Creating families / Créons des familles by Fertility Matters Canada

HELP US HELP YOU

TAKING CHARGE OF OUR ADOPTION PROCESS

INFERTILE IN EGYPT

19 HELPING YOUR FRIENDSHIPS SURVIVE INFERTILITY Canadian Magazine of Reproductive Health • Revue canadienne de la santé reproductive

Creating FAMILIES Créons des familles

COLUMNS / CHRONIQUES President’s Message . . . . 6 Message de la présidente . . 7 What’s New? . . . . . . . . . 8-11 Quoi de neuf ? . . . . . . . . . 8-11 Adoption Corner . . . . . . . . . 24

FALL / AUTOMNE 2013

FEATURES / DOSSIERS

Patient’s Perspective . . . . 42 The Naturopathic View . . . 56 The Doctor’s Column . . . 60

A Letter to My Future Daughter ................................................................. 13 by DAN COGHLAN

You Know What They Say About Best Laid Plans ....................................... 30 by ANDREA QUERIDO

La chronique du médecin . . 61 Reader’s Corner . . . . . . . . . . 62 Le coin des lecteurs . . . . . 64

The Benefit of a Mind/Body Approach When Struggling with Infertility ........ 46 by AMIRA POSNER

51 Have you registered or donated yet? Family Matters Challenge – IAAC fundraiser event (see page 40) Avez-vous fait votre don et complété l’inscription? Défi Affaire de Famille – levée de fonds pour l’ACSI (voir page 54)

À QUI LA FAUTE ?

The Infertility Awareness Association of Canada (IAAC) L'Association canadienne de sensibilisation à l'infertilité (ACSI) 475 Dumont Ave., Suite 201, Dorval, QC H9S 5W2 • 514 633-4494 • 1 800 263-2929

www.iaac.ca FALL/AUTOMNE 2013 • Creating Families

Creating FAMILIES Créons des familles

SILVER SPONSORS I A A C NATIONAL BOARD OF DIRECTORS ACTING EDITOR-IN-CHIEF • Gloria Poirier gloria@iaac.ca

PRESIDENT • Jocelyn Smith VICE-PRESIDENT • Janet Takefman

EDITOR • Véronique Robert carotexte@videotron.ca TRANSLATIONS Véronique Robert

Pamela Burton • Ellen Greenblatt Dalit Dell Hume • Sherry Levitan Al Yuzpe

ARTUS Centre Astra Fertility Clinic Fertility Centers of Illinois First Steps Fertility Genesis Fertility Centre Grace Fertility Centre Hannam Fertility Centre Heartland Fertility & Gynecology Clinic ISIS Regional Fertility Centre IVF Canada & The LIFE Program

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FALL/AUTOMNE 2013 • Creating Families

President’s

Photo by Lisa Minnini

MESSAGE

Jocelyn Smith

ne good thing about retirement is I now have more time to read Creating Families! I was particularly taken with this issue’s articles, which are at once instructive and heartfelt. We listened to your requests for more personal experience articles. During Canadian Infertility Awareness Week, many of you confided that personal stories help you in letting you know that you have company on this often lonely journey. If you feel the urge to share your experience, by all means contact Gloria, our Executive Director. She will be delighted to talk to you. Please don’t worry if you are not a writer. Our wonderful editor makes even my messages sound good…

I was fascinated with Dr. Hassan Sallam’s article, Infertile in Egypt. Dr. Sallam details the historical, religious, cultural and medical aspects of infertility in Egypt. Until

now, I had heard very little about infertile women’s struggles in his country. I also learned from The Doctor’s Column. Dr. Gunn does a beautiful job of educating us about Asherman’s Syndrome. If adoption is on your mind, you will be better prepared through Amanda Yeaman’s moving and informative account. If it is resolution you seek, Charmaine Graham’s magnificent column will bring you hope and peace. Did you know microwaving your dinner in a plastic bowl is a bad idea when trying to conceive? Me neither. In Help Us Help You Dr. Monnier offers much-needed lifestyle advice on the changes people should – and can – make to optimize their fertility. I have always thought that the infertility journey needs teamwork, and its team members are you and your physician. How can we thank our wonderful fundraisers enough? Lenore Tochor’s team, from Grand Prairie, took part in the North Face Canadian Death Race, a grueling 24hour relay at high altitude over three mountains. They did this to raise funds for IAAC. I got tired and sore just thinking about what this amazing team achieved! Alison and Sean from Edmonton held a private house party and, in lieu of gifts, asked people to donate to IAAC the amount of money they would normally have spent on dinner and drink. What a great idea! Thank you, so much. At this year’s CFAS meeting in Victoria, Mara Lucato, my dear friend and owner of Gravida, is organizing the 1st annual

Chinese Acupuncture and Herbal Clinic • Acupuncture specialists (Dr.Ac.) • Chinese medicine doctors (C.M.D.) • Ph.D. from the University of Toronto • Trained in China with over 20 years experience • Board of directors of CMAAC We treat both men and women for infertility, pain, stress and more. Disposable needles only and group insurance covers the treatment.

North York: 6257 Bathurst St. Tel: 416 227 1686 Mississauga: 3450 Cawthra Rd. Tel: 905 275 8288

Family Matters Challenge Walk. All monies raised will go to IAAC. If you are in Victoria September 27th, come and walk with us. Looking for more reading material? A terrific educational piece was published in the National Post recently. IAAC contributed the foreword to this 8-page supplement on infertility and pregnancy which was promoted by Media Planet. You can read it at ca.mediaplanet.com/fertility-pregnancy. Allow me to add a word about RB – the Royal Baby. I understand it was exciting for many people to hear about the baby and see his lovely parents holding him. I know it lifted people’s moods, and the paparazzi had a field day. BUT. I also know that for those who are praying with all their heart and soul for a baby to grace their lives, this non-stop media frenzy was a slap in the face. However, there is no point in getting worked up about it. My advice is, if the RB is being talked about on the radio or TV and it pains you, turn it off. Don’t read the magazines. Instead, let others know about your struggles. Let them know you are hurt. Tell them about the tests and treatments you have had to endure. Talk about the costs involved. Let them know you personally have to pay for your fertility treatments although Canada boasts about Universal Health Care. Give them with a copy of Creating Families so they better understand how you feel. Ask your friends and family to make a donation – the stronger IAAC is, the louder our voice will be. Become involved. There are many ways to do this. Help with fund-raising, write and article, be a board member, write to your MP and demand coverage. It will make you feel better, I promise. Have a great Fall, as colourful and hearty as the leaves on this cover.

Toronto: 932 Bathurst St. Tel: 416 640 9166

Website: www.chinesehealthway.com Jocelyn Smith 6

Créons des familles • FALL/AUTOMNE 2013

MESSAGE

de la présidente

n des bons côtés de la retraite est que j’ai maintenant plus de temps pour lire Créons des familles ! J’ai été charmée par les articles de ce numéro, à la fois enrichissants et émouvants. Nous avons écouté vos demandes d’articles relatant des expériences personnelles. Pendant la Semaine canadienne de sensibilisation à l’infertilité, nombre d’entre vous nous ont confié que les textes personnels vous aident en vous envoyant le message que vous avez de la compagnie sur ce parcours souvent solitaire. Si vous ressentez le besoin de partager votre expérience, n’hésitez surtout pas à contacter Gloria, notre directrice générale. Elle sera ravie. Ne vous en faites pas si vous n’avez pas l’habitude d’écrire : notre rédactrice réussit à donner fière allure même à mes messages…

J’ai trouvé fascinant l’article du Dr Hassan Sallam, Infertile in Egypt. Le Dr Sallam explique les aspects historiques, religieux, culturels et médicaux de l’infertilité en Égypte. Jusqu’à maintenant, j’avais très peu entendu parler des difficultés auxquelles sont confrontées les femmes infertiles dans son pays. J’ai aussi appris de La chronique du médecin, où la Dre Gunn nous renseigne sur le syndrome d’Asherman. Si vous avez l’adoption en tête, vous serez bien préparés grâce au compte rendu touchant et instructif d’Amanda Yeaman. Si vous avez plutôt envie de tourner la page, la superbe chronique de Charmaine Graham vous apportera paix et espoir. Saviez-vous que chauffer votre souper au micro-ondes dans un contenant de plastique

est une mauvaise idée si vous tentez de concevoir ? Moi non plus. Dans Help Us Help You – qui paraîtra en français dans un prochain numéro – la Dre Patricia Monnier dispense des conseils fort nécessaires sur les changements de mode de vie que les gens devraient – et peuvent – effectuer pour optimiser leur fertilité. J’ai toujours pensé que le périple de l’infertilité exigeait un travail d’équipe, et les membres de l’équipe sont vous et votre médecin. Comment remercier nos collecteurs de fonds ? L’équipe de Lenore Tochor, de Grande Prairie, a pris part à la North Face Canadian Death Race, relais éprouvant de 24 heures en haute altitude. Elle a relevé ce défi pour collecter des fonds pour l’ACSI. J’avais mal partout seulement à penser à ce que cette équipe extraordinaire a accompli ! Alison et Sean, à Edmonton, ont organisé une soirée et, plutôt que des cadeaux, ils ont demandé aux invités de verser à l’ACSI l’argent qu’ils auraient normalement dépensé pour un repas et des boissons. Quelle idée formidable ! Un énorme merci ! Au congrès de la SCFA à Victoria, cette année, ma grande amie Mara Lucato, propriétaire de Gravida, organise la première marche annuelle Défi Affaire de Famille. Toutes les sommes recueillies iront à l’ACSI. Si vous êtes à Victoria le 27 septembre, venez marcher avec nous. Vous cherchez autre chose à lire ? Le National Post a publié récemment un dossier éducatif remarquable. L’ACSI a fourni la préface de ce supplément de huit pages sur l’infertilité et la grossesse, avec le soutien de Media Planet. On peut le lire à ca.mediaplanet.com/fertilitypregnancy.

sont donné à cœur joie. MAIS. Je sais aussi que, pour ceux qui prient jour et nuit pour qu’un bébé vienne compléter leur vie, cette folie médiatique était une gifle. Mon conseil : si on parle du BR à la radio et à la télévision et que cela vous importune, éteignez le poste. Tenez-vous loin des magazines. Faites plutôt connaître vos difficultés à vos proches. Ditesleur que votre âme est blessée. Parlez-leur des tests et traitements que vous devez subir. Faites-leur savoir que vous devez payer vos traitements de votre poche même si le Canada se vante d’avoir un programme de santé universel. Donnez-leur un exemplaire de Créons des familles pour qu’ils comprennent vos sentiments. Demandez à vos parents et amis de faire un don – plus l’ACSI sera forte, mieux notre voix sera entendue. Soyez proactifs. Il y a plusieurs façons de participer : aidez à collecter des fonds, écrivez un article, joignez-vous au conseil d’administration, écrivez à votre député et réclamez le financement des traitements fertilité. Vous vous sentirez mieux, je vous le promets !

Je vous souhaite un automne coloré et en forme de cœur, comme les feuilles sur notre couverture.

Jocelyn Smith

Un mot sur le BR – le bébé royal… Je comprends que cela ait passionné les gens d’entendre parler du bébé et de le voir dans les bras de ses fortunés parents. Je sais que cela a égayé des tas de gens et que les pararazzi s’en

FALL/AUTOMNE 2013 • Creating Families

What’s New? Headlines in the fertility world

No luck with IVF? Check your Vitamin D levels Scientists keep finding good things

might be beneficial to measure

to say about Vitamin D, and the

vitamin D levels during infertility

simple way to boost their chances

improve the likelihood of pregnancy.

latest could provide women with a

treatment and to supplement to

of success when undergoing IVF. A

Said Dr. Kimberly Liu, fertility spe-

Sinai Hospital in Toronto, Ontario,

Centre for Fertility and Reproductive

study of 173 IVF patients at Mount

revealed that women in this group

with sufficient vitamin D levels had

significantly higher pregnancy rates

per cycle (52.5%) compared with

women whose level of the sunshine

vitamin were inadequate or deficient

(34.7%). The authors suggest it

cialist at Mount Sinai Hospital’s

Health: “We know that Canadians

are prone to vitamin D insufficiency,

especially during the winter months,

and this study suggests that vitamin

D supplementation could provide an

easy and cost-effective means for

improving pregnancy rates.”

Pas de chance avec la FIV ? Vérifiez votre taux de vitamine D

Les scientifiques ne cessent de

connu des taux de grossesse par

trouver de bonnes choses à dire au

cycle significativement plus élevés

pourrait donner aux femmes qui

de la vitamine du soleil étaient

sujet de la vitamine D, et la dernière subissent une FIV une manière

simple d’augmenter leurs chances de succès. Une étude sur 173

patientes de l’Hôpital Mount Sinai, à Toronto, a montré que les femmes de ce groupe dont les taux de

vitamine D étaient adéquats ont

Créons des familles • FALL/AUTOMNE 2013

« Nous savons que les Canadiens

sont portés à manquer de vitamine

(52.5 %) que celles dont les niveaux

D, surtout pendant les mois

insuffisants ou déficients (34.7 %).

spécialiste en fertilité à l’Hôpital

Les auteures de l’étude croient qu’il pourrait être bénéfique de mesurer les taux de vitamine D pendant les

traitements de fertilité et de donner

des suppléments pour améliorer les

possibilités d’obtenir une grossesse.

d’hiver, » dit la Dre Kimberly Liu, Mount Sinai. « Cette étude

sugggère que la supplémentation

en vitamine D pourrait représenter

une manière facile et peu coûteuse

d’augmenter les taux de

grossesse. »

Quoi de neuf ?

Les manchettes dans le monde de la fertilité.

Free fertility treatment now accessible to all women in Argentina

Traitements de fertilité pour toutes les Argentines

No point crying for you, Argentina! This country’s government announced last June 5th that it would implement what could turn out to be one of the most generous fertility treatment funding policies in the Western world. Argentina’s lower house voted a law mandating health care providers to grant fertility treatments to all women older than 18 who request them. Women will be eligible regardless of their sexual orientation and marital status. The new law will apply to both private medical plans and the public health care system. What is now left to be determined is how often a person can benefit.

Le gouvernement de l’Argentine a annoncé le 5 juin 2013 qu’il mettrait en œuvre ce qui pourrait s’avérer l’une des politiques de financement des traitements de fertilité parmi les plus généreuses des pays occidentaux. La Chambre basse de ce pays a voté une loi obligeant les prestataires de soins de santé à fournir des traitements de fertilité à toutes les femmes de 18 ans et plus qui en feront la demande. Les femmes seront admissibles au programme peu importe leur orientation sexuelle et leur statut civil. La nouvelle loi s’appliquera autant aux régimes privés qu’au système de santé public. Il reste maintenant à déterminer le nombre de traitements qu’une personne pourra recevoir.

The number of couples waiting for every baby placed for adoption in the United States.

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888-809-5577

Nombre de couples en attente pour chaque bébé placé en adoption aux États-Unis.

FALL/AUTOMNE 2013 • Creating Families

Free IVF linked to higher birth rates

What’s New?

Access to free fertility treatment has a positive effect, albeit small, on national birth rates. Such is the conclusion of a study led by health economist Mark Connolly, from the University of Groningen in the Netherlands, and first presented at the annual meeting of the European Society of Human Reproduction and Embryology in Istanbul, Turkey, in July of 2012. Dr. Connolly’s team assessed the reimbursement policies of 23 European countries. It was found that countries with the most generous funding policies were Belgium, France and Slovenia, while the UK, together with Russia and Ireland, were the least generous. A significant relationship was seen between reimbursement levels and the annual contribution of assisted reproduction technology (ART) to national birth numbers. Greater access to free IVF, in particular, led to fertility treatment making a bigger impact on national birth statistics. According to Dr. Connolly, "This finding has important policy implications for national authorities concerned about ageing populations and interested in policies for influencing national birth rates."

La FIV gratuite augmente le taux de natalité

L’accès aux traitements de fertilité gratuits a un effet positif, bien que modeste, sur les taux de natalité de plusieurs pays. Telle est la conclusion d’une étude dirigée par l’économiste de la santé, Mark Connolly, de l’Université de Groningen, aux Pays-Bas, et présentée à la réunion annuelle de la Société européenne de reproduction et d’embryologie humaines à Istanbul, en Turquie, en juillet 2012. L’équipe du Dr Connolly a évalué les politiques de remboursement de 23 pays européens. Les pays aux politiques les plus généreuses étaient la Belgique, la France et la Slovénie, alors que le Royaume-Uni, la Russie et l’Irlande étaient les pays les moins généreux. Les chercheurs ont établi une relation significative entre les taux de remboursement des traitements et l’apport annuel des TPA au nombre des naissances dans les pays concernés. Un plus grand accès à la FIV, en particulier, s’est traduit par un impact plus important des traitements de fertilité sur les statistiques nationales. Selon le Dr Connolly, « Ces résultats ont des implications substantielles pour les politiques des autorités nationales inquiètes du vieillissement de leur population et intéressées à des mesures visant à influencer leur taux de natalité. »

Créons des familles • FALL/AUTOMNE 2013

Quoi de neuf ?

Un palmarès

Embryos’

Top Ten?

des embryons ?

Spanish researchers at the Marques Institute Fertility Clinic in Barcelona were quite surprised to discover that music may have a positive effect on embryo development. Their experiment had to do with mimicking in an IVF lab the conditions in the womb to foster fertilization of the eggs. While there have been studies on light and temperature, it occurred to the researchers that no one had studied the effect of sound. They injected sperm into nearly 1,000 eggs and placed them in incubators, half of which were equipped with iPods playing everything from classical selections to Michael Jackson. Surprisingly, the rate of fertilization seemed higher in the incubators with music. Considering an embryo may not hear before 14 weeks of age, it is not the sound that may have been beneficial, but rather the vibrations. According to Oxford University fertility expert, Dagan Wells, “Embryos produced naturally are wafted down the fallopian tubes, rocking and rolling all their way to the uterus. This movement means that the embryo experiences a very dynamic environment, which may have some advantages, particularly in terms of getting rid of waste products. The vibrations caused by music may stimulate this effect. One might speculate that techno music, with its pounding bass beat, might to do the best job of all.”

The number of women in the United States who become infertile every year from undiagnosed sexually transmitted infections.

Des chercheurs espagnols ont eu la surprise de découvrir que la musique a peut-être un effet bénéfique sur le développement des embryons. Leur expérience visait à imiter les conditions dans l’utérus dans un laboratoire de FIV, afin de favoriser la fécondation des ovules. Alors qu’il y a eu des études sur la lumière et la température, il leur est venu à l’esprit que personne n’avait étudié les effets du son. Ils ont injecté des spermatozoïdes dans près de 1 000 ovules et les ont placés dans des incubateurs dont la moitié étaient munis de iPods faisant jouer tout le répertoire, de pièces classiques à Michael Jackson. Étonnamment, le taux de fécondation a semblé supérieur dans les incubateurs avec musique. Compte tenu qu’un embryon ne peut entendre avant l’âge de 14 semaines, ce n’est pas le son qui pourrait avoir eu des effets positifs, mais les vibrations. Selon un expert en fertilité de l’Université d’Oxford, Dagan Wells : « Les embryons créés naturellement sont transportés à l’intérieur des trompes de Fallope, et leur parcours jusqu’à l’utérus est plutôt « rock and roll ». Les mouvements auxquels ils sont soumis signifient que l’embryon fait alors l’expérience d’un environnement très dynamique qui peut présenter des avantages, en particulier pour ce qui est de l’élimination des déchets. Les vibrations causées par la musique pourraient stimuler cet effet. On pourrait penser que la musique techno, avec ses notes basses martelées, est la plus efficace à cet égard. »

24,000

Nombre de femmes aux États-Unis qui deviennent infertiles chaque année par suite d’infections sexuellement transmissibles non diagnostiquées.

FALL/AUTOMNE 2013 • Creating Families

My Story A Letter to My Future Daughter by Dan Coghlan The day we learned about the challenges we’d face bringing you into the world, your mother and I held each other’s hands very tightly. We’d spoken to one doctor, who’d told us that my diabetes was complicating things and that was frightening. Then we spoke to a second who told us that conceiving a child was going to be further convoluted by issues with your mother’s body, and that was more than we thought we could bear. Over the course of several meetings we saw the growing potential for all our dreams to be destroyed.

resources left to make more. Our little snowflakes, frozen in a lab. The technician transferred two of them to your mother’s womb and, once again, we rode a twoweek emotional roller coaster while we waited to be able to test for a viable pregnancy. Just like every other time, we re-lived every emotion that had brought us to this point: fear, frustration, helplessness, anger and, against our better judgment, a strange sort of faith that we felt guilty for feeling.

All our dreams. You. With each new problem the doctors discovered, the costs of overcoming them climbed. Family offered to help and making an attempt began to seem possible, but we knew that realistically our chances ran only as deep as the money available and there was only so much. I watched as doctors filled your mother with medication after medication, only to be unsatisfied by the results and start all over again. I took my little pills while she took painful injections from long needles that punctured her flesh and left stinging bruises on her skin. Every time we got far enough in the treatment to make an attempt at conceiving we would remind each other not to get our hopes up, not to set ourselves up to be hurt.

We held each other’s hands again and we waited...

Now, as I write this, I’m listening to your mother and grandmother comparing notes down the hall, preparing your new room as the date of your impending birth approaches. I’m telling you these things not so that you will feel guilty about how much we suffered to have you, but to understand just how much you are worth to us. You are the culmination of a massive amount of effort, work and foolish optimism, and no matter who you will be when you are grown, I believe that you will be worth it. We love you,

And each time we got our hopes up. Each time we got hurt. Finally we were down to three little embryos and no more

~Daddy FALL/AUTOMNE 2013 • Creating Families

Help US

Help YOU by Dr. Patricia Monnier

As a specialist in infertility I treat both women and men, and one sentence that my patients often hear from me is, “Help me help you!” This is because, in my opinion, lifestyle has a major influence on fertility and this fact is not sufficiently well known. This means that you may be able, using simple strategies, to enhance your fertility, or at least help us make your fertility treatments more effective.

You may be able, using simple strategies, to enhance your fertility, or at least help us make your fertility treatments more effective.

If you are overweight, lose a few pounds One aspect you can work on is weight control. We all know that obesity has reached epidemic proportions all over the world. This phenomenon has not spared fertility patients, and numerous studies have shown that excess weight damages the fertility potential. In fact, the risk of infertility is three times higher in obese women than in women with a healthy weight. Indeed, fat tissue is not considered anymore as a passive depot for storing excess energy but as an active organ secreting several hormones. One explanation of the negative relationship between obesity and fertility is that fat tissue promotes the production of “bad” hormones which do not help the ovary to perform its duties. If one burns fat through

Créons des familles • FALL/AUTOMNE 2013

The good news is that you do not have to be paper thin to enhance your fertility. A woman with a body mass index over 30 who loses as little as 6.5 kilos (14 lbs.) will improve her ovulatory function.

losing weight, this regulates ovarian physiology, in plain terms, ovulation. The same is true for men. Extra pounds hinder sperm production, especially in overweight men whose diet is high in saturated fats, such as those found in butter, fat cheeses and frying oil.1 The good news is that you do not have to be paper thin to enhance your fertility – in fact, being too thin is equally detrimental to your reproductive health. According to several studies, a woman with a body mass index over 30 – a person with a BMI between 25 and 30 is considered overweight, while someone with a BMI over 30 is considered obese – who loses as little as 6.5 kilos (14 lbs.) will

improve her ovulatory function. After losing weight, an obese woman will have a 90% chance of ovulating on her own, a result which no medical treatment can achieve.2

Think of the children Losing weight is not easy. One factor that may boost your motivation is that by shedding a few kilos you will actually do a great service to your future children. Indeed, there is increasing evidence that the environment in the mother’s womb conditions the health of the child once he or she becomes an adult. An overweight or obese mother will tend to produce children who will be more vulnerable to obesity later in life. These children will also tend to be at risk of problems associated with sugar levels in their blood and of developing insuline resistance. This may lead to an array of health problems, from diabetes to heart disease. Moreover, recently, researchers found a preconceptional impact of paternal obesity, via spermatogenesis, on the offspring’s future health status.3

Ban alcohol, recreational drugs, tobacco… and sauna baths! Other steps which are relatively simple to take and are totally under your control are related to your intake of alcohol, drugs and tobacco products. No matter what you may hear about some positive effects of alcohol, of red wine in particular, alcohol is toxic for the reproductive system.4 And so is cannabis, usually referred to as a “soft” drug. Well, when it comes to your reproductive health, studies show that it is not that soft5… As for tobacco, it should be banned from any household where one

person or a couple is trying to conceive.6 Not only does tobacco lower a man’s sperm count, it also cuts by 50% a woman’s chances of success when undergoing IVF if her partner is a smoker, even if she doesn’t smoke herself. Furthermore, women exposed to passive smoke also take longer to achieve a spontaneous pregnancy. Why ban sauna baths?7 Men are increasingly aware that heat is harmful to the production of healthy sperm, but this may be worth

Tobacco should be banned from any household where one person or a couple is trying to conceive. Not only does tobacco lower a man’s sperm count, it also cuts by 50% a woman’s chances of success when undergoing IVF if her partner is a smoker, even if she doesn’t smoke herself.

FALL/AUTOMNE 2013 • Creating Families

We now know that small doses of endocrine disruptors, day after day, have a cumulative effect that damages not only our reproductive health, but also our health in general.

round of IVF is not rare, indeed even after an appointment with the fertility clinic has been made. We can surmise that the logic behind this phenomenon is that patients’ level of stress goes down once they have achieved a pregnancy or have the assurance they will be taken care of. When my patients ask me what they can do to maximize the chances of implantation following embryo transfer, my answer usually is, “Do not have a bath in the next few days, drink plenty of water so that you will eliminate large quantities of liquid and thus reduce the risk of infection… and cut your head off!” Meaning that they should do their best not to worry.

Beware of endocrine disruptors

repeating: hot baths, saunas, heated seats (in cars), laptops held near their body are all activities that men trying to conceive should stay away from.8

“Cut your head off!” A relationship has been established between the head and the hormonal system, with the result that pregnancy rates are adversely affected in women who suffer from high levels of stress.9 This is why we offer yoga classes to our patients at the McGill Reproductive Centre. Indirect evidence of the influence of stress on the reproductive system is that a spontaneous pregnancy after a successful

Créons des familles • FALL/AUTOMNE 2013

I will admit, however, that it is difficult not worry about “endocrine disruptors”. An endocrine disruptor is a natural or synthetic molecule which interferes with the functioning of our hormones. It does that either through mimicking our hormones or through preventing them from taking effect. BFRs are everywhere… Nowadays, the environment we live in could be described as a “soup” of endocrine disruptors. Unfortunately, they are found in objects we use every day, from plastic containers to lipstick, from computers to hair dryers to personal care and cleaning products. One class of endocrine disruptors which pervades our environment are called BFRs (for “brominated flame retardants”). These chemicals are added to many consumer products to make them less flammable. Our clothes, our electronic devices, even the material covering our sofa are

likely to carry BFRs. We absorb over 80% of the BFRs in our environment in the form of contaminated dust, while the remainder is absorbed through food. An association between the toxins found in BFRs and male infertility has already been suspected, and studies are under way – including some by my McGill colleagues – to assess their impact on men’s and women’s fertility and fetal development. Among the things we have learned in recent years about endocrine disruptors, two stand out. The first one is that one can no longer rely on the age-old principle, “The dose makes the poison”. We now know that small doses of endocrine disruptors, day after day, have a cumulative effect that damages not only our reproductive health, but also our health in general. The second thing we learned has to do with a “cocktail effect”. Much is still unkown about how endocrine disruptors act, and, moreover, how they interact. This notwithstanding, we are nevertheless able to analyze the impact of specific classes of chemicals on specific targets, which may give us indications as to how we may, if not avoid them completely – this is unfortunately not feasible – at least diminish our exposure whenever possible. …and so are phthalates Phthalates are another class of chemicals found in our household objects and living spaces. To give you an idea, a survey found that over 95% of the population in the United States had measurable levels of phthalates in their urine. Phthalates have been associated with fertility problems in animals. In humans, women’s

during preparation or packaging. - Take out your magnifying glass and shop for cosmetics without parabens and phthalates – they exist. Keep in mind that a woman may put kilos of cosmetics on her face throughout her lifetime. The good news is that we are now more aware of the damages inflicted on our health,

Take out your magnifying glass and shop for cosmetics without parabens and phthalates – they exist. Keep in mind that a woman may put kilos of cosmetics on her face throughout her lifetime. exposure to these endocrine disruptors is greater because they are commonly found in cosmetics, particularly in lipstick, mascara, nail polish and moisturizers as well as household products. The literature examining the relationship between human fertility and phthalate exposure is sparse. One epidemiological study suggests that phthalates increased time to pregnancy (the number of menstrual cycles required to conceive).10

What you can do I hear you ask: Considering that endocrine disruptors seem to be inescapable, isn’t trying to avoid them a lost battle? As I mentioned earlier, banishing them from your environment altogether is not easy at the moment – you would have to give up your computer, for one thing. In addition to the

and in particular on our reproductive health, by endocrine disruptors. It is hoped that the numerous studies now being carried out in this field will lead to the replacement of harmful chemicals with safe ones. Until we reach this happy stage, trying to minimize your exposure and leading a healthy lifestyle, including losing a few pounds if need be, and learning to manage your stress, could go a long way in helping you achieve your dream of becoming a parent. This is the best way you can help us help you.

recommendations stated earlier, there are nevertheless measures you can take in order to reduce your daily exposure: - Do not use plastic containers to warm up food in the microwave oven. Doing so would transfer some phthalates into your dinner. Glass containers are preferable. - Avoid wrapping leftovers in plastic film, especially fatty foods. Phthalates are made of “mobile” parts and they love fat. Wrapping fatty food in a plastic film would encourage endocrine disruptors to migrate into your food. - Eat home-cooked meals rather than commercial ready-made dishes that can be contaminated by plastic products

FALL/AUTOMNE 2013 • Creating Families

Norman RJ. Weight loss in obese infertile women results

About the Author Dr. Patricia Monnier is an obstetriciangynecologist specialized in infertility at the McGill University Health Centre Reproductive Centre - Montreal, and an Associate Professor at the Department of Obstetrics and Gynecology of McGill University - Montreal. She holds a Ph.D. in cellular biology and immunology from the University of Nancy, France, and her research projects focus on the impact of environment on reproductive health.

7 Garolla A, Torino M, Sartini B, Cosci I, Patassini C,

in improvement in reproductive outcome for all forms of

Carraro U, et al. Seminal and molecular evidence that

fertility treatment. Hum Reprod. 1998 Jun;13(6):1502-5.

sauna exposure affects human spermatogenesis. Hum Reprod. 2013 Apr;28(4):877-85.

3 Soubry A, Schildkraut JM, Murtha A, Wang F, Huang Z, Bernal A, et al. Paternal obesity is associated with

8 Avendano C, Mata A, Sanchez Sarmiento CA, Doncel

IGF2 hypomethylation in newborns: results from a

GF. Use of laptop computers connected to internet

Newborn Epigenetics Study (NEST) cohort. BMC Med.

through Wi-Fi decreases human sperm motility and

2013;11:29.

increases sperm DNA fragmentation. Fertil Steril. 2012 Jan;97(1):39-45 e2.

4 Joo KJ, Kwon YW, Myung SC, Kim TH. The effects of smoking and alcohol intake on sperm quality: light

9 Csemiczky G, Landgren BM, Collins A. The influence

and transmission electron microscopy findings. J Int Med

of stress and state anxiety on the outcome of IVF-treat-

Res. 2012;40(6):2327-35.

ment: psychological and endocrinological assessment of Swedish women entering IVF-treatment. Acta Obstet

5 Battista N, Meccariello R, Cobellis G, Fasano S, Di

References

Gynecol Scand. 2000 Feb;79(2):113-8.

Tommaso M, Pirazzi V, et al. The role of endocannabinoids in gonadal function and fertility along the evolu-

10 Burdorf A, Brand T, Jaddoe VW, Hofman A,

1 Attaman JA, Toth TL, Furtado J, Campos H,

tionary axis. Mol Cell Endocrinol. 2012 May 15;355(1):1-

Mackenbach JP, Steegers EA. The effects of work-related

Hauser R, Chavarro JE. Dietary fat and semen quality

14.

maternal risk factors on time to pregnancy, preterm birth

2012 May;27(5):1466-74.

6 Soares SR, Melo MA. Cigarette smoking and repro-

Environ Med. 2011 Mar;68(3):197-204.

2 Clark AM, Thornley B, Tomlinson L, Galletley C,

Jun;20(3):281-91.

and birth weight: the Generation R Study. Occup

among men attending a fertility clinic. Hum Reprod. ductive function. Curr Opin Obstet Gynecol. 2008

CrĂŠons des familles â&#x20AC;˘ FALL/AUTOMNE 2013

Just around the time we started trying for a baby, one of my closest friends gave birth to her first child. I remember holding her tiny baby in my arms, looking across at my husband and thinking how wonderful it would be when we had a baby of our own. As the months turned into years, my friend’s baby grew into a toddler, she got pregnant again and gave birth to a second child who also turned into a toddler – and all the while we were being dragged ever deeper into the world of fertility tests and treatments.

Helping Your Friendships Survive Infertility by Kate Brian

My friend and I had known one another since we were teenagers, but it was increasingly difficult for us to spend time together. Her life seemed to revolve around her family, and she had a new group of friends who all had young children. Their conversations were dominated by the relative merits of local nurseries, potty training or how to get their children to eat broccoli… Not only did I have nothing to contribute, I was also starting to find it painful to have to listen to happy chatter about family life as I was no longer certain I would ever have a family of my own. Of course, other friends and colleagues were having babies too, and my small circle of child-free friends seemed to be diminishing by the day. I dreaded pregnancy announcements as yet another friend moved into the club of mothers-to-be. All I could think about was the fact that we couldn’t conceive, and I could tell that some of our friends thought I was becoming obsessed with our fertility problems. They would ask why we didn’t try to forget about getting pregnant for a while and would suggest that going on holiday or trying to relax might help. A friend who had three children of her own told me one day that not everyone could be “blessed with a baby”. In retrospect, she was probably trying to show that she appreciated quite how lucky she’d been, but at the time it felt like a deliberate reminder of our misfortune.

FALL/AUTOMNE 2013 • Creating Families

Conversations were dominated by the relative merits of local nurseries, potty training or how to get their children to eat broccoli… Not only did I have nothing to contribute, I was also starting to find it painful to have to listen to happy chatter about family life as I was no longer certain I would ever have a family of my own. When our first IVF cycle was unsuccessful, many of our friends seemed to assume that meant the end of fertility treatment. A number of people suggested that we should start thinking about adoption or fostering. I felt they were implying that we would never have a child of our own with treatment and I couldn’t understand why they were being so negative, although in reality they were trying to come up with positive alternatives. My relationships with many of our close friends who had children were sometimes

Créons des familles • FALL/AUTOMNE 2013

strained. I felt I was turning into a brittle, uptight stranger standing on the edges of their cosy, cheerful family lives. I stopped wanting to socialise as every gathering seemed fraught with potential reminders of our fertility problems. I was on edge all the time, waiting for someone to ask if we had children, or when we were going to get round to it, waiting for the joyful pregnancy announcements or the discussions about newborn babies and toddlers.

focused on her fertility problems, friends stopped wanting to spend time with her. “A lot of people think if you are going to have IVF, then you are going to have a baby at the end of the year,” she explained. “All our friends turned their backs on us because we had become obsessed with having a baby. They were interested in the first few months, but when it drew out into years, we found that slowly but surely friends began disappearing.”

Having spoken to dozens of other couples with fertility problems when writing my book The Complete Guide to IVF, I know that the difficulties I experienced with friendships were far from unique. Nigel explained how he and his wife found that they were shedding friends as they went through fertility tests and treatment. “At one point, we were down to pretty much no friends, and that is very upsetting, as we used to have a large social circle,” he said. “You start to take it personally and feel isolated, and that people don’t care.”

As Kylie recognised, we can become focused on getting pregnant to the exclusion of pretty much everything else when we’re going through treatment, and it can be harder to take pleasure in the things we used to enjoy. This is often combined with a feeling of emotional fragility that can make us feel very sensitive, and easily upset by things. Polly admitted that even people who were trying to be kind to her found it hard to strike the right tone. “People could never understand how terrible it was,” she said. “They could never say the right thing. They really didn’t have a hope of getting it right.”

This diminishing social circle is something Kylie and her husband experienced too. She says that as she became more and more

It is true that it can be hard for our friends to

I stopped wanting to socialise as every gathering seemed fraught with potential reminders of our fertility problems. know how best to help when we are experiencing fertility problems. Sometimes they may try to avoid the subject completely, but this is often because they don’t know what to say or don’t want to make us feel worse. They may delay telling us about their own pregnancies because they don’t want to upset us, not always appreciating that it can be far worse to discover that we were the last to know. Even trying to be sympathetic can sometimes come across the wrong way as feeling that you are an object of pity is hard to take. All this only serves as a reminder of quite how deeply infertility can affect every single area of your life, including your relationships with your friends. So, what can you do if you are experiencing

difficulty with friendships, or with the things that friends are saying? There are no simple solutions, but there are some things you can bear in mind which may make things a little easier, and may help your friendships to survive fertility problems. If certain friendships are causing you particular problems, don’t be afraid to park them for a while. You may find that a very close friend who you’d hoped would be there for you seems to specialise in saying completely the wrong thing, but try not to let this sour a long-lasting friendship. It is better to see less of each other for a while; a close friendship will survive a fallow period, and you may both appreciate one another more after a break.

Accept that pregnancy and babies can be hard for you. There is nothing wrong with spending less time with friends when they are pregnant, or when they have young babies. It’s fine to avoid social situations which you know are going to upset you, whether it’s christenings, family get-togethers or children’s parties. If you are able to explain to close friends why it is difficult for you, they may be surprisingly understanding. If you don’t feel able to be open, making excuses to avoid things you can’t face is perfectly acceptable! Spend more time with friends who get it right for you. You will find that some people are able to offer constructive help and sympathy – but it may not be those you’d expected to be there for you. A woman I wasn’t very close

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FALL/AUTOMNE 2013 • Creating Families

A close friendship will survive a fallow period, and you may both appreciate one another more after a break. to at the start of our fertility problems was wonderful throughout our years of tests and treatment. She always asked how things were, but in a very straightforward, supportive and open way. She never made judgements or told me what we ought to be doing, but was kind and understanding. I loved spending time with her when we were trying unsuccessfully to conceive because I always came away from a conversation feeling better, rather than hurt and upset. Try not to be too sensitive to people’s thoughtless remarks even if they do feel very hurtful. It has taken time, but I realise now that some of the things that felt so awful at the time were not meant maliciously or even unkindly, but were most often just the result of people struggling to know how to deal with something that was clearly causing me so much distress. It’s not easy when people say things that feel mean and unkind, and you may want to avoid friends who always seem to say the wrong things, but try to remember that they are not setting out to hurt you. Sometimes friends who have babies welcome the fact that they don’t talk about children when they are with you. Don’t make the mistake of assuming that this is all they are interested in because they seem so focused on family life. They often find the opportunity to talk about something other than babies very refreshing and this can give your friendship a boost. Counselling can help you to sort out how you feel when friendships are becoming difficult. Talking to someone who is not involved in your life and who listens with empathy can help you to deal with tricky friendship problems. Opting to see a counsellor is never

Créons des familles • FALL/AUTOMNE 2013

a sign of weakness but shows that you are taking positive action to help yourself through a difficult time. Remember, your friends are often finding the situation hard to deal with too. They may worry about how to tell you when they are pregnant, or whether they should ask you to be a godparent, or to come to a family party. This does make things difficult as you may sense that they are withdrawing from you, but this is often down to them not knowing what to say or how best to help. Finding some fertility friends by connecting with others who are living with similar experiences can really help whether it’s through an online forum or by going along to a support group. Debbie made some long-lasting friendships through fertility websites. “There are girls I’ve been chatting

with on the website for four or five years,” she explained. “We know each other so well and sometimes we talk every day. I’d love to actually meet them face to face. I met one friend who lived half an hour away and we’ve supported each other through all our cycles. It’s a special friendship.” Although it may not feel that way when you’re in the middle of it, being stuck in the fertility maze is not a permanent state and at some point there will be a solution to your situation, even if it isn’t always the one that you may have been expecting. Once you are no longer feeling raw about your fertility problems, you will be able to re-build your friendships if they were based on solid foundations. One of the people I interviewed said that infertility could “weed out the shallow elements of friendships”. It is true that some friendships may be lost by the

Spend more time with friends who get it right for you. You will find that some people are able to offer constructive help and sympathy – but it may not be those you’d expected to be there for you. wayside, but this happens as we go through life anyway. Some of my friendships have been changed by our fertility problems, but none were irreparably damaged. You may find that infertility can leave you with stronger friendships in the long run - and perhaps some new ones too!

About the Author Kate Brian has two children who were both IVF babies. She is the author of The Complete Guide to IVF, The Complete Guide to Female Fertility and Precious Babies, all published by Piatkus. Kate is a former television news producer who now works freelance as a writer and editor. She edits the Journal of Fertility Counselling.

FALL/AUTOMNE 2013 • Creating Families

Adoption Corner

TAKING CHARGE of Our Adoption Process

ILLUSTRATIONS: KAREN HIBBARD

by Amanda Yeaman

Most infertile couples go through a long and arduous process before they discover they won’t become parents “the old-fashioned way.” In my case, however, the writing was on the wall at a very early point on my road to parenthood. My husband John and I made the decision not to conceive naturally,

Créons des familles • FALL/AUTOMNE 2013

Adoption Corner not because we couldn’t but because we didn’t want to pass on a gene that I have to our child. You see, I have a brittle bone disorder called Osteogenesis Imperfecta (OI). In layman’s terms, what that means is that my bones break very easily because my body makes only 50% of the collagen your body makes. It means something else too: we would have a 50% chance of passing this disorder on to our child, and there is no way to know how severely the child would be affected. My case is quite mild but our child’s could be much worse. It was a chance we just weren’t willing to take. Our adoption journey started almost five years ago, in November of 2008, when we registered with the Children’s Aid Society (CAS). The home-study process seemed very daunting at first. Imagine spending hours upon hours telling your entire life story to a stranger, talking about your upbringing, your relationship with your parents, your siblings, your friends, and each other – discussing life’s milestones and tragedies; discussing feelings, achievements and goals and prospective parenting techniques, to name just a few. During this experience, I learned that discussing the details of our lives with a third party in fact helped us to learn more about ourselves, about our strengths and weaknesses, our fears and our dreams. In the end, I found it to be a very beneficial, even enjoyable experience. It took a long time to get into the mandatory PRIDE training and start our home-study, and it was finally completed by February of 2012, and we were now waiting to be matched with just the right child for us. We were excited. Our CAS caseworker reassured us that because we had broad boundaries of acceptance, meaning we weren’t just looking for a newborn, we would be a fairly easy family to match with a child. We felt hopeful, and we felt that we were well on our way to completing our family, that we were coming to the end of our wait.

In May of 2012, however, that feeling of “being close” vanished. Our caseworker, with whom we had spent so many hours divulging every aspect of our lives, unexpectedly resigned. We were assigned a new caseworker who knew nothing about us and who we knew nothing about, and our journey came to a standstill.

I learned that discussing the details of our lives with a third party in fact helped us to learn more about ourselves, about our strengths and weaknesses, our fears and our dreams. In the end, I found it to be a very beneficial, even enjoyable experience. After months of waiting for something to happen, John and I made a decision to push forward with our adoption on the private domestic front. At this point, we had waited over three years to complete our home study and get the ball rolling, and we weren’t waiting another minute! We consulted with some sources in the field, who advised that the first step to private adoption was to create a profile, or a book about ourselves, which would be shown to birth parents and used by them to choose a family for their child(ren). After some research and discussion, John and I consulted the owner of Adoption Profiles, to help us develop our adoption profile. I remember sending her a heartfelt e-mail that

outlined our story, our reasons for wanting to adopt and where we currently stood in the process. She called me the same day. We had an amazing conversation. I remember feeling that overwhelming sense of excitement and hope that I hadn't felt for a long time. John and I worked long and hard at writing the content for our profile. Towards the end of November 2012, we had a finished profile and we started marketing ourselves. We just had to help a potential birth parent find us, and I was determined to do everything I possibly could to make that happen. First, we pushed a soft copy of our profile out to our family and friends, telling them of our intent and desire to adopt. We spread the news of our search by word of mouth, as well as through e-mail, and we asked them all to spread the word and share our story. As well, we started registering with adoption agencies. One thing we heard a lot when people found out we were trying to complete our family was, “Why don’t you just adopt?” Most people don’t understand how difficult and time-consuming public adoption is nor how costly private domestic adoption is. In order for birthparent(s) to see our profile, we need to get it out to adoption agencies and licensees. But because these people are taking you on as a client, they first need to meet you and understand your motivation for adoption and set out some expectations with you. For each agency/licensee where you register, you pay a fee. We did a lot of research, trying to make sure that the agencies and licensees we picked would be the best suited to our needs. Because of the cost to register and cost of various services, and in order to increase our exposure, we also tried to find a match on our own. We created a Facebook page (https://www.facebook.com/JohnAmandaAdo ptiveParentsToBe) and a website (http://johnandamandaadopt.weebly.com/). We registered with two online services: AdoptionProfiles.ca (www.AdoptionProfiles.ca)

FALL/AUTOMNE 2013 • Creating Families

Adoption Corner which let us register for free; and Canada Adopts (www.canadaadopts.com). In January, not long after we put out our profile, we found out we were going to be presented to a couple who had decided adoption was the best option for their child. John and I were very excited. I'm not sure why, but we were very confident we would be chosen, even though it was our first time being presented. The wait to find out was extremely nerve-racking. Finally, the phone rang, and it was the adoption worker. I took a deep breath and answered. She let me know that we hadn’t been chosen. Because we had been so sure about the whole thing, the disappointment hit us hard. We were assured that we were one of the top families being considered, but in this game, being second or third runner-up doesn't result in a placement. First, I grieved, and then I set my resolve firmly in place and kept moving forward! A few months later, in early April, we received a call from an agency who wanted to present our profile to a birth mother who was due in May. We agreed to have our profile presented. We didn't hear anything for one week, and during that entire week, each time the phone rang, I jumped, and my heart

started racing. Finally, on Thursday, the phone rang. It was the agency. My heart was in my throat. Our caseworker asked us a few more questions and she let us know that the birth mother’s decision was between us and one other family. We now had a 50% chance at completing our family, and we were closer to our dream than we had ever been. Because this birth mother (let’s call her Jane) had taken so long in deciding, I wasn't sure when to expect her decision. Later that same day, our caseworker called back to tell us that we had been chosen. I was in such shock that I didn’t even know what to say or how to respond. John was at work and when I finally told him the good news, he was ecstatic. We set up a meeting the following Wednesday to meet the birth mother. I’m not normally an anxious person, but I remember being very nervous that day. We met in a room with our respective caseworkers, and the whole group of us just chatted and got to know each other. Jane was very pleasant and soft-spoken. John and Jane found they had some things in common, and they really seemed to make a connection. We left the meeting feeling anxious, excited and nervous

about what was to come. We talked to our caseworker, and she advised that we could start telling family and friends that we had been chosen and that our family was going to be complete. We did, but we also reminded them that after the baby was born, Jane did have about 30 days during which she could change her mind. Still, we were cautiously optimistic. On Thursday, we completed our paperwork with our adoption worker. The plan was to submit the paperwork to the Ministry of Children and Youth Services for approval on Monday. There were a few items still outstanding that might delay the process, but both my caseworker and I were diligently working to square these around. In addition, the two caseworkers (ours and Jane's) had to prepare reports to be filed to the ministry. The whole process was quite overwhelming. Two days later, on Saturday, I was at a family function with my in-laws and John’s extended family (he was at work). Our adoption worker called while I was out and I assumed she was calling about paperwork and reports, but she wasn’t. She let us know that the baby was on the way! I was in shock, and started to cry as I knew John would be hard to reach at this point, and I became very anxious about the fact that the paperwork was neither ready nor submitted. We made it to the birthing room just in time to hear Jane’s baby crying. Jane's 13-year-old daughter and her caseworker were both waiting outside the door. We waited a few minutes, and went in to see Jane. She immediately handed the baby to me. I can't even describe to you the feeling of holding her in my arms for the first time. We named this beautiful child Stella, after my mother, and we stayed in the hospital all night and took care of her. Due to Stella’s early arrival, the caseworkers had to redo some of the paperwork and reports, which resulted in another delay in filing. Everything was finally filed the following Thursday, but we still had to wait for the ministry’s approval

Créons des familles • FALL/AUTOMNE 2013

Adoption Corner

We waited and waited and waited for the call Friday morning. It never came. At the end of the day, Jane just couldn't part with her child. I felt a deep pain at losing this child, who I had never even had the chance to bring home, and when I think of that pain, I feel a bit of understanding for what Jane must have felt and where her heart was.

FALL/AUTOMNE 2013 â&#x20AC;˘ Creating Families

Adoption Corner and waited for the call Friday morning. It never came. Finally, we called our caseworker for some clarification, and we found out that Jane did not want us to bring Stella home yet and that we would reconvene after the weekend. At that point, we were still being reassured that there were many different ways to place a child, and no two cases were the same.

before we could at last bring Stella home. Stella stayed in a foster home while we waited. The foster family was amazing, and they could not have been any kinder. I felt very comfortable leaving Stella in their capable hands. Things were crazy. Between working, visiting Stella, collecting all the baby-care items we were borrowing from friends and family, and getting the nursery ready, we were already exhausted, and we didn't even have Stella home yet! One week after the paper work had been filed, we got the approval to take her home. It just so happened that the approval came through within a half an hour of Jane signing the relinquishment papers at the lawyer's office. At that point, they let her know that we were on our way to pick up Stella. I was at work, saying my goodbyes as I waited for John to pick me up so we could bring our daughter home. When I got back to my phone, I saw that I had received an alarming number of calls and messages from my caseworker. My heart sank. I called her back, and she advised that Jane had asked that we wait until the following day to collect Stella. She wanted a bit more time to process everything and to ensure that her 13-year-old daughter understood what was happening. I immediately had a horrible feeling, but my caseworker reassured me that I had no reason

In a matter of days, we went from feeling the highest high we had ever felt to one of the lowest lows I have ever experienced. to worry as there was no indication that Jane was changing her mind. I was in shock and felt very, very scared. I immediately called John and told him what had happened. Needless to say, he was very upset. Our adoption worker explained that, for Jane, this seemed to be a very normal reaction to an overwhelming day. She told us she would call in the morning and let us know when we could pick up Stella. We waited and waited

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Créons des familles • FALL/AUTOMNE 2013

At noon on Monday our caseworker called. As soon as I heard her speak, I could have hung up the phone because I already knew the situation just from the tone of her voice. She confirmed that Jane had changed her mind. Our worst fears had become a reality. There was no specific reason. It wasn't something we did or said or didn't do or didn't say. We believe it was a culmination of events, and at the end of the day, Jane just couldn't part with her child. I felt a deep pain at losing this child, who I had never even had the chance to bring home, and when I think of that pain, I feel a bit of understanding for what Jane must have felt and where her heart was. We never saw Stella after that, and we never heard from Jane again. Looking back, I keep reviewing the series of events, trying to find a way to sort it all out. I always told everyone that Jane seemed so sure of her decision. We were cautiously optimistic the entire time. We were careful. We never went out and bought brand new clothes or a car seat. We borrowed what we could. But none of those things mattered because, in the end, they didn't make the pain any easier to bear. One thing that I find strange with the whole scenario was that it never felt real. I never felt like I was a parent, even when I was taking care of Stella in the hospital or visiting her in foster care. I always thought to myself, “It will seem real when she is home, when she relies solely on us.” I don't know if it was because I

Adoption Corner

John and I have been on a roller-coaster ride of emotions that we cannot even begin to describe. In a matter of days, we went from feeling the highest high we had ever felt to one of the lowest lows I have ever experienced. I still have some residual feelings of pain, and as much as I know I will get through the grieving process, I also know I will never forget Stella or Jane. As hard as it is, I wouldn’t want to be on this roller-coaster with anyone else. This loss also affected other people and other aspects of my life more than I expected. Friends, family and even acquaintances cried when they found out. The woman who had been hired to replace me at work worried about job security. I had received gifts of baby clothes that I had washed and couldn't return. Our parents were no longer

Adoption is not for the faint of heart. Not so long ago, we thought we had accomplished what we had set out to do, and now, we’re starting all over again. grandparents, as this would have been the first grandchild on both sides. In some ways, I even felt guilty for putting everyone through this, even though I knew it wasn't my fault. You’re probably wondering how we dealt with this loss. Well, we decided that we needed some time alone. We packed up and flew to Cuba the following day. To save us going through some added pain, we asked our family and close friends to inform others about the change in our situation. We talked it over and decided to pick up and move on. Together, we knew that we wanted to continue with our journey.

Adoption is not for the faint of heart. Not so long ago, we thought we had accomplished what we had set out to do, and now, we’re starting all over again. It is an amazing accomplishment to be picked for private adoption, and the wait can be so incredibly long. I believe in the strategy of approaching adoption head on, and our determination to take charge of our adoption process was a strategy that worked for us, even if we haven’t yet had the chance to bring home our child. When things seem difficult, I think of the quote “Anything worth having is worth fighting for.” I believe that whole-heartedly. I also attribute our strength and determination to the amazing relationship that John and I have, and also to our ever supportive friends and family.

What I really want is to know what our story will be. I want to be able to tell a story that has a happy ending, and then, I want to help others who are looking to adopt and pass on what we have learned from this crazy experience. I’d like to try and help to make their dreams come true. As for my own dreams, as I’ve said from the very beginning and will continue to say, it’s not a matter of “if” we become parents; it’s a matter of “when.”

PHOTO: Love the Moment Photography

was subconsciously trying not to become too attached to her. I can't quite explain it. I also can't explain the instant love I felt for her, the hope I had for her, or the sense that I wanted to share a future with her. My feelings never felt forced, like I was “trying” to bond with her. I loved this tiny little person who, prior to her birth, I had no connection with, and I would have given anything to have her in my arms for the rest of my life.

Amanda Yeaman and her husband John.

FALL/AUTOMNE 2013 • Creating Families

You KNOW What They Say About Best Laid Plans ... by Andrea Querido

“The hardest part about accepting the saying ‘everything happens for a reason’ is waiting for that reason to come along.” ~ Unkown

Welcome to the club of which no woman wants to be a member

May is one of my favourite months of the year. Spring officially, well, springs, there’s a warm anticipation in the air and it’s the month I celebrate the best decision I’ve ever made – marrying a man who, as I’ve told him many times, could not have been more perfect for me if I had written out an itemized wish list myself.

When I shared our hope of having a family, I remember one friend in particular (someone who has been one of my rocks these past nine months) warning me it would be an emotional roller coaster. I smiled and shook my head in agreement (or was it naiveté?), but little did I know what that truly meant. For me, pregnancy was something to be worried about, not actually getting there (more about that in a minute). I had a plan, after all.

But this May is a little different. Not that there’s nothing to celebrate, it’s just that the one thing I was hoping to celebrate hasn’t come to fruition… yet: the birth of our first baby. They say you should write what you know and so, as this Sunday marks the start of Canadian Infertility Awareness Week, I will not exempt myself from sharing my story. Before I do, I’d like to make one thing clear: I’m not sharing to elicit pity (I’ve never wanted to be a passenger on that train, thanks very much). I’m sharing so that others who are in the same boat (and whether you think it or not, there are a lot of others) know that they are not alone; the emotions they are feeling are completely justified and worth validating.

Créons des familles • FALL/AUTOMNE 2013

For me, pregnancy was something to be worried about, not actually getting there. I had a plan, after all. Well, since August, I’ve experienced what the term “emotional roller coaster” truly means – despair, disappointment, frustration, hopelessness and helplessness. My emotional compass has run the gamut. There are times when I’m

excited about the possibilities and hopeful of what the future is sure to bring, and others when I wake up (and I hate to admit this because I know I have so much for which to be thankful) despondent at the prospect of having to face another damned day. I’ve felt sorry for myself, shaken my fists at the heavens and convinced myself that God was just a mean kid with a magnifying glass, and we were the ants. Hadn’t we been through enough? Why is every door being slammed in our face? All we want is one healthy baby, is that too much to ask?! Couple those intense emotions with inquiries from well-meaning family or friends, “But you’re in your 30s, you’ve been married for three years, time is ticking … Yes, we know!” Now I’m not insinuating people have not had our best intentions at heart when they ask the age-old question. In fact, considering we’re in our 30s, have been married for three years, and have many relatives in Europe, we haven’t been assaulted with that many questions. When people do ask, their inquiries range from genuinely interested and supportive, “Honey, any baby news yet?” and, “We’re just looking forward to it… you guys will make wonderful parents!” to fearful

At birth, my parents were told that because of my heart condition, I would never be able to have children. Flash forward 35 some odd years and while it’s a possibility, there are still precautions to be taken to ensure this high-risk adventure ends in the best result for everyone. inquisitions of, “When are you having a baby shower?” or, “You gotta get on it, you know!” Yes, I know and I have been… on a regular basis. But thanks for the reminder. Hey, as my father always says, don’t ask the question if you don’t want the answer.

It all began with research Our quest for baby makes three started almost that many years ago, when I, armed with my question-filled notebook and a mind set on getting answers, met with a cardiologist who specializes in pregnancy and heart disease at Toronto General Hospital to talk about the process. Not the process of how to make a baby (I learned that during 3rd grade recess), but what would happen once I got pregnant. You see, at birth, my parents were told that because of my heart condition, I would never be able to have children. Flash forward 35 some odd years and while it’s a possibility, there are still precautions to be taken to ensure this high-risk adventure ends in the best result for everyone. It starts from the moment I find out I’m pregnant. I’m switched to twice daily injections (taken in the stomach with the piercing sting of what 100 angry bees probably feels like) for the first trimester to ensure the blood thinners I’m on to deter blood clots that could cause a stroke don’t harm the baby. I’m then treated as a VIP at Mount Sinai Hospital and monitored closely, as high blood pressure and increasing blood volume throughout pregnancy could cause issues. Then, in the last month, I’m once again switched to injections so that, during an induced and highly controlled labour, I won’t bleed out.

Daunting? Yes. But totally doable. I know this because there have been approximately 100 women before me who have taken this journey, 99 of which have had healthy pregnancies and babies. I also know this because I’m not a quitter. Some call it stubborn, I like to think of it as optimistically determined, but I wasn’t willing to throw in the towel before I even tried out for the team.

Getting to the heart of the matter The next step in the journey was taken last March when I had to have minor surgery to fix an arrhythmia caused by my last (and 4th) open heart surgery. Basically the scar tissue that had amassed over the years had caused a stitch to disrupt the electrical currents of the heart, causing it to randomly beat at 130 beats per minute (normal resting heart rate is 60 – 100 beats per minute). If I wanted to have a baby, I’d have to be taken off the toxic drug I was on to stop the arrhythmia from recurring, and that meant minor surgery. Another high-risk procedure, another test passed with flying colours, another obstacle checked off the list. Now it was just a matter of waiting six months for the drug to be completely out of my system, to ensure it would not cross over the placenta and cause harm to the baby. So, when August finally rolled around, excitement was met with elation. We were free to start our family. By my calculations, if all went according to plan (can you sense the foreshadowing?), we would

FALL/AUTOMNE 2013 • Creating Families

I began to lose the two things I had always prided myself on, no matter what I was going through… hope and faith. be parents the following May. But I also tried to be realistic; I knew that at our age it might take a bit longer.

Ready, set… wait just a minute As the long, warm days faded into shorter, cooler nights, each new month was met with the same disappointment. I did research, took my temperature and filled out a BBT chart, did yoga, put my legs up in the air and, yes, used a pillow, everything I had read, researched or was told I should do. Initially I was able to remain positive, always thinking there was a good reason it wasn’t happening and next month would be our time. And those times when I couldn’t, my husband, the eternal optimist, kept positive, truly believing it would happen. But deep down I knew something wasn’t right, no matter how many times people would tell me to “stay positive”, “stop stressing” or “it will happen, you’ll see”, I could feel it in my bones.

With each month that passed, each cramp or premenstrual spotting I convinced myself was a sign of implantation bleeding, each twitch in my uterus I told myself could only be one thing – the beginning of our family. I began to lose the two things I had always prided myself on, no matter what I was going through… hope and faith.

I relied on those two things throughout each open-heart surgery, as well as the emergency surgery I underwent in 2006 when an ovarian cyst burst and bled into my abdomen. At the time, they didn’t know if they could save my ovary, let alone my life, but the amazing surgical team at Credit Valley Hospital (who ruled out laparoscopic surgery after it was discovered my abdomen was too distended by the 4.5 liters of blood that had amassed from the ruptured golf ball-sized cyst) managed to do just that… and assured me that I could still have a family, if I so wished, in the future.

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The results are in… Finally last December, thanks to another close friend who has been a rock these past nine months, we decided to elicit the help of a fertility clinic. Over the last six months, we’ve been poked, prodded, and probed. I’ve gotten up at the crack of dawn for blood work and vaginal ultrasounds (and you thought caffeine was the only thing that could wake you up in the morning!), developed relationships with the staff and watched as countless couples took numbers and waited for their turn as they TTC (try to conceive). Is there something wrong? Yes. But I’ll keep the details between myself, my husband, and the fertility specialist. Although I can confirm that we’ve been told we have a 5% chance of conceiving on our own (being an honour roll student throughout high school, the irony of the conundrum I now find myself in is not lost on me), and so we’ve been medicated, had two cancelled IUI attempts and now we’re faced with one last ditch effort to conceive – IVF. Will it work? I don’t know. But at least we’re taking a step in the right direction. And at the same time, we’ve agreed that we’re only willing to step up to the plate three times. Emotionally, financially and mentally, that’s all we’re willing to put ourselves through. If the statistics are right, we have a 50% chance – and with three times up at bat

Créons des familles • FALL/AUTOMNE 2013

there’s a pretty good chance it will. But I’m not putting all my faith in having hope right now. As we start the next leg of our journey, it’s now about percentages and science to me. As Carl Sagan once said: “I don’t want to believe. I want to know.”

Where do we go from here? Does it sadden me to think we might not have a little person running around who looks like me or, God bless, has the zest for life my husband does? More than you know. But in life, you have to play the cards you were dealt. Once the dealer decides to show us what we’re holding, the only thing we can do is place our bets and hope for the best. In the end, whatever the outcome, whether we’re able to conceive a biological child or receive the closure we need to move on to adoption, one thing is for certain – we’re giving it all we’ve got. I take some comfort in that fact – we’re still trying, we’re not giving up and, throughout this insane experience, we’ve become closer than ever; our relationship is the strongest it’s ever been. And to me, that’s the foundation of a healthy, happy family. As well, during our journey, I have met some incredibly strong and inspiring women who have willingly and honestly shared their stories, offered their ears and lent their shoulders. There have also been those amazing women who have no idea what I’m going through – whether they don’t want kids or haven’t started trying yet – but have been there to listen and support with the utmost care and concern… no matter how many times I talk about the same frustrations I have no control over. In both cases, these fantastic women I have the honour of knowing have always imparted the same message to me – don’t lose hope. To each of you, thank you is not – and will never be – enough. You have inspired me, supported me and saved me from the

constant barrage of negative thoughts that have, no matter how hard I’ve tried to push them aside, plagued me over these last nine months. You have assured me, time and again, that I am not alone.

heartache and every tear has brought us to where we were always meant to be – a family.

Biology alone does not a family make I’d like to think that when we’re finally able to meet the new addition to our family, it’s that same strength and sense of hope we’re able to pass along to him or her, whether it’s through biology or by example. Maybe we haven’t been able to conceive because it would threaten my life in some way, there might be something “wrong” with the baby or there is a child (or children) out there who needs us more than we know, one for which we can provide a life he or she could never have dreamed of. Whatever the reason, I am a firm believer that just because a baby doesn’t grow in your tummy doesn’t mean it can’t grow in your heart. What I know for sure is that when we share the story of how he or she came to be, it will be with the clarity that every frustration, every

In the end, whatever the outcome, whether we’re able to conceive a biological child or receive the closure we need to move on to adoption, one thing is for certain – we’re giving it all we’ve got.

FALL/AUTOMNE 2013 • Creating Families

EGYPT: Infertile in

Science, Myth and Religion

by Hassan Sallam, MD, PhD, FRCOG

Not all couples in the world succeed in starting a family when they so wish, and couples in Egypt are no exception. Since time immemorial, many Egyptian couples have suffered from infertility and have gone to great lengths to have a baby. Infertility touches all aspects of life of affected couples. However in Egypt, infertility is a particularly important problem since it is associated with specific social, economical and cultural aspects stemming from the long and varied history of the country, the ethnic backgrounds of its population and the importance of religion in the life of nearly all Egyptians.

Prevalence of infertility in Egypt According to a study conducted by the Egyptian Fertility Care Society and sponsored by the World Health Organization (WHO), infertility in Egypt affects 12 percent of Egyptian couples. Of these women, 4.3 percent suffer from primary infertility (have never been pregnant) and 7.7 percent suffer from secondary infertility (have been pregnant before, even if the pregnancy ended in a miscarriage or an ectopic pregnancy). The number of women aged 15 to 49 years

CrĂŠons des familles â&#x20AC;˘ FALL/AUTOMNE 2013

exceeds 25 million, which means that at least 3 million women are infertile in Egypt.

Causes of infertility

The causes of infertility in Egypt parallel other Middle Eastern countries and some Mediterranean countries. According to a study by Professor Gamal Serour, past president of the International Federation of Obstetrics and Gynaecology (FIGO) and his colleagues, 64 percent of infertility causes lie with the female partner, while 20.5 percent are due to problems with the male partner. The remaining 12.2 percent ensue from factors in both partners and 3.3 percent remain unexplained. In the female partner, infertility results from tubal problems in 42% of instances, disorders of ovulation in 25.3%, pelvic endometriosis in 5.6%, a malfunctioning cervix in 4.2%, while in 23.4% of cases it is due to a combination of these factors. It is interesting to note that, contrary to sub-Saharan African countries, pelvic infections including HIV and AIDS are not important causes of infertility in Egypt (nor in other North African countries). According to WHO, Egypt is a low prevalence country for AIDS and less than 1 percent of the population is HIV positive.

Socio-cultural aspects of infertility in Egypt Infertile couples in Egypt are under many socio-cultural pressures peculiar to Egyptian, Middle Eastern and African societies. This means that this medical

In Egypt, there are no gamete (sperm or egg) donations. This practice is forbidden both by the Muslim Mufti and by the Coptic Church on the basis that it may lead to possible incest (unknown to the future couple) and that it may disturb the family lineage. problem may acquire a much larger dimension than in Western communities. For example, most Egyptian newly-wed couples stay connected to their extended families and in many instances live with them in the extended family house. All eyes are therefore upon the newly-wed couple to see whether pregnancy has happened after the first month of marriage. The in-laws are usually the first to ask questions and interfere. In many instances, the mother-in-law takes the bride to the doctor after one month of marriage assuming that there must be a problem. In fact, in my practice, I see many couples who have

been married for two or three months commenting that they have come to see me just to please their in-laws. Religion has always had an overwhelming effect on the life of Egyptians since the beginning of history. In his great book “The dawn of conscience” (1932), the famous American Egyptologist James Henry Breasted argues that it was the ancient Egyptians who invented religion. Indeed, by establishing the concept of “Maat” (or conscience), ancient Egyptians were probably the first humans to believe in the afterworld, where one is compensated for good deeds and punished for sins. Subsequently, all Abrahamic religions had roots in Egypt and many important religious figures visited Egypt and left a strong influence: Abraham visited Egypt, Joseph lived there and Moses was born in Egypt. Jesus Christ visited Egypt with the holy family and although Mohamed did not visit Egypt, he was married to Mariam, an Egyptian woman who remained Christian and begot him his first son Ibrahim (who died in infancy). Egyptians have therefore always been very religious and this applies to Muslims, Christians and Jewish Egyptians (before most of them left). Today, Muslims in Egypt are very much swayed by religious rulings (fatwas) of the Muslim religious leaders. Similarly, Egyptian

FALL/AUTOMNE 2013 • Creating Families

the economic pressure of raising many children, this situation persists.

Christians, who make up about 13 percent of the Egyptian population, meticulously adhere to the rulings of their Egyptian Pope, who is head of the Egyptian Coptic Church, one of the oldest Christian churches, established by Saint Mark the apostle. This may explain why, in Egypt, there are no gamete (sperm or egg) donations. This practice is forbidden both by the Muslim Mufti and by the Coptic Church on the basis that it may lead to possible incest (unknown to the future couple) and that it may disturb the family lineage. It is interesting to note that Shiite Muslims, as opposed to Sunni Muslims to which most Egyptians belong, allow gamete donation, which is practiced in all Shiite countries including Iran, on the ground that it does not involve sexual intercourse with the donor (and is therefore considered a treatment like blood or organ donation). Muslims (both Sunnis and Shiites) are also not allowed to adopt children, although they can foster them, but the child cannot automatically inherit from his foster parents. Non-traditional families are, of course, out of the question and nobody may discuss, for example, the possibility of single

CrĂŠons des familles â&#x20AC;˘ FALL/AUTOMNE 2013

women or gay couples having children. Muslim men are allowed to marry up to four women at the same time. Although this practice has largely diminished in recent years, it puts the infertile woman at constant risk of her husband seeking a second wife. In addition, in Sunni Islam, boys inherit twice as much as their sisters and men who do not sire boys, upon death, lose half their inheritance to their brothers and sisters while the remaining half goes to his daughters and wife. This arrangement burdens women with the constant pressure of producing a male offspring. Of course, this is another hidden factor in the male-preference culture dominating Egyptian society (as well as many other Eastern societies). Furthermore, Muslim men are allowed to divorce their wives whenever they wish, which leaves infertile women in a particularly vulnerable position. Egyptians like to have large families, particularly in poor communities where children work at a young age and represent an important source of income for the family. Although the average number of children per couple is diminishing under

The socio-cultural pressures do not only fall on the shoulders of women; infertile men suffer as well. In a society that equates virility to manhood, the man is always under pressure of producing children. Under Islamic law, a woman is allowed to divorce her husband if he is impotent or if he cannot produce children. From experience, whenever I see a couple which has been previously investigated, I immediately understand whether the problem lies with the husband or the wife. When the problem lies with the husband, he is usually extra-polite and courteous, while the wife sits comfortably and speaks confidently. Men are therefore very quick to seek assisted reproduction if their semen analysis is in question or downright bad, and they are prepared to do whatever is needed to sire a child (and pay for it). On the other hand, they may not be so quick in seeking treatment for their wives if the problem

Muslim men are allowed to marry up to four women at the same time. Although this practice has largely diminished in recent years, it puts the infertile woman at constant risk of her husband seeking a second wife.

clearly lies with her. On occasion, you may hear a husband asking in all seriousness whether it would be cheaper for him to pay for an IVF cycle for his wife with blocked tubes or take a second wife. On other occasions, a wife with blocked tubes comes along and decisively states that she will be paying for her own treatment as her husband will not share in the cost because “it is her fault”.

Consequences of infertility in Egypt As in many places worldwide, infertile couples are vulnerable and subject to many negative consequences. In Egypt, there are some added risks and these mainly befall women, as they are particularly vulnerable to divorce, polygamy and domestic violence. They may resort to any measure including spiritual, illogical and nonmedical practices. In addition, infertile couples can be ruined economically. As mentioned, infertile couples in Egypt are under the constant threat of divorce. Divorce in Islam is simple. The husband anounces to his wife that he is divorcing her and sends her the papers later. In Egypt, following the reintroduction of a dormant Islamic law 13 years ago, the wife may also divorce her husband, but only in court after giving back his dowry – no further questions asked. There usually follows a reconciliation attempt by a counseling body, but if the wife insists, the divorce is legalized. Egypt’s divorce rate stands at approximately 12 percent and infertility is one of its major causes. Nevertheless, the divorce rate is not high compared to that of most Western communities. In 2007, when the latest statistics were published, there were 614,848 marriages and 77,878 cases of divorce. Seven out of every ten divorces take place within the first five years of

marriage and one out of every three during the first year. There are 2.5 million divorced women in Egypt today. Polygamy is another threat constantly menacing infertile couples. In many instances, the mother of the husband is the instigating person, even if the cause of infertility lies with her son, sometimes hoping for the impossible. Luckily, the practice is diminishing, and in 2001 less than 3 percent of Egyptian men had multiple wives. In 2008, according to the Central Agency for Public Mobilization and Statistics (CAPMAS), 44,582 men entered into a second marriage, but only 17,617 of them had another existing wife. The others were either divorced or widowed. Violence against infertile women is another threat. This violence is not necessarily physical; it may be verbal, emotional and even economical, which can sometimes be worse than physical violence. The perpetrator is usually the husband, but it can also be the mother-in-law, the sisters-in-law and even the brothers-in-law, particularly if the couple lives in an extended family house. The woman is made to feel worthless, useless and with no right to live. If the husband acquires a second wife, the first (infertile) wife may be too poor to apply for a divorce and live on her own. By accepting her fate, she may become a mere servant to the new wife who has proven her fertility and to the whole family. She is expected to cook for the family, do the cleaning, the washing and just be there to help.

Muslims (both

Sunnis and Shiites) are also not

allowed to adopt

children, although they can foster

them, but the child cannot

automatically

inherit from his foster parents.

With all these pressures, infertile women in Egypt and similar societies may fall victims to many psychological illnesses. I have personally witnessed many infertile women succumbing to depression and even mania. It is no wonder therefore that many of them turn to traditional healers and crooks.

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Religion is deeply rooted in the

Egyptian mind, and

infertile women sometimes resort to many religious or quasi-religious

practices which they believe will free them from their constant agony.

Every now and then an infertile woman, whose husband is azoospermic, suddenly becomes pregnant after visiting one of these healers who are thought to insert a piece of wool impregnated with someone’s semen, usually the traditional healer’s himself, who is usually disguised as a man of God with many “miracles” to his name. People jokingly and sarcastically refer to them as “Mr. Wool” or “Sheikh Wool”. As stated earlier, religion is deeply rooted in the Egyptian mind, and infertile women sometimes resort to many religious or quasi-religious practices which they believe will free them from their constant agony. They may visit the temple of Sety I at Abydos in Upper Egypt, where the statue of Senusert III (with its missing upper half) is located and used as a fertility charm. They walk around it clockwise seven times, and then sit on its lap. They visit Cleopatra’s pond at the Karnak temple in Luxor and walk around the sacred pillar seven times hoping to become pregnant. Muslim women visit the tombs of Sayyeda Zeinab in her mosque in Cairo and

Créons des familles • FALL/AUTOMNE 2013

Christian women visit the Monastery of Saint Menas (Mar-Mina, the martyr and wonder-worker) near Alexandria. You may also find many Muslim women visiting Christian shrines and vice-versa for the same purpose. Other practices include sitting under the willow tree or visiting Beit-El-Seheimy in Cairo and crossing over the remnants of the whale bones it houses, and which are thought to have some magical powers. Eventually, some women, even highly educated women, revert to the Zaar ceremony. In this ecstatic revolvingdance ceremony, the male and female participants dance to very loud music meant to rid them of the spirit which seemingly has taken possession of the infertile woman. At the end of the ceremony, the exhausted woman falls to the floor, presumably having been purified from the evil spirit. This practice, thought to have originated in Ethiopia, persists in many countries of East Africa and the Middle East, including Egypt. Some Egyptian women with secondary infertility may think that their condition stems from some ridiculous happenings. In her series of books, Marcia Inhorn, American professor of anthropology at Yale University who has widely studied infertility practices in Egypt and the Middle East, describes many of these traditions. Women may blame their condition on having been visited by a man who has just shaved his beard, has just circumcised a boy or girl, has just attended a funeral or has just been carrying raw meat. Rituals for undoing this “kabsa” or “meshahra”, as it is locally known, include

wearing seven rings around the wrist or a diamond ring borrowed from the aunt of the woman affected.

Infertility services in Egypt For all these reasons, in Egypt, as in many developing countries, infertility acquires a disproportionate importance compared to other illnesses. This situation coupled with the fact that most medical services in Egypt are self-funded, has led many Egyptian medical professionals to speedily acquire the necessary medical skills for infertility treatment, including assisted reproduction (IVF ad ICSI). It is a fact that assisted reproduction is more advanced in Egypt than many other branches of medicine or surgery. In 2011, Egypt had 82 registered IVF centres performing 28,000 IVF/ICSI cycles every year in addition to hundreds of

thousands of ovulation induction and insemination cycles. This represents about 330 IVF cycles per million inhabitants, compared to 461 in North America, 658 in Western Europe, 160 in Asia and 57 in Latin America. The country with the highest number of IVF cycles performed annually is Israel (3,670 per million), followed by Australia and New Zealand (1,477 per million). The latter numbers most probably result from the fact that infertility treatment is (almost) totally subsidized in these countries. It is worthwhile noting that ESHRE has calculated that the optimum demand for IVF cycles is 1,500 per million inhabitants per year. This means that Egypt, like many other developing countries, only fulfils about one fifth of the population demand. The reasons are numerous and the obstacles are many. They include lack of services, lack of know-how, shortage of funds, difficult access to services even if available, acceptance of fate (curse from God), the negative experience of neighbors whose treatment may have been unsuccessful and, last but not least, belief in traditional (non-medical) healers.

Reproductive Rights and Egypt Treatment of infertility in Egypt is totally self-funded. Government, private or insurance re-imbursement schemes do not exist. There are no charity organizations working in the field but, occasionally, a private charity may partly or totally subsidize the treatment. The obstacles to funding infertility treatment in Egypt are the same as in other developing countries and one always hears the same arguments: infertility is not a disease, infertility is not a serious disease, infertility treatment is expensive, it is not effective and finally that it may be wrong to treat infertility in an overpopulated country. The latter argument is of course ridiculous as it is not

the couple with the odd IVF baby causing overpopulation, but rather the couple begetting ten children when they cannot afford to feed them or send them to school. In addition, this is a total violation of human rights and one of its fundamental principles: reproductive rights. The term “reproductive rights” was first suggested in the 1968 Teheran Proclamation (International Conference on Human Rights). The term was again confirmed at the 1994 Cairo International Conference on Population and Development (ICPD) through the work of Professor Mahmoud Fathalla, who later became President of the International Federation of Gynecology and Obstetrics and also at the 1995 Beijing Fourth World Conference on Women. These, of course, are international conventions legally binding for all the countries which have signed and ratified them. It is important to note that WHO defines reproductive rights as follows: “Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion and violence”.

Religion and IVF in Egypt It may come as a surprise to learn that religious institutions in Egypt, both Muslim and Christian, are very tolerant and that assisted reproduction is permitted by authorities of both religions. However, the sperm has to come from the husband, and the oocyte from the wife, during an existing marriage (which has not been annulled or terminated by divorce or death of one of the partners). Gamete donation

Doctors in Egypt

have long strived

to simplify assisted reproduction (IVF and ICSI) while

reducing its costs. At Alexandria

University and at the Alexandria

Fertility Centre,

we have since 1984 been using simple stimulation

protocols, thereby cutting cost and time, by

eliminating the need for

expensive

subcutaneous and genetically-

engineered drugs.

FALL/AUTOMNE 2013 • Creating Families

and surrogacy are not allowed, but sperm, ovum and gamete freezing are permitted. Preimplantation diagnosis is allowed for the prevention of genetics diseases and is also permitted for “family balancing” by the Muslim Mufti, but not by the Coptic Church. Therefore, for Sunni Muslims, “family balancing” is allowed when a couple has at least three children from one gender (usually girls) and would like to have a baby from the other gender (usually a boy). Reproductive cloning is forbidden by religious authorities of both faiths. Although there are no laws governing the particular treatment of assisted reproduction, IVF clinics in Egypt must be licensed by the Ministry of Health and are monitored by the Doctors’ Syndicate. Counseling and signed informed consent forms are of course mandatory both from husband and wife, as well as a marriage contract (or alternative proof). Clinics or physicians who break the rules are under serious threat of being banned from medical practice.

Simplifying IVF, a must for Egypt

For all these reasons, doctors in Egypt have long strived to simplify assisted reproduction (IVF and ICSI) while reducing its costs. At Alexandria University and at the Alexandria Fertility Centre, we have since 1984 been using simple stimulation protocols, thereby cutting cost

and time, by eliminating the need for expensive subcutaneous and geneticallyengineered drugs. Our team uses simple monitoring techniques with ultrasound only, without resorting to expensive hormonal assays. Oocyte retrieval is performed using a simple syringe and needle, eliminating the need of a pump and expensive sophisticated plastic tubing. Embryo culturing takes place in a simple laboratory, with all the necessary equipment nevertheless. Finally, embryo transfer is carried out under ultrasound guidance using the same simple ultrasound machine which costs only a fraction of the price of more sophisticated equipment. Consequently, patients have been able to undergo IVF treatment and pay one fifth of what the procedure would cost in Europe (and about one eighth of costs in North America), without compromising results.

We are also part of the Arusha Project which comprises infertility specialists trying to introduce this technology to Africa at a minimal price. In July of 2013, during the 29th annual meeting of ESHRE in London, Arusha’s group leader, Professor Willem Ombelet from Ghenk, Belgium and Head of the “Walking Egg” Foundation, and Professor Jonathan van Blerkom from Boulder, Colorado, announced the birth of eight babies following the use of a new, simplified technique which cuts costs to under 200 Euros per IVF cycle, by eliminating the need for the expensive CO2 incubator. Obviously, Egypt will be one of the first countries to benefit from this breakthrough. It is also hoped that our Egyptian experience, together with these new developments will spread and benefit poor infertile women all over the world.

About the Author Hassan Nooman Sallam, MD, PhD (London), FRCOG, is former head of the department of obstetrics and gynaecology in Alexandria University, in Egypt, and clinical director of the Alexandria Fertility and Assisted Reproduction Centre. He was a founding member of the IVF unit at King’s College Hospital (London, UK) in 1981 and St-Luke’s Roosevelt Hospital Center of Columbia University in New York City in 1984. He is former vice-dean and director of research at the Alexandria University Faculty of Medicine. Besides the fellowship of the Royal College of Obstetricians and Gynaecologists (FRCOG), he holds a doctorate degree in Obstetrics and Gynaecology from Alexandria University and a PhD in reproductive biochemistry from the University of London. He has published over 100 papers in national and international refereed journals in three languages as well as three books. He is the coauthor of Infertility and Assisted Reproduction, the reference textbook published in 2008 by Cambridge University Press. Dr. Sallam serves or has served on the editorial boards of many journals including Human Reproduction (2000-2004), Reproductive Biomedicine Online (2002-2008), the Middle East Fertility Society Journal and Facts, Views and Visions in OB/GYN since their inception. He is a founding board member of the Middle East Fertility Society, the founding chairman of the Mediterranean Society for Reproductive Medicine and a board member of the International Society of IVF. His current research interests include biochemical approaches for embryo selection, optimizing embryo transfer, prediction of OHSS, endometriosis-associated infertility and repeated implantation failure. He is also active in the fields of infertility for developing countries and combating violence against women.

FALL/AUTOMNE 2013 • Creating Families

Patient’s Perspective

by Charmaine Graham

When I decided I was ready to have a child, there wasn’t just a spark of excitement; there was an explosion of utter joy that my life was actually moving forward, exactly as planned. I felt so prepared, so enthusiastic about starting the next adventure of my life: motherhood. For me, there was no mistaking the fact that this child my husband and I were going to bring into the world would be nothing less than loved, wanted and planned.

Fifteen months later, after waiting month after month for my dreams to come true, I finally received my infertility diagnosis, an event that seriously pulled the rug out from under my feet and knocked me down so hard I didn’t think I would ever get up. What had come so naturally to most women on the planet ... literally BILLIONS of times … was going to be impossible for me. I felt like a loser, like I had failed my husband as a wife. I

What had come so naturally I’m sure I’m not the only one who, when deciding it was time to bring a child into the world, also dreamed a million other dreams. For instance, I dreamed about how I would tell my husband we were pregnant. Would I write it on my tummy and show him as a surprise? Maybe I’d slip a “congratulations, you’re having a baby” card into his briefcase. I started dreaming about what our child would look like. I dreamed of what kind of parent I would be. I fantasized about how we would tell our parents they were about to become grandparents for the first time. I imagined my growing tummy, adamant that I was going to wear a bikini for as long as I wanted and celebrate every moment.

Créons des familles • FALL/AUTOMNE 2013

to most women on the planet ... literally BILLIONS of times … was going to be impossible for me. felt gutted inside that my body didn’t “work” like everyone else’s did. I felt ripped off that I would never have all those magical “we are pregnant” moments that’d I’d dreamed about. But the biggest fear of all, the thing that turned my heart cold, was the thought that I would NEVER have a child. Unbearable. I felt confused and overwhelmed

ILLUSTRATIONS: ANA KUSMIC

Finding Resolution

and panicked and scared. I felt completely LOST! I remember thinking that it seemed so absolutely unreal to me that I, the woman who had worked so hard to be where I wanted to be in life, was – almost overnight – standing on a life map that I didn’t even recognize. Infertility represented some seriously uncharted territory, and there was a lot to learn. How was I going to find my way? How would I learn everything I needed to learn in order to advocate for myself medically? What clinic should I use? Were some better than others? And while there were a million questions rolling around in my head at the time, the biggest problem was not only that I was sailing in uncharted territory, but that I felt my entire life had been put on hold until I could get back to that space where I had been on the day I knew it was time to have a child. For a while, I simply concluded that I didn’t have to deal with all the pain of being infertile. I felt a lot of raw emotions, absolutely, but I squished down as many of them as I could. At times, I actually tried to hide from the whole issue because if I felt that if I just

Patient’s Perspective To be able talk to people who knew the bitter disappointment of getting a period after so much money

not working for me, it was, in fact, killing me. And my husband wasn’t doing so well either! Eventually, I sought help in the form of personal therapy.

stopped thinking about it, I would get pregnant, and THEN I wouldn’t be in pain anymore, and my life would be recognizable again. I had some idea in my head that if I just got pregnant, even if it was through in vitro fertilization (IVF), then I could just pick up where I left off. My end-road was my baby. It was a desperate feeling, and if you’re reading this article, I suspect quite a few of you already know what I’m talking about.

Personal therapy was good; it helped, but even more helpful was the fact that I found a support group of other people who were suffering the same pain and loss as I was. To be able talk to people who knew the bitter disappointment of getting a period after so much money and hard work was so important to me. Also, it helped to have somewhere to dump my pain because, to be brutally frank, when it came to offering support, try as they might, my husband and friends didn’t always know how to help me. Try as they might, they couldn’t really understand the devastation and pain I was enduring every single day of my life.

After my third failed transfer (1 fresh, 2 frozen IVF transfers), I came to realize that not only was my strategy of ignoring my fears

During one of the support meetings, the wonderful woman who ran the group reassured us that although the pain we were

and hard work was so important to me.

feeling was intense, and the journey isolating and even horrific at times, we would find our way through it. She promised us that, somewhere down the road, each one of us would find our own form of resolution. I eventually came to realize that while it was beneficial for me to be around other people who understood exactly what I was going through, my situation was unique to me, and I would need to find my own way to wrap my head around it. For me, resolution wasn’t just about holding my baby in my arms; it was also about finding something inside of me, and I knew I had to find that “something” on my own. Resolution. It’s a very tricky thing. In my case, I was determined not to stop infertility treatments because, to me, stopping meant that I had failed, yet again. How could I make the choice to simply quit trying to have a child and move on with my life? It would mean my husband would be childless too, and I couldn’t live with that concept either. But still, I knew that if I was going to survive,

FALL/AUTOMNE 2013 • Creating Families

Patient’s Perspective

if my husband and I were going to survive, I would have to really consider what resolution meant to me and to us, and I would have to decide what kind of resolution I could live with. Gradually, resolution started to be about

Créons des familles • FALL/AUTOMNE 2013

finding myself again. I became honest and real about the pain I was feeling, and I started allowing myself to feel it openly. I realized that a lot of the anger I felt about my struggle and infertility was being turned inwards, and depression was starting to take over. I recognized that acknowledging my anger would serve me better than any depression would. As I began to honour my anger, I did so with the understanding that I couldn’t hold on to all my pain forever; I would have to find an end point somewhere along the line and accept what the truth of my life was going to be. I learned to accept that my life might not, in the end, turn out exactly as I had planned. So I kept going, but I never stopped searching for my own personal form of “resolution.” I achieved a pregnancy once, about halfway through this process. It was a pregnancy that I could not believe was real. I swear I peed on multiple pregnancy test sticks every day, all the while hiding my neurotic behaviour from my husband and my friends. Finally, I let

I came to realize that while it was beneficial for me to be around other people who understood exactly what I was going through, my situation was unique to me, and I would need to find my own way to wrap my head around it. myself acknowledge that it was real, and my husband and I told his parents we were finally pregnant. Two hours later, I started bleeding. I sobbed in my husband’s arms in a way that I had never done before and have yet to do since. I think this was the turning point for me. I had struggled deeply for a very long time, weighing all the options and pros and cons of pursuing or stopping infertility treatments.

Patient’s Perspective Stopping was OK. In fact, stopping was an incredibly powerful choice made by a strong woman who felt ready to live her life again. And then, one day, I just stopped. Why? I have NO idea. How? NO clue. All I know is that one day we were sitting in the infertility specialist’s office, talking about our next IVF procedure, this time with a gestational surrogate, and I just said, “I think I am done.” I had no idea I was going to say that. I had no warning. I hadn’t talked to my husband about it first. We were just sitting there discussing the next course of action, and I just blurted out: “I think I am done.” After the shock of my announcement wore off, and my husband and I had discussed it further, I felt an incredible sense of relief sweeping over me. It wasn’t that I was happy about quitting our infertility treatments; I still wanted a child. It was the act of realizing that stopping did not make me a failure. Stopping was OK. In fact, stopping was an incredibly powerful choice made by a strong woman who felt ready to live her life again. Initially, having a biological child was all I could consider as an option, but I eventually came to realize that the process I was putting myself through to achieve that goal was also killing me emotionally. Furthermore, my

body had had enough. I simply had this sudden realization that perhaps I deserved a bit more out of life than spending all my energy on chasing after an outcome that just wasn’t coming to us. Perhaps, I thought to myself, I deserved to put the emphasis on “me” again. I talked to my husband and asked whether he would consider adoption. Well, after enduring the roller-coaster ride of 11 IVF transfers, he said he was definitely OK with adoption, and so, pursue adoption we did! Within a few months to the day I found my resolution and decided to quit IVF, my phone rang, telling me that our son had been born two hours earlier. Our son. A beautiful 7-pound, 1ounce baby boy. I met him two days later. The minute I walked into that hospital and saw this tiny baby waiting for me in the maternity ward, I was stunned. Was this it? Was my difficult journey really over? Would I

love him like I would a biological child? I will be honest: for the first few minutes, as I looked at him, I pondered a million questions. And then ... I picked him up. I sat in a rocking chair in that hospital room, and I cradled his tiny body to mine, kissed his little, fuzzy head and whispered, “I love you. And you will always be enough.” And he always has been. The process of finding resolution is different for everyone, and by necessity, it’s one that’s always full of a great deal of soul-searching. How far do you have to go before you can see the writing on the wall? Is there a “right time” to stop, and does stopping mean that you’re giving up? When do you stop creeping along one path and start moving forward on another? There’s no right answer to any of those questions. The only thing I do know for sure is that as you go through your trials and tribulations on your journey towards parenthood, there will come a day when you will know. It might be hard to recognize at first. Perhaps it will be based on financial constraints. Perhaps it might be the determination of one partner to reclaim something resembling a real life again, even without children. Or it might be a moment of brilliant revelation. Whatever yours turns out to be, please know this: resolution isn’t just external; it lies within as well, so be open to it, trust it, and know that it is coming. Resolution is coming. You just have to hang in there until it does.

FALL/AUTOMNE 2013 • Creating Families

The Benefit of a Mind/Body Approach When Struggling with Infertility by Amira Posner

Créons des familles • FALL/AUTOMNE 2013

The relationship between stress and infertility is a hot topic in the news today. However, living with infertility no longer needs to mean living with stress and its detrimental effects. Mind-body techniques help women struggling with infertility combat stress and emerge with skills that will support them through any life struggle. The emotional challenges that come along with trying to conceive a child without success are severe and taxing. When we are confronted with an experience of uncertainty, such as infertility, fear and anxiety can create an emotional surge that sets the body into a physical spin. When that level of stress and anxiety is maintained for extended periods of time, it creates a stress response within one’s body, which can exacerbate the pain and struggle a woman may feel. It is this mind/body relationship that has become a focus of research today. The same connections that cause the high level of stress can be used to reduce the stress. This focus shines on the idea that integrating a mind/body approach when dealing with infertility can optimize chances of achieving a pregnancy. The benefits of participating in a mind/body group during infertility have been researched in the last decade. In a study by Helen Adrienne, author of On Fertile Ground, Healing Infertility, it has been demonstrated that mind/body support groups can create an environment that fosters acceptance and optimism towards the infertility journey. Helen also found that many of the women who attended a mind/body group reported a relief in physical tension due to the increased knowledge of how to reduce stress. Stress reduction techniques such as practicing mindful awareness, meditation, and self-care exercises can support women in creating a mind/body balance. Calming the way our bodies respond to stress and purposefully choosing where we focus our attention can impact the stress effects arising from infertility.

The same connections that cause the high level of stress can be used to reduce the stress. This focus shines on the idea that integrating a mind/body approach when dealing with infertility can optimize chances of achieving a pregnancy. In another study published in the Journal of Fertility and Sterility by Alice Domar, Director of the Domar Center for Mind/Body Health, it was revealed that the women who were involved in a mind/body program for stress reduction, while undergoing IVF treatment, had a significantly higher pregnancy rate than those who did not participate. These research initiatives have brought more awareness to the fact that the body’s natural stress response may impact the conception rate. In order to optimize the chances of treatment success, it is important to understand the powerful role our minds and bodies can play when we learn to work with them in new ways.

Fight and Flight: The Body’s Natural Stress Response System Our bodies are hardwired to perform certain activities. And our brains are hardwired to conceptualize things in certain ways. The fight and flight response is one such example. The fight and flight response is the body’s primitive automatic response that prepares us to “flight” from any perceived threat. The

limbic system, which is the part of our brain that determines a fight and flight response, cannot differentiate between real danger and excessive stress. Unfortunately, many women struggling with infertility have an activated stress response system which can play out on an emotional and physical level, potentially impacting conception. When our fight and flight system is aroused, we tend to perceive the things in and around our environment as a threat. Fears, negative thinking and our belief systems can become distorted. On a physical level, nerve cell firing releases chemicals such as adrenaline, noradrenaline and cortisol into our system. These chemicals can alter the homeostasis – the ability to maintain equilibrium – of our physical bodies. Our body actively looks for the enemy; we gear up to flee the enemy. The only problem is there in no enemy in infertility. It is the painful experience of not being successful at conceiving a baby and all the associated anxiety that can set off the fight and flight response. Taking charge of oneself through mind/body interventions can restore a deeper connection with self and the experience of infertility. It also mitigates the worry that the stress may be contributing to the infertility.

Mind/Body Techniques: “The present moment is all that we have. It’s the best way to live, but most of us, infertility patients especially, spend their time ruminating about the past or the future. From the vantage point of the present moment, the physiology of stress can be eased if not reversed.” - (Helen Adrienne, 2006). Infertility is such that it requires a lot of energy and resiliency. The reality is that infertility could go on for many years. Mind/Body techniques can be seen as a letting go strategy that can neutralize stress and make it easier to deal with the negative results and hardships, while at the same time helping us to keep on

FALL/AUTOMNE 2013 • Creating Families

The last thing any woman dealing with infertility wants to ILLUSTRATION: Nathalie Lagden

hear is, “Relax and it will happen;” however, there may be some truth to it. going forward with trying to conceive. The key to any mind/body technique is to train the mind to focus on the present with full concentration and focused attention. If we can bring our attention into the present and purposely take it away from focusing on the pain we are experiencing, we can strengthen

Créons des familles • FALL/AUTOMNE 2013

the mental muscle of positive coping. Mindful Awareness, The Relaxation Response (Benson & Stuart 1992), and cognitive restructuring, which will be explained in more detail, are just a few of many Mind/Body techniques available. These techniques can be

practiced alone in a quiet space or in a supportive group setting.

Mindful Awareness: “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” - Victor Frankl Mindful awareness simply means paying attention to the present moment experience with openness, inquisitiveness and tolerance. It is an invitation to allow yourself to slow down enough so you can pay full attention to what is going on in and around you, while at the same time it is an offer of tolerance to all that is. It allows us to see past the covering of our automatic thoughts and feelings. It sounds easier said than done, and this approach to life can be applied anytime, anywhere. When we use this tool, we soon realize how often and how much our minds

are filled with worry, fear and judgment. The more we can pay attention to our fearful mental patterns, the more control we gain in our effort to quiet and shift them. There are many ways to bring mindful awareness into one's life. Mindfulness meditation, yoga, breathing, eating and walking mindfully are just a few examples. You can do almost anything in your life with a mindful awareness; it just takes a little effort. With practice, this tool helps balance narrow-minded thinking related to infertility, allowing more space for compassion and acceptance. With any action or task that you are undertaking, become aware of the nuances within the sights, sounds and sensations that you are experiencing. Focus your attention on this experience, and re-focus every time your mind returns to other things. Training your mind in this way helps one flex the mental muscles necessary to regain control of one’s thoughts and life experiences.

The Relaxation Response The Relaxation Response (Benson and Stuart 1992) was developed by a mind/body medicine pioneer, Dr. Herbert Benson. This method consists in using your breath and attention to help your body reach a state of complete relaxation. By resorting to this technique as often as possible, you are encouraging your body to return to a state of relaxation from the heightened state of constant arousal brought upon by the stresses of infertility. In this state of relaxation, your system releases chemicals that allow your physical body and inner organs to slow down while increasing blood flow to the brain. Focusing on the breath, visual imagery, prayer, energy healing and hypnosis are a few ways you can elicit the relaxation response. Following is the Relaxation Response technique taken directly from Dr. Herbert Benson’s Book, The Relaxation Response. His

The key to any mind/body technique is to train the mind to focus on the present with full concentration and focused attention. website is loaded with beneficial information about the research he has done demonstrating the benefits of the Relaxation Response.

Steps to Elicit the Relaxation Response • Sit quietly in a comfortable position • Close your eyes • Deeply relax all your muscles, beginning at your feet and progressing up your face. Keep them relaxed. • Breathe through your nose. Become aware of your breathing. As you breathe out, say the word “one” silently to yourself. For example, breathe in and then out, and say “one” in and out, and repeat “one.” Breathe easily and naturally. • Continue for 10 to 20 minutes. You may open your eyes to check the time, but do not use an alarm. When you finish, sit quietly for several minutes, at first with your eyes closed and later with your eyes opened. Wait a few minutes before getting up. • Do not worry about whether you are successful in achieving a deep level of relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace.

Cognitive Restructuring: To combat the thoughts that continuously

FALL/AUTOMNE 2013 • Creating Families

Stress reduction techniques such as practicing mindful awareness, meditation, and self-care exercises can support women in creating a mind/body balance. arise regarding infertility, one may find cognitive restructuring a beneficial tool. Cognitive Restructuring helps us gain understanding around the negative thoughts we have in order to challenge and eventually replace them. Our mood and demeanor are driven by the stories that we tell ourselves. These stories are most often based on our own interpretation of the environment around us. When struggling with infertility, the interpretation of our environment can often be skewed depending on how long we have been trying to conceive. As treatment fails, hopes for a family diminish and our attitude and energies can change. Often, we take our beliefs about ourselves and our experience for granted and just assume that they are true. Cognitive restructuring helps us evaluate and test these interpretations, allowing room for more positive perspectives. Through the process of cognitive restructuring, we can reframe our thinking. The last thing any woman dealing with infertility wants to hear is, “Relax and it will happen;” however, there may be some truth to it. Integrating these different Mind/Body techniques helps us ease through the experience of infertility. The holistic model of treating the mind and body as a whole, and

Créons des familles • FALL/AUTOMNE 2013

nourishing their relationship, can have powerful physiological effects. When we begin to understand that we can actually reverse stress and how we respond to it, a new world opens up. Gaining an awareness of the Mind/Body connection allows us to use our minds to alter our physiology and connect with something deeper all within ourselves.

About the Author Amira Posner, BSW, MSW, RSW, founder of Healing Infertility Counseling and Support, works with women, men and couples who are struggling with infertility. Amira provides support in dealing with the emotional pain associated with infertility. Her mind/body approach to infertility has helped many women gain perspective and strength on their journey towards having a family. Amira facilitates mind/body infertility support groups providing women with specific tools they can utilize in order to optimize their infertility treatment. These groups are run out of the Centre for Fertility and Reproductive Health at Mt. Sinai Hospital as well as at different locations throughout Toronto.

References: Adrienne, H, (2011). On Fertile Ground, Healing Infertility, New York.

Adrienne H, (2009). Infertility’s built-in opportunities for growth using Mind-Body Techniques, Journal of Fertility Counselling, volume 6, 3, winter pp. 32-41.

Amen, D (1999) Change Your Brain, Change Your Life. New York: Three Rivers Press, Benson, H & H Stuart.

Benson, H., & Stuart, E.M. (with the staff of the Mind/Body Medical Institute). 1992. The Wellness Book: The Comprehensive Guide to Maintaining Health and Treating Stress-Related Illness. New York: Citadel.,

Domar, AD, Zutermeister, PC, Friedman, R, (1993) The Psychological Impact of Infertility: A Comparison with Patients with Other Medical Conditions, Journal of Psychosomatic Obstetrics and Gynecology, 14, Suppl. pp. 45-52.

Eliahy Levitas, et al., "Impact of Hypnosis During Embryo Transfer on the Outcome of In Vitro Fertilization-Embryo Transfer: A Case-Control Study," Fertility & Sterility 85, 5 (2006): 1404-1408.

N Rappoport-Hubschan, Y Gidron, R Reicher-Atir, O Sapir, & B Fisch, (2009) “Letting go coping is associated with successful IVF treatment outcome,” Fertility and Sterility, 92, 4, pp. 1384-1388.

À QUI LA FAUTE ?

Les répercussions négatives du blâme sur la détresse des conjoints par Katherine Péloquin, Audrey Brassard et Susan Bermingham Recevoir un diagnostic d’infertilité et entreprendre des démarches de traitement est une expérience difficile pour plusieurs couples. Bon nombre d’études montrent que les personnes touchées vivent toutes sortes d’émotions, incluant la peine, la surprise, la colère et l’anxiété, pour n’en nommer que quelques-unes. Les recherches portant sur le stress ont démontré que les évènements stressants possèdent quatre caractéristiques communes, soit l’absence de contrôle, l’imprévisibilité, la nouveauté et la menace à l’ego. L’infertilité répond à tous ces critères. Il n’est donc pas surprenant qu’elle génère toute une gamme d’émotions !

à risque de s’attribuer la faute ou de blâmer son partenaire pour le problème de fertilité et ce, que la cause biologique du problème soit identifiée ou non. Ceci nous amène donc à nous poser la question : le fait d’attribuer la responsabilité du problème à l’un ou l’autre des partenaires a-t-il un effet positif ou négatif sur les conjoints?

Chez les couples touchés, la recherche des causes biologiques de l’infertilité est un processus très sain. L’évaluation diagnostique, par contre, est susceptible d’identifier un partenaire comme étant à la source du problème plus que l’autre. Les études montrent toutefois que chaque partenaire est

problème de fertilité et ce,

Chaque partenaire est à risque de s’attribuer la faute ou de blâmer son partenaire pour le que la cause biologique du problème soit identifiée ou non.

Le blâme Nos travaux de recherche menés auprès de 279 couples québécois suivis pour des traitements de fertilité nous ont permis d’examiner le rôle du blâme sur la détresse ressentie par les partenaires. Nos résultats montrent que lorsque l’homme se blâme pour l’incapacité du couple à concevoir, lui et sa conjointe vivent plus d’insatisfaction dans leur relation de couple. De plus, lorsqu’il se blâme, l’homme rapporte davantage de symptômes d’anxiété et de dépression. « Le jour, ça va, car je suis au travail et je n’y pense pas. Par contre, de retour à la maison, je la vois pleurer, sa peine est tellement lourde que je ne veux plus rentrer à la maison, je sais que c’est de ma faute. J’ai commencé à aller dans les 5 à 7 avec les collègues pour réduire le stress de rentrer à la maison ; ainsi je ressens moins le résultat de mon incapacité à lui faire un enfant. » - Christian

FALL/AUTOMNE 2013 • Creating Families

Les recherches portant sur le stress ont démontré que les évènements stressants possèdent quatre traits communs, soit l’absence de contrôle, l’imprévisibilité, la nouveauté et la menace à l’ego. L’infertilité répond à tous ces critères. Lorsque c’est plutôt la femme qui se blâme pour le problème de fertilité, elle et son conjoint ressentent tous les deux davantage de symptômes d’anxiété et de dépression. Ainsi, le fait de se blâmer semble avoir des effets négatifs sur le bien-être de l’individu et celui de son ou sa partenaire. S’attribuer le blâme peut aussi s’avérer un affront pour l’estime personnelle. Il n’est donc pas étonnant que ce sentiment entraîne des symptômes dépressifs. « Je ne suis bonne à rien. Il devrait partir et essayer de se trouver une autre femme qui pourra lui faire un enfant. Il est jeune, il a la possibilité de rencontrer une autre femme avec qui fonder une famille. Moi, je ne fais que pleurer sur mon sort, sur mon ventre qui reste vide. Je ne suis pas capable de faire un enfant… je ne suis rien… » - Julia

trouve difficile de lui faire vivre ça, c’est comme si je lui imposais ça. Si elle était avec quelqu’un d’autre, peut-être qu’elle pourrait avoir des enfants facilement. Là, avec moi, elle subit tous ces traitements. C’est compliqué, c’est toujours compliqué. » - Pierre « Je vis tellement de colère, je ne suis pas capable de contrôler ma peine et ma frustration… Je sais que c’est dû à toute cette médication… Est-ce

que je vais empêcher que ce traitement fonctionne… et si ça ne fonctionne pas… on se calme… on se calme … on respire… » - Clémentine Notre travail auprès de ces couples nous montre qu’il faut d’abord reconnaître cette culpabilité, puisque c’est une émotion qui tend à engendrer de l’anxiété et de la dépression. Ensuite, il peut être utile et même bénéfique de l’exprimer à son ou sa partenaire

Inc.

Aina Zhang « Un membre important de l'équipe de rêve de Céline Dion » - Le Journal de Montréal, 1er juin 2010

La culpabilité

U Maîtrise en gynécologie (Chine)

Il est possible que les personnes qui se blâment vivent une culpabilité face à l’infertilité et, malheureusement, celle-ci est susceptible d’amplifier le stress déjà considérable lié aux traitements de fertilité.

U Reconnue par l'Ordre des Acupuncteurs du Québec

« Je vis beaucoup de culpabilité, parce que j’ai l’impression que c’est de ma faute ce qui arrive, c’est moi qui ai les problèmes de fertilité. Je

Créons des familles • FALL/AUTOMNE 2013

U Diplôme de médecine (MD) en médecines chinoise et occidentale (Chine)

U Plus de 30 ans d'expérience clinique en médecines chinoise et occidentale U Acupuncture sur place pour les patientes de FIV des cliniques de fertilité 365 jours par année

4177 boul. Décarie s Montréal, QC s H4A 3J8 (514)

483-6669

ainazhang@sinocare.ca

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(ou à une autre personne de confiance) afin de faciliter une meilleure compréhension de cette expérience émotionnelle. Parfois, ouvrir le dialogue avec une personne bienveillante, qui s’abstient de porter un jugement, peut permettre une prise de conscience quant aux éléments appartenant à la personne et à ceux hors de son contrôle.

nos recherches montrent que l’homme qui attribue le blâme à sa partenaire est généralement moins satisfait de sa relation conjugale. Lorsque c’est plutôt la femme qui attribue le blâme à son conjoint, les deux partenaires se disent plus insatisfaits de leur relation, et la femme rapporte davantage de symptômes dépressifs.

« J’ai compris qu’elle veut faire un enfant avec moi comme père, avoir une famille avec moi. Elle a aussi de la peine à être incapable de garder les embryons transférés, même si c’est moi qui porte le diagnostic d’infertilité. »

« Je suis tellement en colère contre la situation, contre tout ! Je ne peux pas m’empêcher de me dire que j’aurais pu avoir un enfant avec quelqu’un d’autre parce qu’il n’y a pas de problème de fertilité de mon côté. Puis je me sens terriblement mal. Je sais que ce n’est pas de sa faute, qu’il se sent mal lui aussi… Mais c’est plus fort que moi. Et ça nous éloigne. Ça me fait de la peine. »

- Benjamin Ultimement, le fait de se blâmer est rarement productif puisqu’il paralyse la personne plutôt que de favoriser sa mise en action et son sentiment de contrôle.

Le blâme de l’autre Il arrive aussi qu’en cherchant à comprendre les raisons de l’infertilité, une personne en vienne à blâmer son/sa partenaire pour les difficultés à concevoir (parce que c’est le/la partenaire qui a une condition médicale ou qu’il ou elle apparaît moins engagé(e) dans les démarches de traitements). Les résultats de

- Lauriane Ces résultats concordent avec les conclusions d’études portant sur la satisfaction conjugale, qui montrent que le fait d’attribuer la cause des difficultés de couple à une personne plutôt qu’à des éléments contextuels est systématiquement associé à l’insatisfaction conjugale. Dans le cas où la personne blâme l’autre en raison de son diagnostic médical, il est important de rappeler que l’autre n’a pas choisi et n’est pas responsable de cette

condition. Ainsi, il ou elle en souffre possiblement tout autant, comme c’est le cas pour le couple Pierre et Lauriane.

Chacun sa réaction face à l’infertilité Dans le cas où la personne blâme l’autre pour sa façon de réagir face aux démarches de fertilité, notre travail auprès des couples nous indique qu’il y a différentes façons de réagir à un diagnostic d’infertilité et aux multiples traitements qui servent à y remédier. Ainsi, les couples doivent prendre en considération que chacun trouve ses propres stratégies pour s’adapter à cette situation difficile et qu’on ne doit pas assigner de mauvaises intentions à ces différents comportements. Chacun vit l’expérience de l’infertilité et de la procréation assistée à sa manière et à son rythme. Il est parfois très utile d’en discuter pour mieux comprendre, accepter et transiger avec les réactions de l’autre. Ainsi, Christian, qui ne rentre pas directement à la maison après le bureau, pourrait bénéficier d’une discussion avec sa conjointe plutôt que de s’étourdir dans un 5 à 7 avec des collègues. Notre expérience nous montre qu’il n’est pas rare que les couples aux prises avec un problème de fertilité s’isolent de leurs proches,

« J’ai commencé à aller dans les 5 à 7 avec les collègues pour réduire le stress de rentrer à la maison ; ainsi je ressens moins le résultat de mon incapacité à lui faire un enfant. »

FALL/AUTOMNE 2013 • Creating Families

de mes ami(e)s et de ma famille… personne ne comprend vraiment la détresse et la peine que nous vivions. Finalement, on est plus proche et plus solide comme couple… Mon conjoint est aussi mon meilleur ami, je n’aurais jamais pensé que nous pouvions être aussi forts ensemble. » - Élisabeth

Le fait de se blâmer est rarement productif puisqu’il paralyse la personne plutôt que de favoriser sa mise en action et son sentiment de contrôle. pour diverses raisons. Ainsi, chaque conjoint peut n’avoir que l’autre comme soutien, confident et partenaire de conversation quant aux traitements à venir. En fin de compte, chaque conjoint peut sentir que son ou sa partenaire est la personne la plus proche. Une bonne communication au sein du couple est donc fondamentale et, en ce sens, les deux conjoints doivent apprendre à s’entraider malgré tout. « Suite à tout ce qu’on a vécu pour avoir un enfant, il n’y a que mon conjoint qui comprenne vraiment ma détresse…alors je me suis éloignée

En somme, si la culpabilité, le blâme de l’autre ou les réactions personnelles de chacun face au problème de fertilité génèrent trop de tensions au sein de votre relation, il peut s’avérer utile d’envisager le recours aux services d’un professionnel. Cette personne saura vous guider et vous accompagner dans cette expérience qui possède toutes les caractéristiques des évènements les plus stressants. Il est important de noter ici que les médecins, les endocrinologues, les gynécologues et les urologues, à l’instar des psychologues spécialisés en fertilité, considèrent le couple comme une entité à part entière. Peu importe l’origine des troubles de la procréation, ces différents spécialistes envisagent l’homme et la femme comme un tout soudé. Cependant, à l’extérieur du bureau du médecin, chaque conjoint doit composer avec ses propres émotions. En parler avec un psychologue peut au moins aider à départager les blâmes, la culpabilité et l’absence de contrôle. Suggestions de lecture : Les lectures qui portent sur la gestion du stress et l’adaptation à l’infertilité peuvent aider la réflexion et permettre de mettre les émotions ressenties en contexte. Bermingham, Susan. (2011). Vivre avec l’infertilité. Montréal : Bayard Canada. Lupien, Sonia. (2010). Par amour du stress. Montréal : Éditions Au Carré.

À propos des auteures Katherine Péloquin, Ph.D., est professeure au département de psychologie de l’Université de Montréal et chercheure au Centre de recherche interdisciplinaire sur les problèmes conjugaux et les agressions sexuelles (CRIPCAS). Ses travaux de recherche traitent du fonctionnement conjugal, tant chez la population générale que chez des populations cliniques. Elle s’intéresse tout particulièrement aux impacts psychologiques, conjugaux et sexuels de l’infertilité, ainsi qu’aux interventions visant à favoriser le bien-être des couples touchés par ce problème. Audrey Brassard, Ph.D., est professeure au département de psychologie de l’Université de Sherbrooke et chercheure au Centre de recherche interdisciplinaire sur les problèmes conjugaux et les agressions sexuelles (CRIPCAS). Ses travaux de recherche portent sur le fonctionnement conjugal et sexuel chez les adultes, en particulier l'attachement amoureux, la sexualité et les dysfonctions sexuelles chez les adultes, ainsi que les facteurs de prédiction de la détresse et de la violence conjugale. Susan Bermingham, M.Ps., est psychologue clinicienne et travaille depuis 1992 auprès des couples ayant des difficultés à concevoir à des cliniques de fertilité à Montréal. Elle a participé aux divers groupes d’études et aux comités d’éthique concernant la procréation assistée mis en place par les gouvernements provincial et fédéral. Elle est l’auteure du livre Vivre avec l’infertilité, qui a pour objectif de donner des clés pour comprendre l’infertilité et les difficultés psychologiques vécues par les couples qui s’engagent corps et âme dans une démarche pour fonder une famille lorsque l’enfant tarde à venir.

FALL/AUTOMNE 2013 • Creating Families

The Naturopathic View

CELIAC DISEASE, GLUTEN INTOLERANCE AND FERTILITY by Judith Fiore, ND

Celiac disease is a digestive disease that damages the villi which line the small intestine and prevents the absorption of nutrients, vitamins and minerals from food. When celiacs eat foods containing gluten, the villi are flattened by the huge influx of antibodies produced by the immune system in the body’s attempt to digest the gluten.1 This is why celiac disease is usually thought of as an allergy to gluten. Without healthy villi, a person becomes malnourished despite eating a healthful diet. Gluten is a complex mixture of proteins that is found in many grains, including wheat, barley, and rye. Gluten is the protein that allows bread to rise in the baking process and

Créons des familles • FALL/AUTOMNE 2013

stirs our senses when we smell freshly baked bread. However, gluten is not only found in food; it may surprise you to discover that it may also be found in medicines, vitamins, and lip balms. Celiac disease is both a disease of malabsorption – meaning nutrients are not absorbed properly – and an abnormal immune reaction to gluten. Celiac disease is often found to be genetic. It is also seen in higher percentages amongst people of European ancestry.2 Many of the research studies that have looked at celiac disease originate from Europe. Celiac disease may be activated after surgery, pregnancy, viral infection, or even severe emotional stress or trauma.3,4

Symptoms of celiac disease vary, and may occur in the digestive system or in other parts of the body. They may include: abdominal bloating and pain; chronic diarrhea; constipation; pale, foul-smelling or fatty stools; weight loss or weight gain due to water retention; irritability; unexplained irondeficiency anemia; fatigue; bone or joint pain; arthritis; bone loss or osteoporosis; depression or anxiety; tingling and/or numbness in the hands and feet; canker sores in the mouth; itchy skin rash; and seizures. That is quite the list of possible symptoms, but what about possible effects on fertility? For women, it is not unusual to suffer from amenorrhea (absence of periods) or to miss

The Naturopathic View For women, it is not unusual to suffer from amenorrhea (absence of periods) or to miss menstrual periods, resulting in irregular cycles. Recurrent miscarriage has also been linked to celiac disease. menstrual periods, resulting in irregular cycles.5 Recurrent miscarriage has also been linked to celiac disease.6 Other complications during pregnancy such as pregnancy-related hypertension, severe anemia and intrauterine growth retardation are found four times more often in women with celiac disease. It has been noted that men who are celiac have abnormal levels of reproductive hormones which often result in low sperm counts and motility, as well as higher percentages of abnormal morphology.7 In some cases, there are no symptoms. The disease is silent and somehow the individual is enjoying what appears to be good health and fertility. There are no digestive problems, no signs of anemia, cycles are regular in women and men have good sperm counts and motility. There is no history of miscarriage, and the only thing that a couple is hearing is that their fertility problem is unexplained. It may be years before symptoms of the disease appear, or, worse, illnesses such as liver diseases and intestinal cancers are diagnosed.8,9

producing antibodies to gluten. The test is called the anti-gliadin antibody test. If you are having any of the above symptoms, or just being told that there’s no explanation for your inability to conceive or carry a pregnancy to term, I recommend you speak to your doctor and get tested. The most conclusive blood test is called the antitissue transglutaminase antibody with measurement of serum IgA levels. Keep in mind that before having either test you should be consuming gluten daily for at least three weeks. This is necessary to determine if you are producing antibodies to gluten. There are other tests, such as an intestinal biopsy, where very small pieces of tissue from the small intestine are removed to see if the villi are damaged. Whether you go through more tests will be something you will need to discuss with your physician.

Eating a gluten-free diet The only cure for celiac disease is a gluten-free diet. While this presents a challenge, with time and experience most people find they are able to prepare and eat delicious meals. More importantly, their health is better and research is showing that this may be enough to overcome infertility.10 To help get you started, I have included the following chart. It’s not the full list of foods that do or do not contain gluten. You can find those lists by simply googling

It has been noted that men who are celiac have abnormal levels of reproductive hormones which often result in low sperm counts and motility, as well as higher percentages of abnormal morphology. “gluten-free foods” and “foods containing gluten”. I would also suggest that you google “gluten-free recipes” to find many websites to use as resources as you learn to avoid eating gluten. While you are surfing the net, the following are websites that you can go to for more information: www.celiac.ca www.Celiac.com www.Celiac.org www.Celiaccentral.org www.foodintol.com/celiac.asp www.gluten.net www.Glutenfreedom.net

A simple blood test can determine if you are

FALL/AUTOMNE 2013 • Creating Families

The Naturopathic View Gluten-free Flours, Grains and Foods Almond Amaranth Bean, adzuki Bean, lentil Bean, mung Buckwheat Corn and Cornmeal Cornstarch Flax Millet Oatmeal (especially steel cut) Potato flour and Potatoes Quinoa Rice Soy Soybean Tapioca Teff flour

Flours, Grains and Foods That Contain Gluten Baking powder Barley grass, Barley malt, Pearl Barley Blue cheese Bran Brewer’s yeast Bulgur Graham flour Kamut Miso Mustard powder Rye Seitan Soba noodles Spelt Soy sauce Stock cubes Triticale Wheat Wheat germ, Wheat grass

Créons des familles • FALL/AUTOMNE 2013

The only cure for celiac disease is a gluten-free diet. While this presents a challenge, with time and experience most people find they are able to prepare and eat delicious meals. More importantly, their health is better and research is showing that this may be enough to overcome infertility.

The Final Word As a naturopathic doctor, I have found that at least half of my patients do better on a gluten-free diet, regardless of whether they had a positive or negative anti-gliadin antibody test result. Perhaps this is because removing gluten from the diet helps make it more likely that a person will avoid processed foods, trans fats and sugar, and/or because it helps by increasing the variety of grains in our daily diets. Moreover, gluten is a protein that is fairly difficult to digest, in comparison to other grains. Once you have been gluten-free for a couple of months, and you experience no change in your health, then it's fine to resume eating foods that contain gluten. However, I would still encourage you

Oatmeal doesn’t contain gluten, but it is *usually contaminated with wheat flour during processing in facilities that are not dedicated to being gluten free. Steel-cut oatmeal, because it is the least processed of the oatmeal types, is therefore the safest to eat. However, for celiac patients, oatmeal is not always a grain they are able to eat.

to also eat gluten-free grains like brown rice, buckwheat, quinoa and millet. After all, a typical day would have us eating toast and/or cereal for breakfast, a sandwich for lunch, crackers for the afternoon snack, and then pasta or bread with dinner. That is four servings of wheat in one day, or maybe five if you have a piece of cake or a cookie for dessert. That’s a lot of gluten for our bodies to be dealing with, and most of us eat this way every day for all of our lives. Just imagine what happens when you decide to go without gluten. All of the convenience foods, like sandwiches, pastas, crackers, cookies, granola bars and so on are now off limits. Instead you are eating whole grains like quinoa and brown rice with your meals. For breakfast, rather than eat a bagel that’s loaded with cream cheese and jam, you are having a bowl of steel cut oatmeal with berries and milk. Rather than eating a cereal bar for a snack, you grab an apple from the store. If you add plenty of vegetables, lean proteins, nuts and seeds, and healthy oils through the day you will be eating in a way that can dramatically improve your health.

The Naturopathic View For some of you, the best and most magical thing will be that avoiding gluten will allow you to greatly improve your fertility. Something as simple as that could be what gives you the joy of becoming a parent. It may take several months before you experience positive changes, but it is well worth the effort if you end up feeling healthy and well and are blessed with a child.

References:

8 Jamron R. “Liver damage, celiac disease and the

1 Rodrigo L. Celiac Disease. World Journal of

intestinal mucosa.” Celiac.com, http://www.celiac.com/articles/1010/1Liver-DamageCeliac-Disease.

Gastroenterology. 2006;12(41):6585-6593. 2 National Digestive Diseases Information Clearinghouse, “How common is celiac disease?” http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/. 3 Mayo Clinic medical information and tools for healthy living, “Celiac disease: Causes,” http://www.mayoclinic.com/health/celiacdisease/DS00319/DSECTION=3

9 Sanders DS, Patel D, Stephenson TJ, Milford-Ward A, McCloskey EV, Hadjivassilou M, et al. “A primary care cross-sectional study of undiagnosed adult coeliac disease.” Eur J Gastroenterol Hepatol 2003;4:407-13. 10 Rajput R, Chatterjee S. “Primary infertility as a rare presentation of celiac disease.” Fertility & Sterility 2010 May; published online ahead of print.

4 Catassi C, et al. “Gynaecological & obstetric disorders

About the author Dr. Judith Fiore, ND, is a licensed Naturopathic Doctor dedicated to providing naturopathic therapies to individuals and couples with fertility issues. She practices in downtown Toronto and in central Mississauga. For more information, please visit her website at www.naturalfertility.ca.

in CD: frequent clinical onset during pregnancy or puerperium.” Eur J Gastroenterol Hepatol. 1996 Jan;8(1):63-89. 5 Martinelli D, et al. “Reproductive life disorders in Italian Celiac women. A case-control study.” BMC Gastroenterology 2010;10:89. 6 Foschi F, et al. “Celiac disease and spontaneous abortion.” Minerva Ginecologica, 2002 Apr;54(2):151-9. 7 Farthing MJ, Rees LH, Edwards CR, Dawson AM.

“Male gonadal function in coeliac disease: sex hormones.” ,9)BDQQ&) /D\RXW $0 3DJH Gut 1983;24:127-35.

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FALL/AUTOMNE 2013 • Creating Families

Dr. Beth Gunn

I had a D&C following a miscarriage two years ago. I haven’t been able to become pregnant since and have noticed my periods have gotten much lighter. Could this be related to the procedure? If I have scarring from my surgery, what other symptoms might I have and what are my chances of pregnancy?

: Dr. Beth Gunn: Your description suggests Asherman’s Syndrome, characterized by intrauterine adhesions (scar tissue) along with symptoms such as menstrual disturbance, cyclic pelvic pain, infertility or recurrent miscarriage. In mild cases the scarring may only affect a small portion of the uterus ; however, in severe cases, the front and back wall of the uterus may be completely adherent to one another and the cavity obliterated. Asherman’s is responsible for 1.5% of female infertility cases.

Pregnancy-related trauma accounts for 90% of Asherman’s cases. This may occur due to a dilatation and curettage (D&C) after a miscarriage, to remove retained placenta following a delivery, or for a voluntary termination of a pregnancy. The uterus is at highest risk of scarring from trauma within four weeks of delivery. The risk of Asherman’s developing after a D&C is estimated at 5-30% and increases with repeat procedures. Trauma outside of pregnancy may also result in

The Doctor’s Column intrauterine adhesions (IUA). The risk following resection of a uterine septum (surgical removal of a congenital "partition" in the uterus) is 6.7%, while the risk following hysteroscopic removal of fibroids is 31% for a single fibroid and 45% for multiple fibroids. Infection may also cause IUA and, although rare in North America, so can tuberculosis and schistosomiasis (a parasite-induced disease). The most common symptom of Asherman’s is a change in menstrual cycles – lighter, more infrequent or absent periods. This occurs either because scar tissue has replaced most of the normal endometrium, leaving less to shed with a period, or because the scarring is obstructing the cervix therefore trapping blood inside the uterine cavity, which can also lead to cyclic pelvic pain. Moreover, affected women may have difficulty becoming pregnant, or have multiple miscarriages as the scarring may affect implantation. The best method to diagnose Asherman’s is direct visualization by hysteroscopy. With recent advancements in imaging, 3D sonohysterograpy can identify polyps, fibroids and scarring within the uterine cavity and has the added benefit of assessing patency of the fallopian tubes. Contrary to conventional 2D sonoshysterograms, 3D better estimates the

amount of scar tissue affecting the cavity. Treatment aims at restoring the uterine cavity and removing the scar tissue. The surgery is performed using a hysteroscope – a small camera is inserted into the uterine cavity and scar tissue is carefully resected. This may be combined with a laparoscopy – a small camera is placed through the umbilicus to visualize the outer surface of the uterus to ensure perforation does not occur. Afterwards, it is important to prevent new scar tissue from forming. Often a balloon-shaped catheter is left inside the uterus to keep the front and back wall of the uterus apart while the endometrium is healing. The catheter is removed a number of days later in office. Typically, antibiotics are prescribed. Estrogen and progesterone are also given to promote regrowth of the endometrial lining. Repeat assessment of the uterine cavity occurs two to three months post-surgery to confirm there are no further IUA present. Following surgery, the chance of pregnancy depends on the severity of the adhesions, the success of the surgery and other factors affecting fertility, namely the woman’s age. Overall, pregnancy rates are about 60%, with live birth rates just under 40%. A woman suspecting the presence of intrauterine adhesions and trying to conceive should definitely be evaluated.

Dr. Beth Gunn is a Reproductive Endocrinology and Infertility specialist at LifeQuest Centre for Reproductive Medicine. She has made numerous academic presentations on various topics relating to the treatment of infertility, has published in peer-reviewed journals, and taught students and residents at the University of Toronto in the areas of obstetrics and gynecology and infertility. Her current clinical and research interests include ovulation induction in patients with Polycystic Ovarian Syndrome (PCOS), improving clinical outcomes in assisted reproductive technologies, and Celiac Disease and Infertility.

Créons des familles • FALL/AUTOMNE 2013

La chronique du médecin Q:

J’ai subi une D et C à la suite d’une fausse couche il y a deux ans. Depuis, je n’ai pu devenir enceinte et mes règles sont beaucoup moins abondantes. Est-ce lié à cette intervention ? Si elle a laissé du tissu cicatriciel, quels autres symptômes pourrais-je avoir et quelles sont mes chances d’obtenir une grossesse ?

: Dre Beth Gunn : Votre description suggère un syndrome d’Asherman, caractérisé par des adhésions intra-utérines (tissu cicatriciel) et par des symptômes tels que changements dans le cycle menstruel, douleurs pelviennes cycliques, infertilité ou fausses couches à répétition. Dans les cas bénins, les cicatrices peuvent n’affecter qu’une petite portion de l’utérus. Cependant, dans les cas graves, les parois antérieure et postérieure de l’utérus peuvent adhérer l’une à l’autre et obturer la cavité utérine. Ce syndrome est en cause dans 1.5 % des cas d’infertilité féminine.

Les traumatismes liés à la grossesse – dilatation-curettage après une fausse couche, retrait de fragments de placenta après un accouchement, ou IVG – comptent pour 90 % des cas. L’utérus est à risque maximal de cicatrisation posttraumatique dans les quatre semaines suivant un accouchement. Le risque de développer un Asherman après

une D et C est de 5 à 30 % et il croît à chaque intervention. Un traumatisme non lié à la grossesse peut également produire des adhésions intra-utérines. Le risque est de 6.7 % après la résection d’un septum utérin (excision chirurgicale d’une « partition » congénitale à l’intérieur de l’utérus), de 31 % après l’enlèvement d’un fibrome par hystéroscopie et de 45 % s’il y a plusieurs fibromes à retirer. Les adhésions peuvent aussi être causées par une infection ou, bien que rarement en Amérique du Nord, par la tuberculose et la schistosomiase (maladie causée par un parasite). Le symptôme le plus courant du syndrome d’Asherman est une modification des cycles menstruels – règles plus légères, moins fréquentes ou absentes. Ceci survient soit parce que le tissu cicatriciel a pris la place d’une grande partie de l’endomètre normal, ce qui en laisse moins à éliminer lors des règles, soit parce que le tissu cicatriciel bloque le col de l’utérus, emprisonnant le sang dans la cavité utérine, ce qui peut entraîner des douleurs pelviennes cycliques. De plus, les femmes affectées ont de la difficulté à devenir enceintes, ou encore font des fausses couches à répétition puisque le tissu cicatriciel peut nuire à l’implantation. La meilleure façon de diagnostiquer un syndrome d’Asherman est de visualiser directement l’utérus par hystéroscopie.

La Dre Beth Gunn, spécialiste en endocrinologie de la reproduction en en infertilité au LifeQuest Centre for Reproductive Medicine, a fait de nombreuses présentations sur divers sujets liés au traitement de l’infertilité, a publié dans des revues révisées par des pairs et enseigné à des étudiants ainsi qu’à des résidents de l’Université de Toronto dans les domaines de l’obstétrique-gynécologie et de l’infertilité. Ses intérêts actuels de clinique et de recherche incluent l’induction de l’ovulation chez les patientes atteintes du syndrome des ovaires polykystiques (SOPK), l’amélioration des résultats cliniques des technologies de procréation assistée de même que les rapports entre la maladie cœliaque et l’infertilité.

Grâce aux progrès en imagerie, la sonohystérographie en 3D peut détecter les polypes, les fibromes et le tissu cicatriciel à l’intérieur de la cavité utérine, en plus d’évaluer la perméabilité des trompes de Fallope. Contrairement au sonohystérogramme conventionnel en 2D, la technologie en 3D permet de mieux estimer la quantité de tissu cicatriciel. Le traitement vise à restaurer la cavité utérine et à retirer le tissu cicatriciel. La chirurgie s’effectue à l’aide d’un hystéroscope – une petite caméra est insérée dans la cavité utérine et le tissu cicatriciel est excisé avec soin. On peut combiner cette intervention avec une laparoscopie – une petite caméra installée à travers l’ombilic permet de visiualiser la surface externe de l’utérus pour prévenir une perforation. Après la chirurgie, il est important d’empêcher la formation de nouveau tissu cicatriciel. On laisse souvent un cathéter en forme de ballon à l’intérieur de l’utérus pour garder ses parois séparées pendant que l’endomètre guérit. Le cathéter est retiré au cabinet du médecin plusieurs jours plus tard. En général, on prescrit des antibiotiques. On donne aussi de l’estrogène et de la progestérone pour favoriser la régénération de la paroi de l’endomètre. On réexamine la cavité utérine deux ou trois mois après la chirurgie pour confirmer qu’elle est libre d’adhésions. Après la chirurgie, les chances d’obtenir une grossesse dépendent de la gravité des adhésions, du succès de l’intervention et d’autres facteurs affectant la fertilité, notamment l’âge de la femme. Le taux de grossesse est d’environ 60 %, alors que celui des naissances vivantes atteint presque 40 %. Toute femme qui soupçonne la présence d’adhésions intra-utérines et tente de concevoir devrait absolument consulter. FALL/AUTOMNE 2013 • Creating Families

Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner

Readers’ Corner

Readers’ CornerReader Readers’ CornererReader Readers’ CornererReader er Readers’ Corner ReaderLes’coin Corner Readerdess’ Corlecteurs ner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner er Readers’ Corner Readers’ CornerReader er Readers’ Corner Readers’ CornerReader Dear readers, this section of the magazine belongs to you. We welcome your comments on articles in the magazine, IAAC’s activities, government policies or your personal experience. You can also ask questions about anything related to fertility, and our experts will be happy to answer.

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In 2008 I was a newly wed and eager to have my first child. I got pregnant quickly, only to have a miscarriage a few weeks later. We kept trying, but with irregular menstrual cycles, I was having difficulty. I started charting my Basal Body Temperature first thing in the morning only to see that my temperatures were erratic and my cycles were sometimes over 60 days long. How was I going to get pregnant? The doctor recommended I see a gynecologist, who later diagnosed me with Polycystic Ovary Syndrome (PCOS). He suggested I take Clomid to stimulate my body to ovulate regularly but I wanted to try less invasive means.

prepared for conception. I exercised three to five times a week to get my heart rate up and engaged in stress-reducing activities like yoga and meditation. I lost weight and felt fit.

While I charted my cycles and monitored my diet, I also started the unusual practice of Lunaception. To practice this method, I needed to sleep in complete darkness for two weeks from the first day of my period. Then I slept with a light on for three nights, before going back to sleeping in complete darkness again. The purpose of sleeping with the light on for three lights was to stimulate my body to ovulate. This was the perfect method for me because of my ovulatory irregularities.

Readers’ Corner I made an appointment with a naturopath. He found that my liver was inflamed so he suggested that I begin a diet cleanse. I was to avoid eating wheat, dairy and sugar for three months! It was going to be

During the third month of following the naturopathic health plan and practicing lunaception, I conceived! Now, I have a beautiful and healthy 3-year-old daughter and a 1-year-old son.

Note from CF: The views expressed in this column are personal and do not necessarily reflect those of Creating Families.

Créons des familles • FALL/AUTOMNE 2013

Readers’ Corner

Readers’ CornererReader Readers’ CornerReader er Readers’ Corner er Readers’ CornerReader Readers’ Corner ReaderLes’ Corncoin s’ Cornerlecteurs Readers’ Corner er Readerdes Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ Corner Readers’ CornerReader er Readers’ Corner Readers’ CornerReader er Readers’ Corner I was surprised by how easily and effectively these natural methods worked for me. I wanted other women to know about my story. I received funding to make an animated short film “Dancing with the Moon.” It is an inspiring and entertaining story on my natural health fertility journey. It traveled to many festivals and won awards. You can view it online at: https://vimeo.com/51958666

The App is designed to help women struggling with Polycystic Ovary Syndrome achieve balanced fertility health. PCOS is the most common hormonal disorder among women of reproductive age and is a leading cause of infertility. I hope that women can use the combination of natural fertility methods that I used to achieve similar happy endings with successful pregnancies.

Now I am working on the “PCOS Natural Health Fertility App” to continue in my quest to support women struggling with infertility. This approach calls on the combination of natural methods that I practiced - charting cycles, practicing Lunaception and following a Naturopathic Health Plan.

If you have any questions, I would be happy to receive emails at: kpettit@shaw.ca

I am not alone…

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Katherine Pettit, Vancouver, BC

Building families... ONE baby at a time

that means there are many others who are suffering like me.

Coralie

Readers’ Corner FALL/AUTOMNE 2013 • Creating Families

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Chers lecteurs et lectrices, cette section du magazine vous appartient. Nous vous invitons à nous envoyer vos commentaires sur les articles du magazine, les activités de l’ACSI, les politiques gouvernementales ou des témoignages. Vous pouvez aussi poser toute question liée à la fertilité et nos experts seront heureux de vous répondre.

L’étiquette de l’infertilité Presque toutes les personnes infertiles vous diront qu'elles se sont fait dire un jour ou l'autre : « Tu y penses trop ! » ou son dérivé « Arrête d'y penser ! ». On pourrait en faire une overdose, un sitcom, une thèse de doctorat ! Comme si le simple fait de ne pas penser à quelque chose va faire que cela va se produire ! Ah oui ? Essayez donc cette superbe technique dans votre quotidien. Ça fonctionne ? Et le pire... c’est quand on nous dit qu'une femme est parvenue à tomber enceinte le mois où elle était très occupée, qu'un parent est décédé, bref, vous voyez le topo... Lorsque les gens entendent parler d'une femme devenue enceinte alors qu'elle avait l'esprit ailleurs, on se fait dire : « Tu sais, une telle, eh bien ça lui est arrivé ! » Eh oui ! Mais c'est un hasard de la vie. Évidemment, on n’entend parler que des histoires de celles pour qui cela a fonctionné... Imaginez-vous donc : pendant nos essais, j'ai vécu le décès de ma mère, le décès de ma grand-mère, je suis retournée aux études tout en travaillant... Euh… non ! Je ne suis pas devenue enceinte

du fait que j'y pensais moins ou que j'étais complètement débordée !

D’autres phrases que nous aimerions ne plus entendre ? - Si ça n'arrive pas, c'est parce que ce n'est pas encore le moment. - Ben, y'a toujours l'adoption?! - Tu es jeune, laisse-toi le temps. - Prête-moi ta blonde et je vais te régler ça ! - Je te prête mon chum, il m'a donné deux enfants... - Achète-toi un chien! - Profites-en ! Parce qu'avec des enfants, tu ne dormiras plus, tu n'auras plus de vie... Tu en veux vraiment ?

Bon, d’accord, ce n'est pas pour mal faire, c'est peut-être même une tentative maladroite de nous réconforter, ou encore pour nous faire rire ou sourire. Et poutant, même si cela peut avoir l'air bien

Note de CF : Les vues exprimées dans cette chronique sont personnelles et ne reflètent pas nécessairement celles de Créons des familles.

Créons des familles • FALL/AUTOMNE 2013

inoffensif, ça ne l'est pas ! Il peut nous arriver de rire (jaune), mais au fond de nous, ça bouillonne tellement... La meilleure attitude à adopter envers un couple infertile ? Être là. Apprendre à écouter. C'est difficile ce que vit ce couple. Ne le sous-estimez pas. Marie L’auteure de ces message tient le blogue Émotions in vitro (emotionsinvitro.com)

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Ils attendent dans la garde-robe... « Ils sont en solde, pourquoi ne pas les acheter ? » « Notre bébé sera chou avec ces pantoufles... » J'entre dans le magasin. Je regarde les vêtements pour femmes et j’en essaie quelques-uns dans la cabine d'essayage. Puis… je tombe sur le présentoir de vêtements pour bébés en solde de fin de saison. Pas cher ! « Je peux bien en acheter quelques uns. Ah non ! Ça va me porter malheur... Ah voyons, c'est n'importe quoi ! » Je les regarde soigneusement, je choisis des

couleurs neutres. Quelques pyjamas, ce n'est jamais de trop… Je dis même à la caissière : « On ne sait pas le sexe, alors on y va neutre ! ». C'était lors de notre première année d'essais. Maintenant... j'évite les rayons pour bébé autant que possible. Il y a quelques mois, il y avait une vente de fermeture dans un magasin et j'y suis allée. Heureusement, il ne restait plus grand-chose. Mais j'ai tout de même acheté un Nid d'ange bleu foncé et orange. Je l'ai laissé dans son sac et je l'ai mis avec ses « autres amis de couleurs neutres » dans la garde-robe de la chambre de futur bébé... Marie

FALL/AUTOMNE 2013 • Creating Families

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