to have a positive medical experience with pregnancy, and hopefully a surrogate could provide that."

"My mother took DES while she was pregnant with me. As a result, my uterus is malformed and I've been told that I would never carry a pregnancy to term. I've known this ever since I was a young teen, so I've had plenty of time to get used to the idea, and I had always a.s.sumed that I would adopt children.

But when Stan and I learned that gestational surrogacy would make it possible for us to use my eggs and his sperm to create embryos, it opened up a whole new world. I would be willing to see whether we could become parents with the help of a surrogate. And if that doesn't work, then my second choice would be to explore adoption. I'm just relieved that my useless uterus doesn't prevent us from becoming parents."

"We have had two babies born with genetic problems who lived only a few months. I desperately need to have a healthy baby, and it scares me to take the chance of adopting when the birth mother may not have good health, good nutrition, or good 216 Different Dreams: Opening New Doors to Life Opening New Doors to Life prenatal care. With a surrogate, we could be more confident that she would have a healthy baby, although I understand that there never can be any guarantees." prenatal care. With a surrogate, we could be more confident that she would have a healthy baby, although I understand that there never can be any guarantees."

"Chuck and I had just about given up on our hopes for becoming parents when I read an article about surrogacy that sounded really promising. It erased many of my misconceptions and suggested Web sites and articles that I've [since] read. Before thinking seriously about using a surrogate, we spoke to a lawyer so that we could understand what we could do to minimize the risks of an unexpected negative experience with a surrogate. We appreciate how a reputable agency and a good lawyer can improve our chances of working constructively with a surrogate. The lawyer with whom we spoke has developed gestational agreements and helped to educate us on how we could take an active role in the process. He also said that in all of the cases when he worked with surrogates, they were warm and caring women who wanted more than anything to bring happiness into the lives of a couple like us. At this point I think we'd like to give it a try for up to four or five IVF cycles.

If no pregnancy results, then we'll need to decide whether to find a new surrogate or to rea.s.sess how determined we are to become parents."

"We have a daughter, but I've been unable to get pregnant, in spite of years of infertility treatment. Steve and I have decided that we'd like to work with a surrogate so that our daughter could have a sibling to whom she is genetically related. If it turns out that our embryos don't result in a healthy pregnancy after a couple of cycles, then we would be prepared to use donor eggs with my husband's sperm for another couple of cycles. For us, genetic ties are very important, so if a surrogate isn't the answer, 217then we'll just accept that the three of us are a family and get on with our lives."

"I was the only adopted child in our family, and I always felt different from my siblings. So now that I'm unable to get pregnant, I'm pretty cautious about the prospect of adopting. I know what it feels like not to be connected genetically to my family. If we could use a surrogate, either with my eggs or donor eggs, at least we could rea.s.sure our child that one or both of us is the genetic parent. And we would really mean it when we point out the dimple or the curly hair as belonging to our family! I desperately want our child to feel a sense of truly belonging to us."

Child-free Living Couples and individuals who have undergone infertility treatment have done so in the hopes of becoming parents some day.

When the hopelessness or the expense or the exhaustion of infertility has taken a toll, the next step is to a.s.sess how important it is to bring a child into your family. This a.s.sessment period is gradual, often beginning during infertility treatment as you desperately wonder when or whether your life will ever get back to "normal," whatever that may be!

The infertility treatment experience has been one in which you and your partner nurtured hopes of parenthood as the ultimate outcome. However, as the months dragged on, as hope began to dim and finances dwindled and life disruptions increased, it also is likely that both of you began to ask how strongly you still felt about your early dreams of becoming parents. Infertility changes people in many ways, and as you reflect on the person you are becoming in the process of 218 Different Dreams: Opening New Doors to Life Opening New Doors to Life grappling with infertility, you may discover that child-free living is an option you are ready to consider. The decision to be child free is distinct from being childless. "Child free" implies an open approach to life that is positive and can lead to fulfillment, whereas "childless" suggests a void. Undoubtedly as you pursued infertility treatments, you thought of yourself as childless, characterized by feelings of emptiness and the yearning to complete your family by having a child. grappling with infertility, you may discover that child-free living is an option you are ready to consider. The decision to be child free is distinct from being childless. "Child free" implies an open approach to life that is positive and can lead to fulfillment, whereas "childless" suggests a void. Undoubtedly as you pursued infertility treatments, you thought of yourself as childless, characterized by feelings of emptiness and the yearning to complete your family by having a child.

So how can you envision yourself, after so many months or years of infertility, considering life without a child? Just as the decision to end treatment involves some careful insight into your needs and motivations, so do the decisions about alternatives. Some couples, now well acquainted with the disruptions that medical treatment has caused in their lives, may yearn for an orderly existence once again and may decide that bringing a child into their lives would precipitate more juggling of time, money, career, education, and family relationships. Such couples are understandably exhausted after the tensions of infertility. As they resume their lives without the intrusiveness of medical regimens, they may find pleasures in one another and in other neglected relationships; they may discover that life can be fulfilling even without children. These couples will often make a conscious decision to view themselves as a complete family, to enjoy one another, and to move ahead with plans that have been on hold during the lengthy period of infertility treatment.

In the process of discussing child-free living, partners may disagree on their needs and the impact of the decision on their lives together. As with any decision, both partners deserve time to contemplate new ideas fully and to antic.i.p.ate the consequences on each of them of a decision to be child free. In many ways, earlier decisions the couple made during their period of 219infertility treatment allowed them to emphasize their shared goal of parenthood. The decision of child-free living, while liberating at one level, has a feeling of finality to it. If partners differ in their attachment to the goal of parenting, this is a time to consider talking with child-free couples, reading literature on child-free living, and perhaps meeting with a counselor who can help to sort out how important parenting continues to be for at least one partner.

It is not only the couple who will have feelings about the decision to be child free. Prospective grandparents, aunts, and uncles may weigh in, urging the couple not to "give up." These family members may remind you of the huge investment in medical treatment you made to become parents. They may challenge you to direct that same energy to adoption or to considering a surrogate.

The important issue here is that you have the right to make decisions about your future, despite the belief of loved ones that they know what is best for you. Even though they may have been there emotionally for you during the dark days of infertility treatment, this does not mean that they understand the person you have become as a result of this life-changing experience.

So you will need to help them to understand your hope that child-free living can offer its own joys and opportunities for you and your partner. You undoubtedly will remind loved ones that you look forward to having children in your life, even if you are not a parent - the special ties with nieces, nephews, and children of good friends can be mutually very special.

The challenges after ending infertility treatment take many twists and turns as individuals grapple with whether a child-free future could possibly be fulfilling. The women with whom I have spoken have ranged from those who initially cannot imagine a fulfilling life without parenthood to those who ultimately 220 Different Dreams: Opening New Doors to Life Opening New Doors to Life develop a conviction that child-free living is the right choice for them: develop a conviction that child-free living is the right choice for them: "You know, even as we're in the midst of infertility treatment, I find myself wondering what we'll do if I can't become pregnant. For so many years Brad and I have imagined ourselves as parents, yet neither of us is at all interested in pursuing adoption.

Frankly, after all the stress and uncertainty of our infertility, I can't see myself opening that same door with a surrogate, even if we could afford the expense, which we can't. So that leaves me asking myself whether I could be happy without a birth child. Heaven knows we have the option of having children in our lives, with all the nieces and nephews in our families. So I find myself asking Brad - on our long walks together or after we've spent a peaceful weekend - whether we ever could think of the two of us as a 'family.' "

"Matt has two teenage children from his first marriage, and he's said all along that he'll support me in my hopes of becoming a parent, even though he doesn't feel that we need a birth child to be a family. That was fine until infertility tests indicated that my chances of becoming pregnant are very slim.

So naturally I am willing to explore adoption or surrogacy, and I was completely unprepared for Matt to say to me that he doesn't want to 'parent another woman's baby.' He's right that a big part of my motivation for parenthood is tied up with pregnancy, delivery, and nursing; he's also right that we both have the opportunity to parent his two boys. But I feel betrayed when he says that adoption and surrogacy are options he cannot support.

I think we both need to see a counselor because we're making no progress in our discussions, and I just don't know whether I can feel fulfilled in my limited role as a stepmother."

221."I actually began to mourn the loss of my dream child during the early days of our infertility treatment. With each failed cycle it seemed more and more clear that I would never become pregnant. I felt a raw agony, a huge emptiness, and an all-consuming sadness. By the time the doctors concluded that they had nothing more to offer, I was seriously depressed. I had refused to consider taking antidepressants while I was trying to get pregnant, in case they might harm my baby. But once I stopped treatment I felt ent.i.tled to ask for antidepressants. I am feeling more emotionally steady now, part of which may be thanks to the support of my counselor, part of which is because my hormones are settling down at the same time the antidepressants are kicking in, and part of which is because I've been grieving for over two years. That's a long time to come to terms with all the losses of infertility, and at some level I feel ready to move forward out of the misery I've been in. Chuck tells me that it feels as if I'm finally coming back to him, and I think it's true that I lost myself in the infertility struggle in ways I never would have imagined.

We've briefly talked about adoption, but neither of us feels that we have the emotional energy to pursue it. And, frankly, I really want to figure out what is going to make Chuck and me happy as we move ahead with our lives. He is such a sweetheart and even though he never felt strongly about our having a baby, he was there for me every step of the way. At least for now I want to focus on our relationship and how we can rediscover each other and all the non-parenting joys that I know are out there."

"I'm spending a fair amount of time trying to decide whether Mike and I have the strength and the emotional energy to let go of our dream of parenthood and to accept that life without birth 222 Different Dreams: Opening New Doors to Life Opening New Doors to Life children can be good. We know that we're nearing the end of the time when our infertility doctor can hold out any statistical hope for us. Both of us know several families who have had serious adoption problems, and we know we're not interested in pursuing surrogacy. But the real question is, what will life be like for us when we remove parenthood from the equation? We just haven't imagined this before, but we're coming to a time when we need to envision how we can sustain our good relationship and build our lives together without being haunted by the void of an empty nest." children can be good. We know that we're nearing the end of the time when our infertility doctor can hold out any statistical hope for us. Both of us know several families who have had serious adoption problems, and we know we're not interested in pursuing surrogacy. But the real question is, what will life be like for us when we remove parenthood from the equation? We just haven't imagined this before, but we're coming to a time when we need to envision how we can sustain our good relationship and build our lives together without being haunted by the void of an empty nest."

"I'm feeling so empty and lost now that we have ended our treatments. Some of the emptiness is from knowing that I won't ever become pregnant, some of it is from the loss of control I feel in my life, and some of it is from not knowing what the future holds for us if we can't have a birth child. My friends in my support group have been great, but they're mostly still trying to get pregnant or pursuing adoption, and I'm not doing either of those.

Bob doesn't seem to be at loose ends as much as I am, probably because he has always said that he'll go in whatever direction will make me happy. But I'm far from happy right now. Several of my support group friends have given me the names of infertile couples who decided not to pursue parenthood, and I think I should talk with them to see how they reached that decision and see how they've been able to shape their lives as a non-parenting couple.And before I ask my doctor for an antidepressant, I think I'll call a counselor that some of my friends say is very sensitive to issues of infertility so that she can help me find some light in this darkness."

"Jason and I often are amazed that our love for one another has grown during this crisis of our infertility. In spite of the stress, 223in spite of the hormones, in spite of the tears and disruptions and the monthly sadness of my period, we have come to know each other better than we would have if life had been smooth sailing. And through it all, we have said that we have each other no matter what happens. When we ended our treatment a few months ago, neither of us rushed to search the Web or scour the local bookstore for information on adoption or surrogacy. At one level, we just needed some downtime to absorb the realization that a birth child was not going to be possible for us. But at another level, I think we have been more and more comfortable about building our lives together in new ways, now that the shadow of infertility treatment isn't hanging over us. Don't get me wrong - we still think of ourselves as infertile, and I know that a piece of us always will wish that we could have had children. But that isn't going to happen, so now we need to decide how to make new choices about how we can be happy without being parents."

"The uncertainty about why I couldn't get pregnant was our main reason for seeing an infertility specialist. It took a number of months before the diagnosis was clear, and now that I know what we would have to do to try to conceive, I realize that we don't have the financial or emotional resources to go any further. And the more Sam and I talk about it, the more we realize that having children was something we wanted because that's what our friends and siblings were doing. But, as we see them sleep deprived, preoccupied with babies, and barely able to go out with us for dinner or a movie, we've really re-evaluated whether parenthood is what we want. And we've decided it's not. So, in a perverse way, infertility gave us enough time to pause and to decide that children are less important to us than we are to one another."