Creating families / Créons des familles by Fertility Matters Canada

13 A STORY OF EMBRYO DONATION

EXPRESSIONS OF INFERTILITY

REDUCING CANADA’S REPRODUCTIVE TECHNOLOGY-RELATED MULTIPLE BIRTHS

38 BÉBÉS MAGIQUES UN CONTE POUR ENFANTS

Canadian Magazine of Reproductive Health • Revue canadienne de la santé reproductive

COLUMNS / CHRONIQUES

Creating FAMILIES Créons des familles

President’s Message . . . . 5 Message de la présidente . . 6 What’s New? . . . . . . . . . 8-11 Quoi de neuf ? . . . . . . . . . 8-11 Patient’s Perspective. . . . . 50

SPRING / PRINTEMPS 2013

The LGBTQ Column . . . . . . . 56

FEATURES / DOSSIERS

The Doctor’s Column . . . 60

The Pratten Case: A Landmark Decision Coming Up ................................... 20

La chronique du médecin . . 61

by SARA COHEN

The Naturopathic View. . . . 62

Leçons de survie - parce que notre monde est une jungle! ......................... 25

Reader’s Corner . . . . . . . . . . 66

par YVONNE CAMUS

Le coin des lecteurs . . . . . 69

Magical Babies - A Children’s Tale ............................................................ 42 by NATHALIE COURCY

Patient's Perspective - What Infertility Did to My Marriage ......................... 50 by CHARMAINE GRAHAM

The Naturopathic View - Natural Conception .............................................. 62 by JUDITH FIORE

Introducing a new column: Reader's Corner / Le coin des lecteurs Are employees who miss work to undergo fertility treatments protected? Creating Families / Créons des familles asked three lawyers to answer the question.

45 A JOURNEY TO OVERSEAS EGG DONATION

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 SPRING/PRINTEMPS 2013 • Creating Families

Creating FAMILIES Créons des familles

SILVER SPONSORS

ACTING EDITOR-IN-CHIEF • Gloria Poirier iaacadmin3@bellnet.ca I A A C NATIONAL BOARD OF DIRECTORS EDITOR • Véronique Robert carotexte@videotron.ca ASSISTANT EDITOR • Sylvan Lanken sylvan.lanken@gmail.com TRANSLATIONS Sylvan Lanken Gabrielle Filteau-Chiba Véronique Robert

PRESIDENT • Jocelyn Smith

First Steps Fertility

VICE-PRESIDENT • Janet Takefman

Genesis Fertility Centre

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

Hannam Fertility Centre

Grace Fertility Centre Heartland Fertility & Gynecology Clinic ISIS Regional Fertility Centre IVF Canada & The LIFE Program

ART DIRECTOR / GRAPHIC DESIGN Sheldon Kravitz sheldon.kravitz@sympatico.ca SPECIAL ILLUSTRATIONS Ana Kusmic anakusmic@bell.net

ARTUS Centre Astra Fertility Clinic

GOLD SPONSORS CReATe Fertility Centre Fertility Centers of Illinois LifeQuest Centre for Reproductive Medicine MUHC Reproductive Centre Shady Grove Fertility

London Health Sciences Centre, The Fertility Clinic Mount Sinai Centre for Fertility & Reproductive Health ONE Fertility, Burlington Ottawa Fertility Centre Pacific Centre for Reproductive Medicine Regional Fertility Program

Karen Hibbard karen.hibbard@sympatico.ca ,9)BDQQ&) /D\RXW $0 3DJH

Toronto Centre for Advanced Reproductive Technology (TCART)

IVF Canada/Life has been of providing infertility treatments 2008 marks the Program 25th anniversary IVF Canada/LIFE Program providing to patientstreatments across Canada and around theCanada world for years!the world. infertility to patients across and30around A leader in the field of Assisted Reproductive Technologies (ARTs), IVF Canada/LIFE Program is a free-standing surgical facility offering the most advanced technologies available for the treatment of male and female infertility. Our personalized patient care, consideration of couples with unique circumstances and timely access to treatment has made us the most patient-focused and accessible private IVF clinic in Canada.

IVF Canada/LIFE Program provides a comprehensive list of fertility services: U IVF (In Vitro Fertilization) U ICSI (Intracytoplasmic Sperm Injection) U IVM (In Vitro Maturation) U Blastocyst Culturing U PGD (Preimplantation Genetic Diagnosis) U Egg Freezing U Egg Gestational DonationSurrogacy U Gestational Many, manySurrogacy more Many, many more

What makes us different? U 25 30 years proven experience providing IVF and other ART treatments U Anaesthetist-administered anaesthesia for ovum retrievals U Laparoscopic ovum retrievals with general anaesthesia for those patients with inaccessible ovaries U Treatment for the older female (where appropriate) IVM – treatment with polycystic ovaries U Special facilities for forpatients hepatitis-positive patients U No Waiting Lists ! - Quick access to treatment U Less work absenteeism because our unique monitoring schedule requires only once-per-day visits IVF Canada & The LIFE Program (and sometimes less) 2347 Kennedy Road (Suite 304), Scarborough, Ontario, M1T 3T8 U Success rates comparable to the top units in the world ! Telephone: (416) 754-1010 754-8742 Fax: (416) 321-1239 U Compassionate IVF Treatment Program Email: info@ivfcanada.com Website: www.ivfcanada.com

SPRING/PRINTEMPS 2013 • Creating Families

President’s

Photo by Lisa Minnini

MESSAGE

Jocelyn Smith

ight now he temperature in downtown Toronto feels like minus 2,000 degrees. Spring seems so very far away! But come it will and then, in a few weeks, we shall welcome Nature’s long-awaited renewal. Year after year, I marvel at this cyclical miracle…

our annual Canadian Infertility Awareness Week. The CIAW takes place across the country during the week following Mother’s Day. This year, from May 19 through May 26, memorable activities will remind everyone that, indeed, infertility is a disease and that all Canadians struggling with this challenging condition deserve equitable access to treatment. As serious as infertility is, CIAW can be fun: for example, we are planning events both enlightening and enjoyable, and we would love to hear YOUR plans for CIAW. Don’t be shy. Please let us know. We will be happy to assist you in any way we can. You will notice a renewal in our magazine as well. This issue features a brand new section dedicated to you, our readers. There you can comment on articles in the magazine, IAAC’s activities, government policies, whatever you want to communicate at large. Moreover, this is a venue where you can ask questions about anything related to fertility, and our experts will be happy to answer.

This issue innovates in many ways. We publish several of the winning entries of the “Expressions of Infertility” art exhibition, a wonderful initiative of the Ottawa Fertility Clinic captained by its Managing Director, Mark Evans. This event drew enthusiastic attention, not only in the Ottawa region, but internationally as well. Other art work is showcased in this Spring issue: two young girls illustrate a delightful children’s tale written by their mother, Nathalie Courcy, from Gatineau, Quebec. LISA SHATFORD:LISA SHATFORD 7/16/07Nathalie 9:11 just AM gave Page 1 to her fourth birth One important event we need help with is donor-conceived child, and she wrote this Speaking of renewal, it is a buzz word at IAAC these days. Our new IVF-funding campaign is in full swing in British Columbia; we launched a newsletter to regularly let you know just what we are up to; we have begun preliminary work on a brand new, more user-friendly website; our main office has moved to new premises; new volunteers are generously donating time to help us raise funds and organize events.

25 years experience helping clients navigate the stress of infertility and its treatment, understand the implications of treatment options, and make sound choices in family building. Consultation, assessment, stress management, education, and psychotherapy. Individual and couple support. Psychologist fees are covered by most employee benefits plans.

Créons des familles • SPRING/PRINTEMPS 2013

Dr. Lisa Shatford

fairy-tale story, as she says, “to explain in simple terms to children born from donor insemination their origins and their parents’great desire to bring them into the world”. The exquisite poem The Teacup, by Scott John, quoted in the moving article he wrote about a trip with his wife to the Czech Republic for egg donation, was part of the “Expressions of Infertility” exhibition. Scott is currently preparing a documentary about his trip, and he is one of the volunteers helping with the B.C. IVFfunding campaign. Thanks for all this, Scott, and congratulations for your upcoming twins! Another must-read is the story of Cheryl Dancey’s awesome daughter – check that smile! – born form embryo donation here in Canada. It underlines that embryo donation is an underused option for infertile couples in this country. Don’t miss Kimberley Weatherall’s exhaustive piece on the risks of multiple births, Judith Fiore’s views on natural conception or lawyer Sara Cohen’s in-depth coverage of the possible implications of the Pratten decision regarding the rights of donor-conceived persons – the upcoming judgment by the Supreme Court of Canada could change the rules of third-party reproduction in this country. IAAC is an allinclusive organization – witness our LGBTQ column on reproductive options for trans people. “The times they are a-changin’”, goes Bob Dylan’s song. We at IAAC are intent on keeping up with the changes. Remember to pass this magazine along to others to help this happen! I wish you a lovely Spring, filled with the new ideas and energy that accompany this time of renewal.

Registered Psychologist 25 Imperial Street Suite 310A Toronto, Ontario M5P 1B9 416.795.5183 drlisa@sympatico.ca

Jocelyn Smith

MESSAGE

de la Présidente

n ce moment précis, on a l’impression que la température au centre-ville de Toronto est de moins 2 000 degrés. Le printemps semble décidément très loin ! Pourtant, il sera là bientôt, dans quelques semaines, et alors nous accueillerons avec bonheur le renouveau tant attendu de la nature. Chaque année, ce cycle miraculeux m’émerveille…

Il est beaucoup question de renouveau à l’ACSI ces jours-ci. Notre nouvelle campagne en vue d’obtenir le financement public des traitements de fertilité bat son plein en Colombie-Britannique; nous avons lancé un bulletin pour vous informer régulièrement de nos activités; nous avons entamé des démarches pour concevoir un nouveau site Web et le rendre plus convivial; notre bureau principal vient d’emménager dans de nouveaux locaux ; de nouveaux bénévoles nous donnent généreusement de leur temps pour nous aider à collecter des fonds et à organiser des événements. Un événement important pour lequel nous avons besoin d’aide est notre Semaine canadienne de sensibilisation à l’infertilité. La SCSI se tient chaque année à travers le pays, après la Fête des mères. Cette année, du 19 au 26 mai, des activités mémorables rappelleront

à tous que l’infertilité est bel et bien une maladie et que tous les Canadiens aux prises avec ce défi méritent un accès équitable aux traitements. Aussi sérieux que soit le problème de l’infertilité, la SCSI peut être amusante : par exemple, nous planifions des événements à la fois instructifs et divertissants, et nous aimerions connaître VOS plans pour la SCSI. N’hésitez pas. Tenez-nous au courant. Il nous fera plaisir de vous aider de notre mieux. Vous noterez un renouveau dans notre magazine également. Ce numéro comporte une toute nouvelle section consacrée à vous, nos lecteurs et lectrices. Vous pourrez y commenter les articles du magazine, les activités de l’ACSI, les politiques gouvernementales, tout ce que vous aimeriez communiquer au grand public. De plus, vous pourrez y poser des questions sur tout sujet lié à la fertilité, et nos experts seront heureux de vous répondre. Ce numéro innove à plusieurs égards. Nous publions plusieurs des œuvres primées à l’exposition « Expressions of Infertility », une merveilleuse initiative du Centre de fertilité d’Ottawa pilotée par son directeur général, Mark Evans. Cet événement a suscité l’enthousiasme non seulement dans la région d’Ottawa, mais également au-delà des frontières. D’autres œuvres d’art sont en vedette dans ce numéro du printemps : deux jeunes filles illustrent un délicieux conte pour enfants écrit par leur mère, Nathalie Courcy, de Gatineau, au Québec. Nathalie vient de donner naissance à son quatrième enfant conçu avec l’aide d’un donneur, et elle a créé cette histoire dans le style d’un conte de fées, comme elle dit, « pour expliquer simplement aux enfants issus de l’insémination avec

donneur leurs origines et le grand désir de leurs parents de leur donner la vie. » Le très beau poème The Teacup de Scott John, cité dans l’émouvant article qu’il a écrit sur un voyage avec son épouse en République tchèque pour y recevoir un don d’ovules, faisait partie des œuvres présentées à l’exposition « Expressions of Infertility ». Scott prépare actuellement un documentaire sur ce voyage, et il est l’un des bénévoles qui participent à la campagne visant à promouvoir le financement de la FIV en Colombie-Britannique. Merci pour tout cela, Scott, et félicitations pour vos jumeaux qui naîtront bientôt ! Un autre article fascinant est l’histoire de la magnifique fillette de Cheryl Dancey – quel sourire ! – née d’un don d’embryon ici même au Canada. Il souligne que le don d’embryon est une option sous-utilisée pour les couples infertiles dans ce pays. Ne manquez pas l’article fouillé de Kimberley Weatherall sur les risques des naissances multiples, les conseils de Judith Fiore sur la conception naturelle ou la couverture en profondeur, par l’avocate Sara Cohen, des conséquences éventuelles du jugement Pratten touchant les droits des personnes issues d’un don de gamètes – la décision à venir de la Cour suprême du Canada pourrait changer les règles de la procréation avec tiers donneur au pays. L’ACSI est une organisation inclusive – témoin notre chronique LGBT sur les avenues de procréation accessibles aux individus transgenre. « The times they are a-changin’ » – les temps changent – dit la chanson de Bob Dylan. À l’ACSI, nous tenons à suivre les changements. N’oubliez pas de faire circuler ce magazine pour aider à faire changer les choses ! Je vous souhaite un doux printemps, marqué par des idées nouvelles et l’énergie qui accompagne cette période de renouveau.

Jocelyn Smith

SPRING/PRINTEMPS 2013 • Creating Families

What’s New? Headlines in the fertility world

Having trouble conceiving?

Cut your animal fat intake

Couples with high levels of environmental pollutants such as PCBs in their system take longer to achieve pregnancy that couples with lower levels. This is the conclusion of a preliminary study conducted by researchers at the prestigious National Institutes of Health in the United States. PCBs include industrial chemicals and chemical by-products as well as pesticides, and they are often present in soil, water and the food chain. Even though several of them have been banned, they may persist in the environment for a long time. As they accumulate in fatty tissues, the study’s authors suggest that people may limit their exposure by removing and avoiding the fat from meat and fish, as well as by limiting their intake of animal products.

Difficulté à concevoir ?

Réduisez votre consommation de gras animal

Les couples dont l’organisme contient des niveaux élevés de polluants environnementaux tels que les BPC mettent plus de temps à obtenir une grossesse que les couples affichant des taux plus bas. Telle est la conclusion d’une étude préliminaire menée par des chercheurs des prestigieux National Institutes of Health aux États-Unis. Les BPC, qui incluent les produits chimiques industriels, les sous-produits chimiques et les pesticides, sont souvent présents dans le sol, l’eau et la chaîne alimentaire. Bien que plusieurs d’entre eux aient été bannis, ils peuvent subsister longtemps dans l’environnement. Vu qu’ils s’accumulent dans les tissus adipeux, les auteurs de l’étude suggèrent que les gens limitent leur exposition en retirant ou évitant le gras de la viande et du poisson, ainsi qu’en limitant leur consommation de produits animaux.

Créons des familles • SPRING/PRINTEMPS 2013

The Pratten decision overturned by the B.C. Court of Appeal On November 27, 2012, the British Columbia Court of Appeal overturned a ruling which had initially granted a young woman’s request to amend the province’s Adoption Act so that donor-conceived individuals could access identifying information about their biological parents. In 2008, Olivia Pratten, now 30 years old, argued before the court that donor-conceived people should enjoy the same rights as adoptees, who have access to this information. The case, the first of its kind in North America, is expected to go to the Supreme Court of Canada for a final decision. Since 1985, 10 jurisdictions (seven European countries, New-Zealand and two Australian states) have prohibited anonymous gamete donation.

Quoi de neuf ?

Les manchettes dans le monde de la fertilité.

Le jugement Pratten renversé par la Cour d’appel de la ColombieBritannique Le 27 novembre 2012, la Cour d’appel de la ColombieBritannique a renversé une décision rendue en faveur d’une jeune femme qui réclamait des amendements à la Loi sur l’adoption pour permettre aux personnes issus d’un don de gamètes d’accéder à des renseignements personnels sur leurs parents biologiques. En 2008, Olivia Pratten, aujourd’hui âgée de 30 ans, avait plaidé devant le tribunal que les personnes issues de donneurs devraient jouir des mêmes droits que les individus adoptés, qui ont accès à ces renseignements. On s’attend à ce que cette cause, la première du genre en Amérique du Nord, se rende jusqu’à la Cour suprême du Canada. Depuis 1985, 10 juridictions (sept pays européens, la Nouvelle-Zélande et deux États australiens) ont décidé d’interdire les dons de gamètes anonymes.

New fertility clinics open up in Quebec When the province of Quebec agreed to public funding of fertility treatments in August 2010, five fertility clinics offering the full range of treatments, including IVF, were operational in the province. Since then, three new full-service clinics have been opened in large hospitals: the CHUS in Sherbrooke, the CHUM in Montreal, and Sainte-Justine, in Montreal as well. “As Sainte-Justine is a motherchild hospital centre, our clinic will be in a good position to offer young patients fertility preservation services”, says Johanne Martel, Development Coordinator of the mother-child program. Moreover, thanks to its renowned team of geneticists, Sainte-Justine has been mandated by the Quebec government to offer pre-implantation genetic diagnosis for all fertility clinics in the province.

De nouvelles cliniques de fertilité au Québec Au moment où la province de Québec a accepté de financer les traitements de fertilité en août 2010, cinq cliniques de fertilité offraient la gamme complète des traitements, y compris la FIV. Depuis, trois nouvelles cliniques offrant les services complets ont ouvert leurs portes dans de grands centres hospitaliers : au CHUS de Sherbrooke, au CHUM à Montréal et à l’hôpital Sainte-Justine, à Montréal également. « Étant donné que Sainte-Justine est un centre mère-enfant, notre clinique sera bien placée pour offrir aux jeunes patients des services de préservation de la fertilité », dit Johanne Martel coordonnatrice au développement au programme Santé de la mère et de l’enfant. De plus, grâce à son équipe renommée de généticiens, Sainte-Justine a été mandatée par le gouvernement du Québec pour offrir le diagnostic préimplantatoire à toutes les cliniques de fertilité de la province.

SPRING/PRINTEMPS 2013 • Creating Families

What’s New?

India

L’Inde

resserre les règles sur la maternité de substitution

tightens the rules on surrogacy claims these changes were necessary because several children born from surrogacy arrangements were left stateless as several countries, namely Italy, Germany and Norway, do not recognize children born from such agreements.

One can no longer travel to India on a tourist visa and enter into a surrogacy agreement. People are now required to apply for a “medical” visa; moreover, single people and gay couples, who previously could enter into surrogacy arrangements, will be denied this possibility from now on. Only heterosexual couples who have been married for at least two years may qualify, after proving that surrogacy is legal in their home country and that the child will be recognized there as their biological child. The Indian government

Il n’est plus possible de se rendre en Inde avec un visa de touriste pour y conclure un arrangement avec une mère porteuse. On doit maintenant demander un visa « médical ». De plus, les

a Personal Lubricant for Couples trying to Conceive

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Créons des familles • SPRING/PRINTEMPS 2013

célibataires et les couples de même sexe, qui jadis pouvaient conclure une entente avec une mère porteuse, se verront refuser cette possibilité dorénavant. Seuls les couples hétérosexuels mariés depuis au moins deux ans sont admissibles, après avoir fait la preuve que la maternité de substitution est légale dans leur pays d’origine et que l’enfant y sera reconnu comme leur enfant biologique. Le gouvernement indien affirme que ces changements étaient nécessaires du fait que plusieurs enfants nés d’ententes avec des mères porteuses se sont retrouvés apatrides, parce que certains pays, notamment l’Italie, l’Allemagne et la Norvège, ne reconnaissent pas les enfants nés de tels arrangements.

1/3 One-third… Amount of the drop in sperm counts in France between 1989 and 2005.

Quoi de neuf ? Two nutritional tips

Clinical data has shown that if omega-3s are part of a woman’s diet, it may have a beneficial outcome on the quality of her embryos. So said Dr. Nick Macklon, professor of Obstetrics and Gynaecology at the University of Southampton, during a conference on the impact of weight and nutrition on fertility held in England in December 2012. Dr. Macklon cautioned however that these findings need to be confirmed by further research. Another rather surprising suggestion was made at the same event: it would seem that consistency in the mother’s diet is important. Dietary changes could negatively impact the development of her baby as it tries to adapt to different nutrients.

Deux conseils nutritionnels

Des données cliniques montrent que si les oméga-3 font partie de la diète d’une femme, cela pourrait avoir des effets bénéfiques sur la qualité de ses embryons. Voilà ce qu’a proposé le Dr Nick Macklon, professeur d’obstétrique et de gynécologie à l’Université de Southampton lors d’un congrès sur les conséquences du poids et de la nutrition sur la fertilité tenu en Angleterre en décembre 2012. Le Dr Macklon a toutefois prévenu que cette hypothèse devra être confirmée par des travaux supplémentaires. Une autre suggestion plutôt étonnante a été faite au même événement : il semble que la constance dans la diète maternelle soit importante. Les changements diététiques pourraient nuire au développement du bébé, obligé de s’adapter à des nuriments différents.

Inc.

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

33%

U Maîtrise en gynécologie (Chine) U Diplôme de médecine (MD) en médecines chinoise et occidentale (Chine) U Reconnue par l'Ordre des Acupuncteurs du Québec 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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Pourcentage de la diminution de la numération des spermatozoïdes en France entre 1989 et 2005.

SPRING/PRINTEMPS 2013 • Creating Families

ILLUSTRATIONS: KAREN HIBBARD

A Story of Embryo Donation by Cheryl Dancey At 42 years old, and after struggling with infertility for eight years, it is hard to imagine that there was a time in my life when I did not know what IUI, IVF or FET (frozen embryo transfer) were. There was a point when I knew very little about the world of infertility. Sure, I had heard it was something that some people struggled with, but I never thought it would touch my life in the way that it has. When I first sought treatment I was hopeful, optimistic… and very naive. The better part of a decade later, I am so much wiser, still infertile and, miraculously, a Mom. Our first appointment at our clinic was

in January of 2005. My husband and I had been trying to conceive for about a year on our own. As we were a little older we thought it could not hurt to get checked out sooner rather than later. We were both cleared of any detectable medical conditions that would interfere with our fertility. On to IUIs we went, feeling very confident that we would just need a minor intervention to help us have the baby we so desperately wanted. Yet month after month ended in disappointment. Maybe this was not going to be an easy solution. After our seventh IUI we had “the talk” with the doctor – perhaps we

should consider moving on to IVF. It was really hard for us to come to terms with this. On paper our cycles were great, but always unsuccessful. After our 10th IUI we made the decision to try IVF. As it was put to us, the first IVF cycle could be looked at as a diagnostic

When I first sought treatment I was hopeful, optimistic… and very naive. The better part of a decade later, I am so much wiser, still infertile and, miraculously, a Mom.

SPRING/PRINTEMPS 2013 • Creating Families

Maybe this was not going to be an easy solution. After our seventh IUI we had “the talk” with the doctor – perhaps we should consider moving on to IVF. test and help to give some answers as to what may be going wrong.

embryo to transfer, and this ended in a chemical pregnancy.

One problem was obvious right from the start; on our first cycle only two eggs were retrieved. The good news was they both fertilized and became grade one embryos. The bad news was a negative pregnancy test. Our second attempt at IVF ended up with only one

It was one of the most crucial decisions of our lives to continue on to a third IVF. The process was taking a toll on us and on our marriage – emotionally, physically and financially.

Créons des familles • SPRING/PRINTEMPS 2013

A third and fourth IVF each produced

only one embryo to transfer. Our fourth and last attempt ended in a miscarriage after just a few weeks. It was very clear that I was not producing enough eggs to continue on this route. We both came to terms with the fact that I was never going to have children that shared both of our genes. Then we had another huge decision to consider

and make: what would we try next? We started looking into egg donors and initiated the “adoption” process through Children’s Aid along with trying to sort out our lives financially. We were at a point where it did not matter where our baby came from; we were open to any and all avenues. The bottom line was we wanted to be parents.

These embryos are created with love, longing and with the purpose of giving them life. Isn’t it wonderful to know the choice is there to make them part of a loving family? One day we received a call informing us embryos were available if we wanted them from a couple intending to donate them to patients at our fertility clinic. Our instant reaction was: YES! Genetics was not an issue; we would have another chance at becoming parents. That was all that mattered. The only conflict my husband and I had was: Would we tell our family, friends and even our child the origin of his/her conception? Once again we were having discussions that I never pictured would take place in our marriage. We had a lot to take into consideration and, looking at everything from all angles, we came to our decision. We went ahead with the FET and two weeks later we were pregnant! Several beta tests and our 7-week ultrasound later, it was official and we were ready

to share our amazing news. When we told our families and closest friends we revealed the whole wonderful story of the donated embryos. However, when the excitement of the news finally settled we were met with some questions. They, like most people, had never heard of donating embryos to someone else. We have come to find out that a lot of people who have gone through IVF and have unused embryos don’t even know this is an option. Many couples that are left with remaining embryos after they have completed their families believe there are three options only: destroying the embryos, donating them to medical research or keeping them frozen year after year and not really making a decision at all.

everything we went through, and also what the donor couple went through, was to bring our daughter to us. We have been open with everyone in our lives. We are proud of our daughter’s beautiful and very unique story and we will raise her to feel that pride as well. She was conceived from love, generosity and selflessness. Our lives have been touched by people whom we will never know. They made a very difficult decision, and without that decision my husband and I would not be parents and our daughter may never have existed. I am eternally grateful to our donors for choosing to place this miracle in our lives. We are forever changed and blessed. ■

These embryos are created with love, longing and with the purpose of giving them life. Isn’t it wonderful to know the choice is there to make them part of a loving family? Our daughter was born into a family that adores her. She is the center of our lives and we could not love her more. This is the baby that was meant to be ours and we are the parents that were meant to be hers. I truly believe that

Cheryl's daughter, Avery

SPRING/PRINTEMPS 2013 • Creating Families

Expressions of Infertility

Expressions of Infertility is an art exhibition curated in the Fall of 2012 by the Ottawa Fertility Centre and its Managing Director, Mark Evans. It called for visual and literary works by anyone touched directly or indirectly by infertility. Reproduced here, are the winning entries which we were given permission to publish in Creating Families. See all entries at: http://www.expressionsofinfertility.com/

THE MOST TRYING JOURNEYS BREED THE GREATEST TREASURES - Harmony Hawthorn, 1st place (painting)

Créons des familles • SPRING/PRINTEMPS 2013

For butterflies In the beginning, I knew you as butterfliesTremulous anticipation Struggling to be still Against what we knew could come to pass. You, caught in the bonds of your cocoon, Quickening with the spark of life, Then fluttering and flickering, LOSS IN THE LOTUS POND - Karen Paquette, 2nd place (painting)

Wings beating back the darkness. But I lost you there, somewhere in the Days of Awe When it is inscribed who shall live and who shall die. Foot first, you emerged into my reality In time for regret and atonement. Your perfection beyond my imagining, As fragile as you were beautiful. Wings leaving only dust behind, The flickering but a memory. I still see you in the moon, Leah, And Isaac in the rain. My hand cannot grasp the absence Where the wings of butterflies once beat. - Lana Fawcett Helman 2nd place (Poetry)

FINDING ENOUGH HOPE - Karen Paquette, 2nd place (photography) SPRING/PRINTEMPS 2013 â&#x20AC;˘ Creating Families

Popsicle We named it Popsicle. In retrospect, that was a mistake. Popsicle was a leftover, the not-quite-as-nice three-day embryo from a round of IVF. We slid its sibling into me and grew Popsicle out. Two days later, Popsicle had blossomed into a beautiful five-day embryo. “We only see one this good once every two years,” the doctor said. We froze it, and hoped that the one already in me looked just as nice. My next period was not even a day late. Popsicle’s sibling had vanished, absorbed into me or drained out with my period. But we were consoled by the knowledge that we had a model embryo in reserve. We’d had bad luck with IVF before, but now we had an embryo so good that is stood out at a fertility clinic with thousands of successful pregnancies on the books. We couldn’t thaw and implant our model embryo right away, we had to wait: for my hormones to recover from IVF; for a mock cycle to go by; for yet another month when stress made my body skip a period. Three months went by, and while we waited, imagination took over. First I pictured myself with a full, round belly, patting it and calling it Popsicle. Soon we were calling the embryo Popsicle in

conversation. I imagined the nickname sticking well into childhood: an affectionate term for an adorable, two-headed toddler. In my mind, Popsicle scampered around our apartment, teased the cat, asked a million questions, made messes and laughed. Finally, it was time. The clinic measured and approved my hormones and my uterine lining. I had a plush landing pad, ready to receive Popsicle. We set a date: Wednesday afternoon. Wednesday morning, we got a call from the clinic. Our beautiful embryo had died on the table. Popsicle was in the unlucky ten percent that don’t survive the thaw. I cried. My husband cried. We held each other and cried. Not for the model embryo, but for Popsicle. The child we’d allowed ourselves to imagine. Popsicle the baby with the gummy smile; Popsicle the toddler with blonde hair in a bowl-cut and bright blue eyes, or maybe green. Popsicle, who would never exist now, and who we never should have named. That was months ago now, we’ve been through another round of IVF which ended with a period, and we have four more frozen embryos. None of them are as lovely as Popsicle was. And we won’t be naming them. - Anonymous, 1st place (Poetry)

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Undoubtedly, the Pratten1 decision is one of the most important cases decided in the past couple of years relating to assisted third-party reproduction in Canada. If Ms. Pratten is successful at the Supreme Court of Canada, the decision will have far-reaching consequences and implications that will not only affect the practice of third-party gamete donation across Canada, but will also affect our understanding of who is a parent, which decisions ought to be left to parents to determine the best interests of a child and which are to be answered by the state, what are appropriate limits on reproductive freedoms, whether a right to know one’s familial past exists at common law and whether the courts can force the Government’s hand to draft and enact legislation where none exists.

Types of donors: known vs. open-identity vs. anonymous

The Pratten Case: A Landmark Decision Coming Up by Sara Cohen

Créons des familles • SPRING/PRINTEMPS 2013

Before we delve into the Pratten decision, let’s take a brief look at the practice of gamete donation in Canada today. In contrast to the time in which Olivia Pratten was conceived (the early 1980s), when only anonymous gamete donors were available, there are currently three types of third-party gamete donors: known donor2, -open-identity donor (referred to as an “open-ID donor”) and anonymous donor. A known donor is simply a donor who is known to the intended parent(s). In my fertility law practice, I often see sisters, brothers, cousins and friends donating gametes for the recipient’s reproductive purposes. A known donor does not necessarily have any greater obligation than an anonymous donor to provide, among other information, updated family medical histories to the recipient, and the parties have no more of a legal obligation to disclose to the child how he or she was conceived. These obligations, if any exist, ought to be dealt with in a contract between the parties. An open-ID donor is a donor whose identifying information (often including contact information, social insurance number, date of birth, etc.) will become available to the donorconceived child when he or she reaches the age of 18. The donor’s obligation to update his or her medical history, provide updated contact information and provide updated medical histories is determined by the specific contractual obligations (typically between the donor and the sperm bank). The information provided to the donor-conceived person, while

generally quite similar, will vary depending on which sperm bank was used.

Ms. Pratten alleged that donor-conceived people

bank with its own donors, had no openID donors in Canada. It now has several, and the number is expected to rise. Furthermore, about 60% of all sperm imported into Canada is now open ID.

What is the Pratten decision?

who do not have access to

The lower court decision

identifying information

Olivia Pratten was conceived in the early 1980s in the Province of British Columbia through the use of anonymously donated sperm. In 2011, Madam Justice Adair of the Supreme Court of British Columbia heard Ms. Pratten’s case. Ms. Pratten alleged that donorconceived people who do not have access to identifying information about the donor can and do suffer from anxieties and other harms. Ms. Pratten contends that medical information and family medical histories are necessary, but not enough – identifying information about the donor is necessary to alleviate the harm. Olivia Pratten argued that the experience of donor-conceived adults is analogous to that of adult adoptees and that just as closed adoptions are prohibited in Canada, so too should be anonymous gamete donation, and that donorconceived adults should have access to the same information about the donor that adult adoptees do about birth parents3. Ms. Pratten’s argument is that by failing to provide her such information, British Columbia breached her constitutional rights under sections 15 and 7 of the Charter of Rights and Freedoms4.

about the donor can and do suffer from anxieties and other harms. Finally, there is the anonymous gamete donor. The expectation in the case of an anonymous donor is that he or she will remain anonymous, even after the donor-conceived child reaches the age of 18. Depending on the practices of the sperm bank and/or clinic, this may or may not be reflected in an agreement between the donor and the sperm bank, or in an agreement between, for example, an anonymous ova donor and the recipient intended parent. From a legal perspective, there is no reason why an anonymous donor could not be contractually obligated to provide updated medical and family histories in much the same way as are some open-ID donors. However, at this time, with few exceptions, this is not the general practice. Several elements point to how practices and our conceptions of third-party reproductive technologies are evolving. At the time when the Pratten decision was first heard less than two years ago, the evidence before the court was that Repromed, the only Canadian sperm

Madam Justice Adair largely agreed with Ms. Pratten, and found that donor-conceived adults were discriminated against as compared to adult adoptees, that adult adoptees were an analogous group, and that Ms. Pratten’s section 15 (1)

Charter rights had been violated. Accordingly, Madam Justice Adair ordered that the provisions of British Columbia’s Adoption Act and Adoption Regulation specified by Ms. Pratten5 are unconstitutional and are therefore of no force and effect, giving British Columbia fifteen months in which to revise the legislation. She also granted a permanent injunction prohibiting the destruction, disposal, redaction or transfer out of British Columbia of gamete donor records in British Columbia6. Interestingly, although she specifically held at paragraph 215 that “…based on the whole of the evidence, …using an anonymous gamete donor is harmful to the child, and it is not in the best interests of donor offspring,” Madam Justice Adair did not specifically prohibit anonymous gamete donation (and was not specifically asked to do so, although the Pratten decision is generally referred to as doing so), but instead found British Columbia’s adoption legislation unconstitutionally underinclusive (which would have more or less the same effect).

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Olivia Pratten argued that the experience of donor-conceived adults is analogous to that of adult adoptees and that just as closed adoptions are prohibited in Canada, so too should be anonymous gamete donation. The decision of the Court of Appeal for British Columbia At the end of November, 2012, the Court of Appeal for British Columbia released its long-awaited decision on the Pratten appeal. The Honourable Mr. Justice Frankel, writing on behalf of a unanimous court, overturned Madam Justice Adair’s decision and held that even if donor-conceived adults are discriminated against as compared to adult adoptees, this potential breach of section 15(1) Charter rights is constitutionally supported by section 15(2) of the

Charter (the affirmative action provision). In other words, just because the legislature saw fit to provide certain rights to one disadvantaged group doesn’t mean it must legislate the same rights for everyone. The Court of Appeal agreed with the lower court in finding that Ms. Pratten’s section 7 Charter rights had not been breached. Justice Frankel specifically noted that there is no such right in law to know one’s past, referring to Marchand v. Ontario7, an Ontario Court of Appeal decision (which, interestingly enough, the Supreme Court of Canada refused to hear) where an adoptee was seeking the disclosure of her biological father’s name8. In denying the appeal in Marchand, the Ontario Court of Appeal held that, The unconditional disclosure of identifying personal information of third parties, even if they are birth parents of the claimant, without regard to the privacy and confidentiality interests of the persons identified and without regard to any serious harm that might result from disclosure, fails to meet the above criteria. It is not a principle that is vital or fundamental to our societal notion of justice. It is instead a proposition of public policy that continues to be vigorously debated.

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Créons des familles • SPRING/PRINTEMPS 2013

Further, Justice Frankel points out in paragraph 51 of the Court of Appeal Pratten decision that, what Ms. Pratten seeks is far more extensive than what is enjoyed by most people in Canada and would result in state intrusion into the lives of many. There are many nondonor offspring who do not know their family history or the identity of their biological father because of decisions taken by others, or because of the circumstances of their conception. For example, there is presently no law that compels a biological parent to share with a child whatever medical, social, or cultural information he or she may have concerning the other biological parent.

What is the next step in the legal process of the Pratten decision? In a number of interviews, Olivia Pratten has made it clear that she

intends to see her case all the way to the Supreme Court of Canada. We are now waiting to hear whether the Supreme Court of Canada will grant leave to hear her case. If leave is granted, the Supreme Court of Canada would then hear the case and make a final ruling. If leave is denied, the Court of Appeal decision will stand.

What happens if Olivia Pratten is successful at the Supreme Court of Canada? I am frequently asked by clients, doctors and clinics what the consequences will be if Ms. Pratten is successful at the Supreme Court of Canada. Although I don’t have a magic crystal ball, here are some of the expected implications:

• Perhaps, with the exception of Québec, the Pratten decision will affect all provinces across Canada and not just British Columbia. Over the past few decades, provincial legislation has been enacted across Canada setting out the information about birth parents that ought to be made available to adult adoptees9. For example, in 2008, Ontario enacted the Access to Adoption Records Act, 2008, the relevant parts of which are similar to the provisions of British Columbia’s Adoption Act (R.S.B.C. 1996, c. 5) challenged by Olivia Pratten. Should the Supreme Court of Canada restore the lower court decision and determine that donor-conceived people are discriminated against vis-à-vis adult adoptees contrary to section 15(1) of the Charter and that such discrimination cannot be saved by section 15(2) or 1 of the Charter, then it logically follows that all provincial legislation similar to the impugned legislation is similarly unconstitutional.

The order sought by Ms. Pratten is limited to gamete donation. Accordingly, even if Ms. Pratten is

• The Pratten decision will affect the practice of using third-party donor ova in addition to donor sperm. Although Olivia Pratten was born through the use of thirdparty donor sperm and not donor ova, the order she seeks is with respect to all people conceived through donor gametes and not sperm in particular. This is interesting because unless things have substantially changed with the importation of frozen donor ova from the US, ova donors in Canada tend to either be anonymous or known and not open-ID. • It would seem logical that the (far less frequent) practice of embryo donation will be affected as well. To my knowledge, embryo donation is practiced far less frequently in Canada than is either sperm or ova donation. The order sought by Ms. Pratten is limited to gamete donation. Accordingly, even if Ms. Pratten is successful at the Supreme Court of Canada, the order would not necessarily extend to include embryo donation as an embryo is not a gamete. However, the arguments made by Ms. Pratten and her counsel can equally relate to embryo donation, so this would be a logical extension.

successful at the Supreme Court of Canada, the order would not necessarily extend to include embryo donation as an embryo is not a gamete.

The Final Word For now, we don’t know whether the Supreme Court of Canada will even grant leave to hear the Pratten case, let alone

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what it will decide if it does choose to hear it. However, in the interim, sperm banks and clinics may want to consider keeping records on all gamete donors indefinitely. Moreover, it’s important for parents considering the use of anonymously donated gametes, and for anonymous gamete donors themselves, to know that they may be unable to rely on this anonymity in the future. Furthermore, websites such as the Donor Sibling Registry and innovative techniques such as DNA matching make it impossible to guarantee anonymity today. Regardless, whatever the decision, and whether or not we agree with her position, Olivia Pratten has highlighted some important issues for us to think about with respect to the use of donor gametes in Canada. ■

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References 1 Pratten v. British Columbia (Attorney General), 2011

BCSC 656, overturned 2012 BCCA 480 2 Note that in making its finding of fact in Pratten, the

court only took notice of open-identity donors and anonymous donors and did not examine known donors. 3 Pratten v. British Columbia (Attorney General), 2011

BCSC 656. 4 Constitution Act, 1982, c.11. 5 Other than s. 4(1)(e) to (h) of the Regulation 6 Supra note 4 at para. 335 7 2007 ONCA 787, 288 D.L.R. (4th) 762, aff’g (2006),

81 O.R. (3d) 172 (S.C.J.), leave ref’d [2008] 1 S.C.R. ix (sub nom. Infant Number 10968) 8 2012 BCCA 480 at para. 529 See, for example, Alberta’s Child, Youth and Family

Enhancement Act, C. c-12.

About the Author Sara R. Cohen is a fertility lawyer in Toronto, Canada, but with clients throughout the country and beyond. She approaches fertility law with the compassion, empathy and respect it deserves. Sara's passion is to help build families and she considers herself very fortunate to have such a fulfilling career. Sara has been widely quoted in the media about issues relating to fertility law in Canada. She is an advocate for all parties involved in thirdparty reproductive technology and works closely with intended parents, surrogate mothers, gamete donor and recipients, as well as domestic and international businesses in the fertility industry. You can read more about her practice at www.fertilitylawcanada.com, follow her on Twitter @fertilitylaw or on Facebook at www.facebook.com/FertilityLawCanada.

LEÇONS DE SURVIE parce que NOTRE MONDE EST UNE JUNGLE!

« Cherchez à mener la vie de vos rêves, et vous connaîtrez le succès là où vous ne vous y attendiez pas. » Voilà comment je conclus la plupart des exposés que je présente à des équipes, des entreprises, des dirigeants et des étudiants. Une fois prononcés, ces mots semblent sortir de leur banalité et se transformer en un message fort qui nous dévoile tous les possibles.

La première leçon que j’ai apprise est que la clé de la survie, c’est l’attitude.

par Yvonne Camus Traduction : Gabrielle Filteau-Chiba

J’ai eu l’occasion de tester les limites du possible lorsque j’ai participé en l’an 2000 à la course Eco-Challenge à Bornéo, en Malaisie. Cette course d’aventure est certes l’un des plus grands défis auxquels j’ai fait face dans ma vie. Il s’agit d’une course sans escale sur 500 km dans les coins les plus reculés de la planète. Les athlètes sont regroupés en équipes mixtes de quatre personnes, et la plupart sont formées de trois hommes et d’une femme. Les membres de l’équipe doivent rester ensemble en tout temps. Nous transportons toute notre nourriture et tout notre équipement en plus de devoir trouver et purifier l’eau dont nous avons besoin pour survivre. Ce faisant, nous devons nous orienter à l’aide de cartes topographiques et de boussoles – les GPS sont interdits ! « L’EcoChallenge ne fait qu’une bouchée d’Ironman », a dit un journaliste.

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Mon expérience de la course à travers la nature sauvage de Bornéo n’est pas si différente de ce que vivent nombre de personnes qui rencontrent des difficultés familiales. La course à Bornéo se disputait sur plus de 100 km de vélo de montagne, près de 50 km de randonnée dans la jungle, plus de 100 km de canot en eau vive et des dizaines d’heures de pagaie en mer à bord de pirogues à balancier fabriquées par une tribu locale; nous devions aussi escalader des grottes de chauves-souris

Créons des familles • SPRING/PRINTEMPS 2013

et descendre en rappel une falaise de 180 mètres. Vous vous demandez peutêtre qui donc peut accepter de soumettre sa volonté à une telle épreuve. Je pense simplement que tout progrès dépend entièrement de la volonté qu’ont les gens de se dépasser. Ceux qui connaissent le succès savent que s’ils

s’améliorent, leur situation s’en portera mieux. La course Eco-Challenge a été pour moi, en ce sens, un défi à me dépasser. Mon expérience de la course à travers la nature sauvage de Bornéo n’est toutefois pas si différente de ce que vivent

nombre de personnes qui rencontrent des difficultés familiales. Au sein d’une petite équipe de gens dévoués, j’ai décidé de relever un nouveau défi en terrain inconnu. Pour terminer la course, il fallait faire preuve de beaucoup d’endurance, de vision, de confiance en soi et en son équipe, d’adaptation aux changements constants et imprévisibles. S’ajoutait la responsabilité de prendre des décisions importantes qui pourraient avoir des répercussions sur le résultat de tous les efforts déployés par l’équipe. Le défi que vous devez relever ne consiste pas nécessairement à escalader une falaise escarpée ou à esquiver des serpents dans les eaux tumultueuses d’une rivière, mais certaines leçons que j’ai tirées de mon expérience dans la jungle bornéenne s’appliquent à la jungle de notre vie quotidienne. Ces leçons de survie permettent aux gens de maintenir le cap et de réussir, peu importe le défi à relever. La première leçon que j’ai apprise est que la clé de la survie, c’est l’attitude.

Je crois que nous devrions nous poser continuellement la question suivante : « Est-ce qu’on peut faire mieux? », en espérant y répondre de façon positive. La curiosité sans bornes est alimentée par l’enthousiasme –

Le défi que vous devez relever ne consiste pas nécessairement à escalader une falaise escarpée ou à esquiver des serpents dans les eaux tumultueuses d’une rivière, mais certaines leçons que j’ai tirées de mon expérience dans la jungle bornéenne s’appliquent à la jungle de notre vie quotidienne. c’est une « ressource renouvelable » que notre équipe a découverte au fil de la course, lorsqu’il faisait 40 degrés Celsius avec 95 % d’humidité! Plus on apprend à cultiver l’enthousiasme dans l’effort, plus on suscite un élan intérieur qui nous permet d’atteindre nos buts. Prenez le temps de vous rappeler la dernière fois où vous étiez à votre

meilleur. Dans le monde du sport, on porte une attention particulière à l’instant où l’on a fracassé tous ses records. Nous avons malheureusement, en tant qu’êtres humains, la fâcheuse habitude de ruminer les moments les plus sombres de notre vie. Nous nous réfugions dans la tristesse et laissons le bonheur s’évanouir. C’est pourquoi je vous encourage à vous créer un environnement positif et à vous rappeler souvent la personne que vous êtes, à votre meilleur. Garder le moral tout au long d’un chemin ardu est bien plus facile si vous vous entourez de gens incroyables! Vous devez vous créer un réseau puissant qui vous appuie, sans vous critiquer. Il m’a été essentiel d’être dans un environnement où j’étais célébrée, et non simplement tolérée. La deuxième leçon consiste à adopter une approche pour résoudre les problèmes qui vont inévitablement se présenter. Nous avions prévu que d’importants rebondissements surviendraient au cours de l’EcoChallenge, lesquels mettraient à l’épreuve nos plans bien établis. Nous avons convenu au préalable que nous éviterions les confrontations le plus possible. Les disputes consomment beaucoup de temps et d’énergie. Nous avons

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que nous avons trouvée en nous livrant à la course la plus laborieuse au monde est la capacité à composer avec l’incertitude. Comme athlètes, nous savions déjà quels sports feraient partie de la course. Cependant, nous ne connaissions pas la distance à parcourir, la durée de l’exercice, le déroulement ni l’itinéraire de la course – ces détails sont gardés secrets et ne sont dévoilés qu’au fur et à mesure. En outre, les organisateurs de la course ont volontairement apporté des changements de dernière minute pour éprouver la capacité d’adaptation de chaque équipe. C’était comme dans la vraie vie – pas de répétition générale. Nous avons vu certaines équipes paralysées à l’idée que les choses ne se dérouleraient pas exactement comme prévu. Ainsi, nous avons retenu une leçon très ancienne : le sage agit immédiatement, le fou, éventuellement.

Nous avons vu certaines équipes paralysées à l’idée que les choses ne se dérouleraient pas exactement comme prévu. Ainsi, nous avons retenu une leçon très ancienne : le sage agit immédiatement, le fou, éventuellement. plutôt élaboré une stratégie pour faire face à l’adversité. Lorsque nous nous butions sur des obstacles inattendus, nous pensions à la façon de les surmonter en nous posant la question : « Comment pourrait-on améliorer la situation maintenant? ». Cette question nous poussait à discuter sans tarder de la SOLUTION, et non du PROBLÈME. La deuxième étape de notre résolution de problème consistait à prendre une décision CONCERTÉE. Il faut

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absolument s’investir à fond dans une idée pour la mener à bien. Les écoles de commerce à travers le monde ont démontré maintes fois qu’une idée de niveau « A », dont la mise en œuvre est de niveau « B », a moins de chances de réussir qu’une idée de niveau « B », dont l’application est de niveau « A ». Par ailleurs, la réussite tient rarement aux efforts d’une seule personne, tandis que l’échec peut résulter du manque d’effort d’une seule personne. Une autre clé de la survie et du succès

Lorsque les gens apprenaient que nous avions pris part à une course dans une jungle infestée de sangsues, de serpents et de chauves-souris, un des commentaires qui revenait le plus souvent était : « Ne vous sentiez-vous pas MISÉRABLES? 24 heures sur 24? ». En fait, malgré les conditions horribles et les relations tendues, nous avons connu des moments de gloire. Comment? Dans ce même environnement qui aurait pu nous donner l’impression d’être démunis, nous avons vu des orang-outans, des singes ont bondi à bord de nos canots, des volées de toucans étaient perchées dans les arbres, nous avons contemplé des chutes et des fleurs hautes d’un mètre. C’était tout simplement incroyable. Nous avons vu des choses impossibles à voir à moins de pénétrer dans un environnement que la plupart des gens estiment trop hostile pour être agréable. Je pense qu’il

se produit exactement le même phénomène lorsque nous jetons un regard extérieur sur les périples difficiles de notre vie. Enfin, j’ai constaté qu’il ne faut pas oublier que les efforts vains peuvent être une source de frustration, mais que les efforts fructueux nous revitalisent. La dernière leçon, qui est d’ailleurs sous-jacente à toutes les autres, consiste à viser l’excellence. Les bons résultats ne sont jamais dus au hasard. Une performance médiocre peut être accidentelle. Cependant, l’excellence est l’apanage des personnes prêtes à se dépasser. Il est toujours plus facile de fixer de plus hautes attentes pour les autres. Nous nous disons que « s’ils faisaient un peu mieux LEUR travail, les choses iraient mieux dans notre quotidien ». En fait, la situation ne s’améliore que lorsque nous nous efforçons d’évoluer

nous-mêmes.

Se lancer dans une course de 500 km, avec pour seule énergie la force humaine, est une bonne leçon d’humilité. Nous avons découvert l’efficacité « d’accélérer pour traverser la zone accidentée », leçon tirée du Nascar. Nous sommes arrivés à la conclusion qu’en accordant trop d’attention à la difficulté de la course et à son effet sur nos corps et nos esprits, nous nous laissions submerger par l’inconfort; l’enthousiasme et l’effort nécessaires pour franchir la ligne d’arrivée étaient alors plus difficiles à raviver. Si souvent, lorsque les choses tournent mal, nous levons littéralement le pied de l’accélérateur pour en subir ensuite les contrecoups. Nous savions que la douleur était inévitable, mais la souffrance, elle, est facultative.

Au moment de créer votre propre plan pour réussir à braver votre jungle quotidienne, n’oubliez pas ce dont vous êtes capable dans vos meilleurs moments; appliquez-vous et comptez sur les personnes merveilleuses qui sont prêtes à vous tendre la main. Surtout, visualisez le succès – les grandes réalisations prennent forme deux fois : d’abord dans votre imaginaire, puis dans la réalité. ■

Garder le moral tout au long d’un chemin ardu est bien plus facile si vous vous entourez de gens incroyables!

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Reducing Canada’s Reproductive Technology-Related Multiple Births Canada’s Role Through Education by Kimberley Weatherall Recently I spoke at an International Congress on Twin Studies. I was asked to speak about Multiple Births Canada’s role in reducing Canada’s reproductive technology-related multiple births. The following article is based loosely on that presentation and resources created by MBC, with the assistance of the former Assisted Human Reproduction Canada, to help individuals and families understand the risks and challenges surrounding a multiple pregnancy with the goal of reducing Canada’s multiple-birth rate due to reproductive technologies. Canada has one of the highest rates of multiple births in the world due to the use of assisted human reproduction technologies. Multiple Births Canada (MBC) understands the risks and challenges that conceiving and raising multiple-birth children can bring to a family, and therefore we support the move towards single embryo transfer in IVF with

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the goal of giving birth to one healthy child at a time (the province of Quebec mandated a Single Embryo Transfer policy on August 5, 2010). Having said that, we fully appreciate the desire of an infertile individual or family to have a child of their own, and understand just how tempting it may be to accept or even demand that more than one embryo be transferred during an IVF cycle. Often people have an image of life with twins and higher-order multiples (triplets and higher) based on what they see in the media and not based on reality. The chance of conceiving multiples may seem like a wonderful stroke of luck, receiving “two for the price of one.” Unfortunately, multiple pregnancy is a highrisk situation. Most people do not see the anxiety, the miscarriages, preterm births,

The chance of conceiving multiples may seem like a wonderful stroke of luck, receiving “two for the price of one.” infant deaths or long-term disabilities that can be associated with multiple births, nor the financial and emotional stresses that may impact the whole family. The risks and longterm challenges are significant, and the outcome can be heartbreaking. MBC knows that many families receive little or no counselling related to the outcome of conceiving multiples. Many are not made aware of the potential health risks to the mother or to the babies associated with such a high risk pregnancy, and even fewer are made

aware of the possible physical, financial and emotional challenges that they may face in the future. While we love our multiple-birth children, we know a healthy “singleton” baby is definitely a better outcome than those that many of our members have experienced with twin, triplet, or higher-order multiple pregnancies. We feel a responsibility to ensure that families that are planning to use assisted reproduction technologies fully understand the risks they take when agreeing to these procedures, and what some of the realities may be for the pregnancy, birth and long into the future should they conceive twins, triplets or more. In partnership with the former Assisted Human Reproduction Canada (AHRC), Canadian fertility organizations, medical professionals and other patient groups, MBC has been assisting in the development and sharing of educational resources to ensure that all fertility patients are educated about the risks associated with a multiple pregnancy. While the medical community is currently working to implement policies and guidelines as to the number of embryos to transfer, and the various provincial and federal

Many are not made aware of the potential health risks to the mother or to the babies associated with such a high-risk pregnancy, and even fewer are made aware of the possible physical, financial and emotional challenges that they may face in the future.

governments address the funding of fertility treatments, MBC has chosen to use education as a means to help reduce the incidence of multiple births. It is our goal to inform future parents of multiples about the risks and challenges that they may face, while providing them the information they need to make informed choices prior to becoming pregnant.

What are the risks? A multiple pregnancy is almost always labelled “high risk.” The term risk is used to indicate that there is a chance that particular events or situations may occur. The potential for complications increases greatly with each additional baby in a multiple pregnancy.

Preterm specific challenges such as: Low birth weight

Risks to the Mother Miscarriage

Respiratory problems

Bleeding during pregnancy

Bleeding (hemorrhage) into the brain

Placental problems

Infections

Cervix problems

Hearing and vision problems

Gestational Hypertension (high blood pressure)

Heart problems

Rare complications of pre-eclampsia including stroke, heart failure, maternal death

Neurological problems such as cerebral palsy, learning disabilities, slow language development, developmental delays and behavioural difficulties

Gestational Diabetes

Gastro-esophageal reflux disorders

Hyperemesis Gravidarum (extreme nausea and vomiting)

Breastfeeding challenges

Iron Deficiency Anaemia

Complications specific to monozygotic (identical) multiples:

Pre-eclampsia

Haemorrhage Caesarean section delivery

Twin to Twin Transfusion Syndrome (TTTS) Monochorionic-monoamniotic multiples and umbilical cord entanglement

Risks to the Children Because of the complexities of a multiple pregnancy, twins, triplets and higher order multiples have a greater likelihood of health problems or even death during the prenatal period and in the months following the birth. Too much or too little amniotic fluid Restricted growth Early (premature) delivery

Conjoined multiples

Reducing the Risks While it is impossible to list and prepare for all of the possible risks that a multiple pregnancy might present with, it is important for those planning to become pregnant to be aware of the uniqueness and complexity of a multiple pregnancy, and to receive as much

SPRING/PRINTEMPS 2013 • Creating Families

information, support and guidance as early as they can. The following is a brief list of what expectant parents may do to reduce the risks: Before starting fertility treatment: • Make sure to seek counselling about the risks associated with multiple pregnancy before agreeing to specific treatments for infertility issues. • Ask your health care professionals about strategies to reduce the risk of multiple pregnancy. If ovulation induction is a possible treatment, discuss how the cycle will be monitored and what will happen if multiple eggs are produced. In some cases your cycle may be cancelled if too many eggs are developing at once. • If IVF is an option, seriously consider the use of Single Embryo Transfer (SET). Occasionally the embryo may divide into “identical” twins, even when only one is transferred, or sometimes two embryos may

Créons des familles • SPRING/PRINTEMPS 2013

Take time for personal activities such as exercise, massage, friendships, or time with your partner. Celebrate your accomplishments as an expecting or new parent – don’t focus only on the challenges. develop into triplets including an identical pair – or even quadruplets. • Ask about “selective reduction” in the case of higher-order multiple pregnancies, to reduce the number of fetuses to one or two. If you are strongly opposed to this procedure on religious or philosophical grounds, you may want to avoid AHR treatments that risk

conceiving triplets or more. • Investigate the expertise of the fertility treatment centre options including live birth rates, as well as their multiple birth rates. • Find out if there is a family history of twins on the maternal side, i.e. a tendency to multiple ovulations, and discuss with your doctors whether this might influence your choice of ART procedures. During a multiple pregnancy: • Choose an obstetrician specializing in multiple pregnancy and delivery. • If pregnant with triplets or more, or if there are health concerns with a twin pregnancy, seek out the services of a maternal-fetal medicine specialist called a perinatologist. • Where possible request a referral to a care team that specializes in multiple pregnancy (e.g. obstetrics, nutrition, education, social

hospital (e.g. additional childcare costs, travel costs, parking costs). • Potential decrease in income if one parent must stay home after the birth. • Extra costs associated with double, triple, or more in supplies and equipment, including diapers, food and clothing for years to come. • Potential need for additional or larger vehicle. • Possible move to a larger home. • Additional childcare costs after birth and when parent(s) return to work – many families do not qualify for subsidized daycare. services, and peer support).

take longer than with a single baby.

• Find out as soon as possible what the zygosity of the babies are in order to rule out health risks such as Twin to Twin Transfusion Syndrome (TTTS).

• Parents of multiples often feel isolated.

• Ask for a referral to a nutritionist to learn about the additional nutritional needs and expectations around weight gain associated with a multiple pregnancy. • Stay as healthy as possible (under the guidance of a physician), including reducing stress, keeping active, resting where possible, and avoiding alcohol and smoking. • Prepare for childbirth and labour - attend multiple-birth-specific prenatal classes if possible and know the signs of preterm labour.

• Parents may experience challenges within their marital relationship as they give so much of their time and energy to the care of the children. • Parents of multiples, compared to those having one baby, are more likely to have feelings of depression and anxiety. • Birth mothers are at higher risk for postpartum depression. • Parents of multiples can experience stress and frustration as they learn to balance all of the new needs of their family.

• Contact MBC for more information about parenting multiples and to connect with other parents of multiples.

• Having multiples can have an impact on the other children in the family with a potential for behaviour issues, feelings of being left out or resentment with all the attention the multiples receive.

What are the challenges?

Financial

Emotional • Attaching and bonding to more than one baby at a time can be challenging, and may

• Additional costs associated with a mother leaving work early to be on bed rest if required, especially if she must remain at a

• If any of the children have special needs, there will be additional costs associated with caring for the children and for specialized equipment.

Ask your health care professionals about strategies to reduce the risk of multiple pregnancy. If ovulation induction is a possible treatment, discuss how the cycle will be monitored and what will happen if multiple eggs are produced. In some cases your cycle may be cancelled if too many eggs are developing at once. SPRING/PRINTEMPS 2013 • Creating Families

sleep and feeding routines and household chores – encourage others to follow these routines when helping. Make notes and keep track of the babies’ feedings, diaper changes, sleep, medications and other events. It’s easy to lose track when you are sleep deprived. Try to sleep when the babies are sleeping. Have parents and caregivers take shifts so that each gets one longer stretch of sleep at night. 6) Organize your home and priorities

Physical and Logistical Challenges • Premature babies may require additional days or weeks in the hospital, requiring additional hours of travel and time at the hospital, along with additional care for any siblings. • Premature babies usually require more frequent feedings and diaper changes. • Parents of multiples may need additional hands-on help from family, friends or community organizations. • Breastfeeding multiples requires a lot of time, energy and support. • New parents may face an increased amount of sleep deprivation and feelings of being overwhelmed. • Physical recovery from pregnancy, bed rest and delivery could be more challenging in addition to caring for multiples.

What Can Parents do to Meet These Challenges? Top Ten Tips: 1) Prepare for the birth and parenting Learn and prepare for a multiple pregnancy, birth (possibility of caesarean section delivery), and parenting. Take a multiple-birth prenatal class. Request an early referral to

Créons des familles • SPRING/PRINTEMPS 2013

health care specialists with experience with multiple pregnancy. Contact a nutritionist or dietitian to make sure you are meeting your nutritional requirements during pregnancy. 2) Build a social support network Develop a strong support system with health professionals, family, trusted friends. Join your local multiple-birth association for information, fellowship and support. 3) Organize help Plan for the sharing of household tasks and childcare with your partner. Try to recruit practical hands-on help through family, friends, neighbours, community organizations and others who may volunteer. Find out where to hire help in your community if more assistance is needed, including students or agencies. 4) Prepare for how you will feed your babies Take a breastfeeding class during pregnancy. Learn about the benefits of breast milk for premature babies and all infants, pumping milk for babies in the NICU and feeding with bottles as well. 5) Establish a routine Develop routines (which may need to change from time to time) to simplify baby care,

Set up your home for convenience. Consider housework and chores to be a lower priority. Post instructions and lists for helpers so they can perform tasks independently. Use a telephone or computer message system to share news and updates on how the babies are doing. 7) Plan for the financial strains Look for ways to save money using coupons, shopping second-hand, etc. Attend clothing and equipment sales from your local multiple-birth support group and take advantage of their discount programs. Talk to a financial planner. Consider a short-term loan. Start RESP savings. Learn about provincial and federal maternity and parental leave standards, and child tax benefits and allowances. 8) Nurture relationships Try to foster a special bond with each baby. Be attentive to their differences, and call them by name. Learn about strategies for attachment, including skin to skin contact, holding a baby during feeding, eye contact and talking to the baby, infant massage, and using a baby carrier. Practice good communication - discussing your expectations with your partner, and work together as a team. Prepare older siblings for the arrival of the multiples, making special one-on-one time for them. Balance your time and attention between caring for each child and time with partner.

9) Nurture self Take time for personal activities such as exercise, massage, friendships, or time with your partner. Celebrate your accomplishments as an expecting or new parent – don’t focus only on the challenges. Associate with people who are supportive and recognize your abilities as a parent and as an individual. 10) Make a plan regarding public attention Newborn multiples, especially monozygotic (identical) twins or higher-order multiples, attract a lot of attention from family, friends and the public. Try to have a sense of humour, and plan how to respond to questions, interruptions, requests for pictures etc. Talk to your partner about privacy, and how comfortable you are with sharing information or photos publicly (including online). Decide whether you will allow any media exposure for your family, and who might serve as a spokesperson for your family. ■

MORE ABOUT MULTIPLE BIRTHS CANADA Celebrating over 30 years of supporting Canada's multiple-birth community, MBC is the only national support organization and registered charity for multiple-birth families and individuals in Canada. Our mission is to improve the quality of life for multiple-birth individuals and their families in Canada. We fulfill our mission by providing support, education, research, and advocacy locally, nationally and internationally to individuals, families, Chapters, and organizations that have a personal or professional interest in multiple birth issues.

The Challenges of Parenting Multiples Part 2: Twins and Higher-Order Multiples Multiple Birth Facts and Figures Please note: The Fact Sheets can be found at www.multiplebirthscanada.org under Publications. Websites Multiple Births Canada - www.multiplebirthscanada.org Assisted Human Reproduction Canada http://www.ahrc-pac.gc.ca/v2/multi/index-eng.php

RESOURCES Fact Sheets These have been produced to help families understand the risks associated with a multiple pregnancy: Multiple Births Part 1: The Possible Risks Multiple Births Part 2: Risks to the Children

About the Author Kimberley Weatherall is Acting Executive Director of Multiple Births Canada, and is Past Chair of International Council of Multiple Births Organizations (ICOMBO)

Multiple Births Part 3: Reducing the Risks The Challenges of Parenting Multiples Part 1: Couple Relationships

True North Imaging is proud to be the leading provider

of fertility imaging services in Ontario, with locations across the Greater Toronto Area and Kitchener/Waterloo Regions. Our team of professional staff has been providing high quality care and superior imaging services for over 20 years. For more information about the services we provide and our locations, please visit our website at www.truenorthimaging.com.

SPRING/PRINTEMPS 2013 • Creating Families

Bébés

magiques Un conte pour enfants par Nathalie Courcy

Créons des familles • SPRING/PRINTEMPS 2013

Illustré par ses filles Alexane et Lenya

Royaume des Espoirs, un roi et une reine s’aimaient éperdument. Ils habitaient dans un somptueux palais, voyageaient dans tous les royaumes du monde et leurs sujets les adoraient.

Pourtant, ils ne se sentaient pas comblés. Le roi et la reine rêvaient d’entendre des voix enfantines dans leur château. Plus que tout, ils désiraient tenir leurs bébés dans leurs bras et les regarder grandir chaque jour un peu plus.

– Comme ce serait agréable de se faire réveiller par des chansons d’enfants plutôt que par l’horloge grand-père ! disait le roi. – Et j’aimerais tellement jouer à la cachette et à la marelle au lieu de calculer le budget du royaume..., répondait la reine. Cela semblait pourtant impossible. Depuis leurs noces royales, ils essayaient de donner naissance à une charmante princesse ou à un petit prince. Rien n’y faisait : aucune trace de mouvement dans le ventre de la reine. Aucun bébé dans le berceau doré. Aucun gazouillis dans les tours du palais. – Continuons de diriger le royaume de notre mieux. Soyons justes et généreux. Après tout, nos sujets sont un peu comme nos enfants. Mais la nuit, lorsque la porte de leur suite privée se refermait derrière eux et que personne ne les entendait, le roi prenait la reine dans ses bras, la reine caressait les cheveux du roi, et ils pleuraient. Si au moins ils comprenaient pourquoi le mauvais sort s’acharnait sur eux… Un jour, ils annoncèrent que la personne qui conjurerait le sort deviendrait chevalier officiel du palais. C’était leur dernier espoir. Les premiers temps, il y eut bousculade au château ! Un sorcier apporta une potion bleuâtre d’où s’échappait une fumée étrange. – Majestés, cette recette de mon cru vous permettra d’enfanter des

dizaines et des dizaines de princes et de princesses à votre image. Ils seront aussi magnifiques que vous et aimés de tous. La reine goûta à la mixture. Le goût était épouvantable, mais elle cacha son dégoût pour ne pas insulter le sorcier. Sa peau tourna au bleu. Son visage se crispa. Mais son ventre resta vide et plat. Une fée se présenta au château. Elle s’approcha de la reine avec un air énigmatique. Arrivée près d’elle, elle agita sa baguette magique dans tous les sens, comme si elle chassait les mouches. « Babiole et bobinette, bébé bambino dans la bedaine ! » En prononçant ces paroles, elle donna trois coups minuscules sur le ventre de la reine. Rien ne se produisit. Une lutine savante tenta

l’impossible à son tour. – Monsieur le Roi, croyez-moi ! Ma technique fonctionne à tout coup. Prenez cette poudre dans votre main gauche, et soufflez dessus en formant un baiser avec vos lèvres. Avec votre pouce droit, répandez la poudre magique sur la tête de la reine en imaginant votre bébé. L’amour et la tendresse feront le travail… La poudre diamantée se répandit sur tout le corps de la reine grâce au souffle du roi. La robe de la reine se mit à scintiller. Il y avait certes énormément d’amour et de tendresse entre eux. Mais aucun bébé n’apparut, ni à ce moment ni plus tard. – Nous devrions tout arrêter, confia la reine. Cela ne donne rien du tout. Je suis épuisée. Des dizaines de prétendants au poste de chevalier

SPRING/PRINTEMPS 2013 • Creating Families

devenir réalité. Même s’ils avaient peur d’être déçus, la reine et le roi firent exactement ce que le paysan avait dit. La première fois qu’il vit la Lune disparaître dans l’ombre de la Terre, le roi déposa la graine de citrouille sur le nombril de la reine. Malgré leurs doutes, ils se laissèrent bercer par un rayon orangé jusqu’au matin, en espérant que la magie opère. Le lendemain, rien ne se produisit.

royal sont venus à notre rescousse et aucun n’a réussi. C’est peine perdue. Contentons-nous d’être roi et reine. Nous ne serons jamais père et mère. Essayons d’être heureux ainsi. Le roi se résolut à accepter le destin bien que son rêve de fonder une famille avec la reine fût brisé. Quelque temps plus tard, un paysan entendit parler du désir du couple royal. Comme il aimait beaucoup le roi et la reine, il eut une idée. Il prit dans son tablier trois graines : une graine de citrouille, une graine de tournesol, et une graine de marronnier. Plusieurs années auparavant, un mystérieux jardinier les lui avait remises en affirmant qu’il saurait comment les utiliser le moment venu. Le paysan confia les graines au roi en lui conseillant de les placer sur le nombril de son épouse chaque fois qu’une éclipse lunaire aurait lieu. L’homme encouragea le couple royal à être patient puisque les miracles prennent parfois du temps avant de

Créons des familles • SPRING/PRINTEMPS 2013

La semaine suivante, rien. Le roi et la reine pleuraient encore plus qu’ils ne l’avaient fait jusqu’alors. puis, un jour, la reine sentit un petit quelque chose en elle qu’elle ne reconnaissait pas. Un soubresaut, un murmure de papillon dans le creux de son ventre. Très doux, rempli de mystère. Lorsqu’elle en parla au médecin du palais, elle eut la surprise de sa vie : un minuscule bébé s’était installé en elle ! Elle l’annonça au roi en pleurant, de joie cette fois.

Plusieurs mois plus tard, un bébé bien joufflu naquit. Ses cheveux ressemblaient à une cascade de safran. Son sourire était aussi grand qu’une pleine Lune, et ses yeux étincelaient comme une flamme dansante. Le roi et la reine découvrirent le bonheur d’être parents. Ils prirent soin de leur garçon comme du plus précieux des trésors. Ils organisèrent une fête grandiose pour le présenter au royaume. Le peuple couvrit le prince de présents et souhaita aux nouveaux parents de donner naissance à d’autres enfants. Quelque temps plus tard, le paysan consulta la Nature, sa fidèle amie, pour connaître ses plans. La Nature lui annonça qu’une éclipse lunaire se préparait, ce dont le paysan s’empressa d’informer le roi et la reine. Ils attendirent cet événement avec impatience : cette fois-ci, ils savaient que la magie était possible. Lorsque le ciel s’assombrit, le roi déposa la graine de tournesol sur le nombril de son épouse qui n’osait plus respirer, de peur de la faire

tomber. La graine zébrée de noir et de blanc resta bien en place, et la magie opéra. Peu de temps après, la reine ressentit de nouveaux mouvements en elle et elle comprit qu’elle portait un enfant. Le bébé qui arriva dans leur vie était blond et lumineux, tel un soleil. Ses cheveux valsaient dans les airs comme une chanson douce. Ses mains se tournaient sans cesse vers ses parents, l’air de dire « Je vous ai attendus si longtemps ! ». En plus de voir leur fils grandir et jouer, ils avaient maintenant une mignonne princesse à dorloter. Le roi et la reine ne pensaient pas pouvoir être plus heureux.

Mais oui, ils pouvaient se sentir encore plus comblés. Le paysan leur avait donné une troisième graine, une graine de marronnier. Le couple attendit l’éclipse de Lune suivante, et ils refirent le même processus magique : le roi déposa la graine de l’arbre sur le nombril de la reine avec toute la douceur du monde, et l’attente reprit. Lorsque la reine sentit une aile de colibri bouger à l’intérieur de son ventre, elle sut tout de suite que le miracle annoncé par le paysan était complet. Au bout de plusieurs mois, le roi et la reine accueillirent un charmant prince dont la chevelure de bronze rappelait

SPRING/PRINTEMPS 2013 • Creating Families

la richesse des marrons et les yeux, la profondeur d’une forêt enchantée. Avec une si belle famille, le couple royal se sentait choyé.

miens sont devenus adultes et ils ont quitté le royaume ; ils me manquent. Ma cour est terne sans cris d’enfants ni jeux.

Ils voulaient absolument tenir leur promesse. Ils visitèrent donc le paysan qui leur avait remis les graines de citrouille, de tournesol et de marronnier. Ils lui proposèrent de devenir chevalier officiel du palais. – Majestés, leur répondit-il, votre offre me touche. Cependant, je préférerais vous servir en vous apportant les légumes de mon potager, les fruits de mon jardin et les fleurs de mon champ. Cultiver la beauté, c’est ce que j’aime faire et c’est ce que je fais le mieux. S’il vous plaît, pourrais-je rester paysan ?

À partir de ce moment, la reine, le roi et leurs trois enfants visitèrent le paysan chaque dimanche.

La reine fut attendrie par sa généreuse simplicité. Elle lui répondit : – Monsieur, je vous admire. D’abord pour le miracle que vous avez accompli, mais encore plus pour votre fidélité à vous-même. Que pourrais-je vous offrir pour vous remercier ? Le paysan réfléchit quelques secondes : – Ce qui me rendrait le plus heureux serait de rencontrer vos enfants. Les

Créons des familles • SPRING/PRINTEMPS 2013

encore plus de bonté et de bonheur et cela pour une raison : grâce à leur persévérance et à l’aide du paysan, ils avaient réappris à croire aux miracles et à la vie. ■ Nous remercions Alexane et Lenya pour leurs merveilleux dessins.

Le petit garçon roux grandit et apprit à sculpter les citrouilles pour l’Halloween. Tout ce qu’il touchait se transformait en œuvre d’art et en fête. La fillette aux cheveux dorés apprit à faire pousser toutes les espèces de fleurs jusqu’au soleil. Elle pouvait même réveiller les plantes endormies et faire refleurir les buissons rabougris. Et le petit dernier, celui qui avait les cheveux marron, choisit de récolter les fruits et les noix qui croissaient dans les arbres. Il était le meilleur ami des animaux de la forêt et les oiseaux dormaient à son chevet. Non seulement le roi et la reine avaient accompli leur mission de donner naissance à des enfants, ils avaient aussi agrandi leur famille puisque le paysan en faisait maintenant partie. Tout le peuple jubilait de voir le couple royal si heureux. Le roi et la reine traitaient désormais les sujets du Royaume des Espoirs avec

Alexane à l'œuvre

À propos de l’auteure Aux dires de sa famille, Nathalie Courcy est "née avec un crayon dans la main". Elle utilise l'écriture pour créer de la beauté et pour toucher les coeurs et les esprits. Docteure en littératures francophones, elle a enseigné pendant cinq ans à l’Université de l’Alberta, à Edmonton. Elle prend actuellement une pause de l'enseignement pour s'occuper de sa famille et de ses quatre enfants, tous nés d'insémination artificielle avec donneur : Alexane, 8 ans, Lenya, 6 ans, Félix-Olivier, 2 ans, et Izaac, né en janvier dernier. Elle profite aussi de cet intermède pour poursuivre des projets d'écriture qui lui tiennent à coeur. Elle vit à Gatineau, au Québec.

DESIGN BY DearMinds.com

Magical

Babies A Children’s Tale by Nathalie Courcy (Translation: Sylvan Lanken)

Créons des familles • SPRING/PRINTEMPS 2013

Illustrated by her daughters Alexane and Lenya

nce upon a time, in the Kingdom of Hope, there

Olived a King and Queen who loved each other very

much. They had a beautiful palace, adoring subjects, and they travelled far and wide.

However, the King and Queen felt incomplete. They dreamed of hearing children’s voices echoing in the halls. Above all they wanted to hold their babies in their arms, and watch them grow a little each day. “Wouldn’t it be nice to wake to the sound of singing

children instead of that old grandfather clock?” asked the King. “I would much rather play hopscotch and hide-and-go-seek than work on the Kingdom’s budget,” said the Queen. But all of this seemed impossible. Since their royal wedding, the King and Queen had been trying very hard to have a little prince or princess of their own, but without success; the golden crib lay empty. “We will continue managing the kingdom as best we can, with fairness and generosity. After all, our subjects are sort of like our children.” At night, however, when the door to the royal bedroom was closed behind them, the childless King and Queen held each other and cried. If only they could understand why fate had left them childless…One day, the royal couple announced a contest: whoever broke their spell of childlessness would be made the official Knight of the Palace. It was their last and only hope. Almost at once there was a great commotion as a sorcerer appeared, holding in his hand a blue potion from which a strange vapour escaped. “Your Majesties, this secret potion of mine will allow you to have dozens and dozens of baby princes and princesses, all equally as magnificent as you.” The sorcerer handed the potion to the Queen, who drank it. The taste was dreadful, but she did her best to hide her disgust so as not to insult the sorcerer. Her skin turned blue. Her face tensed up. But in the end, her womb remained empty.

A fairy was the next visitor to the palace. She approached the Queen, waving her magic wand around as though swatting at flies, and recited, “Tinkertoys and teething, tiny tot in the tummy!” as she tapped lightly three times on the belly of the Queen. Nothing happened. An elf was next in line to try the impossible. She addressed the King: “Mr. Your Majesty, believe me,” she said, “my technique always works! Take this powder in your left hand, and blow on it gently. Then take your right hand and sprinkle the magic powder on the Queen’s head as you imagine your new little baby. Love will do the rest…” The Queen was covered in magic powder from head to toe; her robes glittered in the light. The love between her and the King was very strong, but still no baby appeared. “We must stop this,” said the Queen. “It simply isn’t working, and I am exhausted. Dozens of would-be royal Knights have come to help us, but not one has succeeded in doing so. It is a

lost cause. We must be content as King and Queen, even if we are never to be parents.” The King vowed to accept this destiny, his dreams of starting a family with the Queen shattered. Weeks later, a peasant farmer heard about the royal couple’s desire to have children. As he was very fond of the King and Queen, he came up with an idea. From his pocket he produced a pumpkin seed, a sunflower seed, and a chestnut. Many years earlier, a mysterious gardener had given the peasant the three seeds and said, “You will know what to do with these when the time comes.” The peasant brought the three seeds to the King and suggested he place them in the Queen’s belly button during a lunar eclipse. If nothing happened the first time, they were to try again during subsequent eclipses. He reminded the royal couple that

SPRING/PRINTEMPS 2013 • Creating Families

spoke with the palace doctor, she received the biggest surprise of her life: a tiny baby had begun growing inside her! As she told the King, tears welled up in her eyes – tears of joy, for once! any months later, a bouncing baby boy was born. His hair was a brilliant red, his eyes twinkled like dancing flames, and his smile was as big as the Moon. At last, the King and Queen discovered the joy of being parents, and took such very good care of their son. They threw a grand party

miracles sometimes take time. And though the King and Queen were very much afraid of being disappointed again, they did exactly as the peasant suggested. At the next eclipse, as the Moon gradually disappeared in Earth’s shadow, the King carefully placed the pumpkin seed in the Queen’s belly button. Despite their doubts, they lay in the orange glow of the eclipse throughout the night, hoping for a miracle. Morning came, but there was no change. A week passed, and still nothing. The King and Queen cried more than they had ever cried before. And then one day, the Queen felt something: a feeling quite unlike any she had experienced before; a tiny fluttering, almost imperceptible, in the hollow of her tummy. When she

Créons des familles • SPRING/PRINTEMPS 2013

to present the new prince to the kingdom, and their loyal subjects answered with gifts and warm wishes for the future. One day, the peasant farmer asked his old friend Nature about her plans. Nature replied that there was a lunar eclipse coming soon, and that the peasant should inform the King and Queen at once. The royal couple had been waiting impatiently for this event, knowing now that magic was real. The eclipse began, and the night sky darkened further. In the royal bedroom, the King placed a sunflower seed in the Queen’s belly button. The Queen was almost afraid to breathe, should her movements disturb the seed. Weeks passed, and then one day the Queen felt a flutter inside her. Before long, they were joined by their second child, a lovely baby girl. With her beautiful blond hair and beaming smile, she shone like the sun. Her hands were ever reaching for her parents, as if to say, “I’ve waited so long for you!” Together with their growing boy, the royal couple had a darling little princess to pamper. They could not imagine being any happier. In fact, they could be happier still: the peasant had also given them a chestnut.

They waited for the next lunar eclipse to begin, and then the King placed the chestnut in the Queen’s belly button with the utmost care. It wasn’t long before the Queen felt that now-familiar feeling, as though a tiny hummingbird were fluttering inside her – and she knew at once that the peasant’s miracle was complete. Months later, the King and Queen welcomed their charming prince to the world, his bronze hair the colour of chestnuts, his dark eyes beautiful as an enchanted forest. With such a wonderful family, the royal couple felt truly blessed. The King and Queen wanted to keep their original promise, so they visited the peasant, determined to make him the official Knight of the

Palace. “Your Majesties,” replied the peasant, “I am truly touched by your offer. However, I would prefer to serve you by bringing you fruit and vegetables from my garden, and wildflowers from the fields. Cultivating beauty is my life’s work – may I remain a peasant?” The Queen was struck by such grace and simplicity. She said, “Sir, I admire you greatly for the miracle you worked, but more importantly I admire you for your loyalty and commitment to your way of life. What, then, can I offer you by way of thanks?” The peasant thought for a moment. “That which would bring me the most happiness would be to meet your

SPRING/PRINTEMPS 2013 • Creating Families

children. My own have all grown up and left for faraway lands; I miss them. My yard is so very dull without the sounds of children playing.” From that day forward, the Queen, King, and their three children would visit the peasant every Sunday. As the little red-headed boy grew, he carved pumpkins for Halloween, and eventually learned to turn everything he touched into a work of art. Meanwhile, the little girl with the blond hair learned to grow all the different species of flowers. She could bring plants back from the dead, and turn scraggly, flowerless shrubs into full, blooming bushes. And the youngest, the little boy with the chestnut hair, chose to harvest the nuts and fruit that grew on trees. He was best friends with the forest animals, and birds even slept at his bedside.

Créons des familles • SPRING/PRINTEMPS 2013

Not only did the King and Queen accomplish their mission of having children, they also grew their family and that of the peasant by making him a part of their own. The people rejoiced at seeing the royal couple so happy. The King and Queen treated

the whole Kingdom of Hope with even more benevolence than before, and all of this because, with the help of the peasant farmer, they learned to believe in miracles. ■ We thank Alexane and Lenya for their wonderful drawings.

About the Author According to her family, Nathalie Courcy was born "holding a pencil". She uses writing to create beauty and touch people's hearts and minds. A Ph.D. in francophone literature, she taught at the University of Alberta, in Edmonton, for five years. She is currently taking a break from teaching to take care of her family and her four children, all born from donor insemination: Alexane, 8 years old, Lenya, 6, FélixOlivier, 2 and baby Izaac, born last January. She is also taking advantage of this interlude to complete writing projects close to her heart. She lives in Gatineau, Quebec. Lenya at work

Second Star On The Right and Straight On ‘Til Morning: A Journey to Overseas Egg Donation by C.S. John

Once I was a teacup My wife and I are on an overnight flight to the far side of the world, and I find myself staring out the airplane window at the brilliant stars overhead, and reflecting on how we got here. It is a long story with so many twists, heartbreaks, and altered dreams that I hardly recognize the person I was when we started down this path. I suppose I should give some background to share what led up to us making this trip. Several years ago, immediately after we got married, my wife and I began trying to start our family… both of us badly wanting to have children. Even though we were in our mid-thirties, we gave no thought to the idea that it might not happen; in fact we had actually held off trying so that we could “schedule” when the birth would fall on the calendar to be optimum for my wife’s work as a kindergarten teacher. It didn’t happen as we had planned; instead several months passed, and no matter how many sticks were peed on, no success. It started becoming obvious that there was an issue stopping us from realizing our dreams

and we went to see a reproductive endocrinologist. A series of treatments followed (IUIs; Traditional Chinese Medicine; Clomid; Superovulation; IVF) with no positive results. Dozens of tests and procedures later, all of which failed to determine a cause for our fertility problem, we were given a (non) diagnosis of “unexplained infertility.” We were crushed… our emotional and financial reserves completely exhausted by the process and there was nothing to point at for blame, nothing that we could “fix.” I am a resourceful person; I have always been able to “fix” everything if I put my mind to it… now I was helpless.

Hope of new life steeped within me, Warm and homey. Shiny porcelain, painted bright. Partying amidst the cups and saucers Of a set, out in the world. When did I put myself away In the back of the hutch, Out of sight. Disappointment riddling me, With a million tiny fractures.

What next? Neither of us had ever considered

Jagged edged and leaking.

a life without children, yet that prospect was

An empty vessel stained by loss

staring us in the face. Our relationship was strained; we had withdrawn from many of

Too brittle for hope,

our friends and support networks as we

The heady, steaming brew of life,

couldn’t face another birth announcement,

Has long since drained away.

baby shower, or children’s party. It was around this time that I wrote a poem – The Teacup. It goes like this:

One more tiny blow and I shatter. Never again whole.

SPRING/PRINTEMPS 2013 • Creating Families

We decided that we weren’t ready to give up on our dream, and began the long process of tightening our budget and saving for another round of IVF. It was a race against the biological clock: we determined it would take 18 months to save for a cycle and we were now facing starting parenthood on the wrong side of 40 years old. We decided to press on and take the chance to reach our dream of a family; every purchase and expenditure was vetted with the question, “Is this more important than having a baby?” Household maintenance fell to the wayside; our already ancient TV got older without the chance to retire peacefully; vacations and dinners out were scrapped. We had a goal, and we were determined to reach it. Impatience set in, and we decided to have some more tests done to ensure that we would give our last ditch IVF cycle the best chance possible. Then we got the devastating news: my wife’s follicle stimulating hormone (FSH) levels had shot up from normal to over 20 in a single year… which effectively meant that she now had the eggs of a 50-year-old. The likelihood of IVF resulting in a successful pregnancy was almost non-existent. We had lost our race against the clock, time had run out as we scrimped and saved for the treatment. Devastated hardly begins to describe where we were, it seemed that our journey had come to an end. What would life look like? Could we conceive a path forward that didn’t involve conception? Our fertility specialist suggested that we look into egg donation, something we knew relatively little about. My wife was willing to look into it, as it would allow her to still experience being pregnant and carrying a child, as well as being able to do everything she could to ensure a healthy baby. Egg donation is not readily available in Canada (more specifically, it is technically legal, but illegal to compensate donors… so it is quite rare to find altruistic donors in Canada). We did not have any young female friends or relatives to ask to be a

Créons des familles • SPRING/PRINTEMPS 2013

Immediately after we got married, my wife and I began trying to start our family… both of us badly wanting to have children. Even though we were in our mid-thirties, we gave no thought to the idea that it might not happen. donor, and were uncomfortable with the thought of having someone so close to us being our donor in any case. Family dynamics are difficult enough without adding in the complexity of your cousin or niece also being the biological mother of your child. It didn’t take much research for us to realize that the costs of going to the United States for treatment were prohibitive, ranging from $25,000-50,000 depending on the clinic and/or agency used. It started to seem like every door that we opened had a brick wall right behind it. Queries into adoption made us realize that it was as difficult and expensive a process as fertility treatments. More research online unearthed some infertility community sites in the United Kingdom, where there were many discussions about undergoing egg donation treatments in European countries that had cheaper

healthcare. Looking at the costs that ranged from $5,000-15,000 (including travel expenses), we had a shot if we were willing to take the road less travelled and head off into the unknown. Intensive research into the countries with the best combination of high quality health care and reasonable costs narrowed down our options to what we felt were the best fits and had the best online reviews from other patients: Spain and the Czech Republic. As my wife is blonde with blue eyes, and of German heritage, our best chance of getting a matching donor was the Czech Republic. Numerous emails and responses resulted in us picking the IVF Cube clinic in Prague. We determined that we would proceed a few months later in the summer when my wife was off work. That brings us back to where we started, staring out the airplane window… flying

We go out quickly to get our bearings and take a gander at our hotel’s surroundings. We find that we are only a few steps away from the centre of the main Old Town Square tourist spot. The area feels very safe, and even though we are very central we are on a quiet street and don’t have to deal with noise or crowds. Being tourists is not our main goal of this trip, but it is a wonderful place to explore and spend a few days.

It was a race against the biological clock: we determined it would take 18 months to save for a cycle and we were now facing starting parenthood on the wrong side of 40 years old. thousands of miles away from home to see if we can kick-start our dreams. For the first time in months we are feeling hope and excitement. I do my best to be as pessimistic as possible, which seems counterintuitive, but the past few years have shown us that hope can be dangerous as it opens your heart up to hurt that you doubt you can recover from. If I don’t let myself believe it will work, then at least maybe I can be a little prepared for it and somehow find a way to help support my wife when things come crashing down on us. After a sleepless night of fending off the fantasies of my imaginary “future” children, we land in Prague. The city is stunningly beautiful, castles and spires overlooking the population from every vista. My first thought is that this looks like a place where dreams CAN come true, it looks like a fairy-tale so maybe a happily ever after is possible. Hope and fear of failure battle inside me as I feel tears fill my eyes at the prospect… I am surprised because I thought I had cried my reservoir dry

months before. We don’t have much time to reflect as our donor is having her egg retrieval done in the morning and we have to head to the clinic.

Upon arrival at IVF Cube the next morning, we are immediately impressed by the “look” of the facility, as well as how proficient all the staff are in English… it was a worry that we would have a difficult time communicating, but no issues at all. We are very early for our appointment as I am obsessive about being on time and we had no idea how long the taxi ride would take from our hotel. As we sit in the lobby, there are three other couples waiting and I can catch a distinctive Irish lilt to their accents even though we are all whispering our conversations; clearly we are not the only foreign patients being treated today. Waiting for our allotted time, we see four young Czech women come in at various intervals and go to the reception. I can’t help but keep glancing at them and wondering

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SPRING/PRINTEMPS 2013 • Creating Families

Family dynamics are difficult enough without adding in the complexity of your cousin or niece also being the biological mother of your child. which one is our donor – it is a very odd feeling (Czech egg donation is mandated to be anonymous so we only know basic information about the woman who is giving us this tremendous gift). Would I see echoes of any of these women’s features in our future children? What are their stories? Their motivations? The compensation for donors in the Czech Republic isn’t enough to make it a purely financial transaction. I am comforted to see that they are all welldressed and checking their iPhones as they wait. One of the main reasons we chose the Czech Republic is that we were not comfortable with a donor being exploited in the

Créons des familles • SPRING/PRINTEMPS 2013

transaction simply due to poverty. I catch the eye of one of the Irish gals, or, to be more exact, we both catch each other “surreptitiously” peeking at the Czech ladies. We give each other a small wry grin as we realize what we were doing. No luck anyways, as each of the Czech women are called in turn and leave shortly after with bags of medications. They are likely future donors just starting their drug therapy… I guess our donor is already here or came in a different entrance. I am called up to do my “business.” OK, it feels a little weird to have just written publicly about something that every 14-year-old boy knows is private. Well I guess infertility is

synonymous with TMI (too much information). I would certainly rather have this little intrusion than having a steady stream of specialists and medical students parading by while my ankles are up in stirrups like my wife has dealt with the past few years. Anyways… after I have done my bit we have five days to wait to see if the eggs fertilize and we get viable embryos. This is our sightseeing time while my wife is able to walk around comfortably, and we explore our beautiful surroundings. We get a phone call the next morning from the clinic stating that there were nine eggs retrieved and eight fertilized, that these are pretty reasonable numbers, and we just need to wait out the full five days to see how many make it to decent blastocyst embryos. Prague is simply amazing… it allows us to take our minds a little off the process and the waiting. The day of our embryo transfer has come at last! We arrive at the clinic and recognize the

So many procedures, so many dollars, so many heartbreaks… and this is it, the final attempt, the final chance to have a family. Pressure doesn’t even begin to describe it.

same couples in the lobby that we saw during our last visit, no more smiles and surreptitious looks… everyone is focussed and nervous about their upcoming procedures. When it is our turn, we enter the procedure room and learn that we only have two good quality embryos for transfer. This is crushing news because it means that this is our only shot. We had assumed we would have at least a couple to freeze for one more try if we really needed. So many procedures, so many dollars, so many heartbreaks… and this is it, the final attempt, the final chance to have a family. Pressure doesn’t even begin to describe it. The actual transfer process itself is painless, or at least so I am told. The microscope has a camera so we can actually see the two embryos on a big screen as they are readied for transfer. With a single glance, just a fraction of a heartbeat, the hope and possibilities that they represent blossom in my chest. In a single shuddering breath images of their whole futures come to life. In those few cells I vividly see the infants they will become grasping my finger in their tiny hands; their toddler faces lighting up with unrestrained joy as they discover every new aspect of the world; their first trip to the emergency ward to cast

up the arm they broke doing something they shouldn’t have been; the heartache of them experiencing their first loves as teenagers; and the fulfillment they feel as adults when they start their own families. So much for pessimism, it is blown away in an instant and replaced by hope so overwhelming my wife and I both start crying uncontrollably not caring that doctors or nurses see us. It is a stark contrast that something so microscopic can fit our dreams, dreams which feel so huge. By the time we are back at our hotel the terror has set in, we are even stressing out about the taxi bumping on the cobblestone streets as if somehow it can jar the embryos loose (we are assured it can’t). The next several days are spent just taking it easy, watching TV and movies, as my wife does everything she can to ensure that the embryos implant. We limit our wanderings to the few blocks around our hotel, but still manage to find some interesting sights and nice restaurants. We have s tarted the dreaded two-week wait… we won’t find out if we are successful until we are back at home in Vancouver. Our last chance for success, and the prospect of the looming abyss of how to live our lives if we are not successful.

We take our trip home in stages, visiting family in the U.K. and relaxing before the long flight over the Atlantic to the West Coast, arriving home just a couple of days before the end of our two-week wait. We have completed a journey halfway around the world but it feels like a jaunt to the corner store when compared with the emotional journey that we have taken in the years since we started trying for our family. Will I ever hear the word “Daddy” come from the lips of my children? Or will I become embittered by pain, loss and hurt… trying to grope my way through an unimagined future? Eventually every story needs an ending and this is ours, regardless of the outcome. ■ (Editor’s Note: C.S. and his wife are currently several months pregnant with identical twins and are well on their way to their “happily every after.”)

About the Author C.S. John is a filmmaker who is currently producing a documentary on infertility. For more information and video of this project, go to www.OnInfertileGround.com

SPRING/PRINTEMPS 2013 • Creating Families

ILLUSTRATIONS: ANA KUSMIC

Patient’s Perspective

WHAT

INFERTILITY DID TO MY MARRIAGE by Charmaine Graham

University. Job. Romance. Engagement. Wedding. House. Baby. This was my life PLAN. I personally think most women hope that this will be the way their life progresses. I sure did. And while I had quite a few glitches in my earlier years that might have changed my course, I did everything I could to make this plan my reality. I will be honest. When my husband and I had been married for a few years and decided it was time to start our family, it was initially my idea. He was aware of my fantasy of having five children, and he seemed agreeable. When I told him one day it was time to begin the next adventure and have a baby, he took a week or two to adjust, and then he was on board. I think he liked the idea of me staying at home and raising our children, baking cookies and doing crafts, having a hot meal on the table when he got home from work, his children running around, happy and content. He is a pure romantic, in truth, much more so than I. I had a plan; he had an ideal. Soon enough, we realized our lives were going to take a turn that neither of us had ever expected. I got so far with my big plan, but in the end, life had another path for me when I hit the last lifegoal: baby. When we found out that fateful afternoon, after 16 months of trying to conceive, that my fallopian tubes were both blocked and

Créons des familles • SPRING/PRINTEMPS 2013

Patient’s Perspective we would have to do IVF to even try to have a child, we were both pretty stunned. I was overwhelmed with guilt and anger; my husband was overwhelmed with fear. My guilt and anger made sense, but what was his fear about? Well, he wasn't afraid of losing our dream of having children; he was afraid of losing me. Like I said, a true romantic. My husband was always relatively gracious about the fact that our infertility struggle stemmed from my physical complications, and he knew me well enough by this time in our years together to be aware that my determination and drive to get pregnant could easily allow him to escape my focus. When it was clear that IVF was the point at which we would start our journey to have a child, my husband said one very clear thing to me before we started the process: "I have no problem doing IVF in our pursuit to have a child, but I will NOT do it at the expense of our marriage." You might think that his desire to stay close to me would be a blessing, that his fear of losing me to the process, combined with my determination to have a child, would help our marriage and would support us through this process. However, in truth, our different approaches and goals (mine to get pregnant, his to maintain a happy marriage) actually caused some complications that we hadn’t anticipated. In my determination to get pregnant at all costs, I lost sight of my husband and could focus only on my treatments. Calling in on day one of my period, starting my hormones, monitoring my follicles and hormone levels, retrieving my eggs, waiting for the phone call to inform me of the fertilization rate, completing an embryo transfer, all followed by 14 days of dreaded waiting, and finally, the beta, which was sometimes complicated by a miscarriage. What did my husband focus on? Well, he focused on trying to get me back, because in all truth, he had lost me. Every decision, every thought in my head was based

I was overwhelmed with guilt and anger; my husband was overwhelmed with fear. My guilt and anger made sense, but what was his fear about? solely on my cycle and on the functions of my reproductive system, and my husband was incredibly frustrated by that. He was alone in the experience. He was alone in life. And honestly, for him, it seemed there was little he could do to change or fix anything. He began to resent my frustrations and my pain, wondering why “just the two of us together” wasn't enough for me. Did I care that he was struggling with our situation? Of course I did. But my internal drive to achieve and complete a pregnancy became so overwhelming that I couldn't really relate to his perspective. It made sense what he was feeling; I understood what he was talking about. I wanted to care. But I merely took the information about how he was feeling and what his experience was like and used it as a mirror to view my own feelings. He was frustrated because I wasn't present like I had been in the past. I wasn't my old carefree, funloving and happy self, delighted in all the little things that happened between us each day.

what I was going through was so much harder than what he was experiencing. Our separate frustrations had developed to such a level – in hindsight, not unexpectedly or unrealistically – that we couldn't hear each other anymore. Then one day something changed. Jim and I went to visit some really close friends, and they were acting strangely. I couldn't understand what was going on. When we left their house and jumped in the car, Jim looked at me, grabbed my hand and told me that our friends were acting weird and felt upset because they were pregnant, and they could not even begin to figure out a way to break the news to me. How could fate be so cruel? They weren't even married yet and this pregnancy was completely unplanned. I sobbed. And sobbed. And sobbed. Finally, my tears subsided and Jim grasped my hand tighter and said, "Honey, you have your own path, and you'll get there; their path isn't your path." I was able to look across at him and see true compassion in his eyes. Having my husband acknowledge my sadness like that was immense for me. It’s totally different for someone to say, "Of course this hurts. Of course this sucks. You'll find your way and I will be here right beside you" rather than "You should be grateful for what you have” or “Just

For my part, I felt he was putting more pressure on me to pretend to be in a place I really wasn't. I felt that he really didn't care whether we had children, and he couldn't relate to the pain and frustration of all I had to go through every month to even try to have a child. And I couldn't understand why he didn't recognize that SPRING/PRINTEMPS 2013 • Creating Families

Patient’s Perspective of the chat groups or dialogue boards out there in North America, most of the people doing the chatting or posting are women. This fact begs the following question: Do we really pay attention to the ways infertility affects men? Can we understand how they feel when they use so few words to talk about it, if they even talk about it at all? Can we accept that their process is different from ours and maybe accept that their path is okay too?

In my determination to get pregnant at all costs, I lost sight of my husband and could focus only on my treatments. stop being so dramatic and relax." On that day, this difference changed our course. A few weeks later, at an appointment with the infertility specialist, I blurted out, "I think I’m done for a while." My husband almost fell on the floor in shock; I think the specialist almost did too! When I walked into that appointment, I had no idea that I would quit infertility treatment that day, but I felt such immense relief in finally letting go. I went home and decided to open up my horizons and see what the world had in store for me. Would I go back to school? Would I travel? Would I look into adoption? Or would I just let the world guide me? I mentioned adoption to my husband, and he reminded me that he had suggested it earlier, but I just wasn't ready to listen at that time. So I enrolled back in school and filed some adoption paperwork in the following weeks. Little did I know that, in less than two years from the day I quit fertility treatments, I would be graced with not one but two

Créons des familles • SPRING/PRINTEMPS 2013

healthy newborn babies, who would enter our lives through private domestic adoption. The two most precious children to ever walk this earth, I promise you!

In the years that have followed, I’ve been involved in infertility support groups, and I’ve come to realize that when couples go through the struggle of infertility, feelings of separation and frustration are relatively common. The women who have shared their experiences with me have often admitted that it’s a challenge to stay connected with their husbands when they feel like their husbands don't really understand how hard the process is for them – how, regardless of where the infertility issues originate, the women still have to do most of the work, enduring most of the physical struggles. And how often do these men come to support groups? How often do they write articles about their feelings, articles that will be published to share with others in the same boat? If you look at any

A friend of mine once said that if a house is on fire, a husband will save his wife first, but a wife will save her children first. I think there is some truth in this statement. At least there is for me. About six months after we had our son, I remember looking across the room at my husband and realizing that I actually owed him an apology for cutting him out of so much of my life during those years. And as I looked at him that evening, realizing how much pain he must have endured as well, I gave him my heartfelt apologies for not really listening to his experience, advice, perspective or feelings. Yes, his experience was different from mine. He wanted me more than he wanted a child. But I realized that night that instead of being frustrated with him for not feeling the pain I was feeling, maybe I could have listened and learned a bit more from him about what really mattered. Maybe, just maybe, I might have gone a bit slower, been a bit softer on myself and on him, thus nurturing the one relationship which mattered most. To my surprise, he apologized as well for getting frustrated with my drive to have a pregnancy. He apologized for not supporting me more, for not encouraging me to hit the IVF highway at 140 miles an hour, and for instead trying to get me to stop for a bit and find some perspective. Maybe, just maybe, we could have worked together a bit more than we did. Hindsight truly is 20/20. But my story and the story of my marriage

Patient’s Perspective Do we really pay attention to the ways infertility affects men? Can we accept that their process is different from ours and maybe accept that their path is okay too? don’t end there. I believed when we finally had our baby that everything would be perfect for us. I now realize that while travelling the infertility road with my husband was certainly difficult and complicated, parenting together has been even more so. We not only had our own personal adult struggles and challenges, but added into the mix, and just 19 months apart, we had become responsible for two other human beings who of course had their own personalities and immense needs that added to our challenges and struggles. Introduce sleep deprivation, differing styles of parenting, and different goals and dreams for our children, combined with children who naturally have their own frustrations, illnesses, developmental goals you don't want to ignore, and, well, things certainly don’t get any easier. I think it’s important to acknowledge all of this. The reality is that parenting is a tough gig, no matter how or when you arrived at the starting line.

Charmaine and her husband Jim

Just as people gave stupid advice during our infertility struggles, people gave us stupid parenting advice too. They judged our parenting, and we judged each other's parenting as well. I loved my children so immensely that I would become frustrated when others might mistakenly see one of my children's personality traits as a sign of failure or concern instead of as a blessing or a sign of something bigger to come. As well, I had a very specific and rather irrational ideal of how I would parent, considering I was going to be the best parent EVER after struggling with infertility. I had to learn that children are fluid

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creatures, that require constant attention and assessment – just exactly like marriage. My husband and I have grown; we’ve changed; we’ve hurt one another on occasion, and we’ve even lost touch with one another at certain points along the road. There have been times when I was not sure whether my marriage would survive the hardships of parenting or the changes my husband and I would endure in our relationship after we became parents. In fact, a few years back, the D Word was quietly mentioned as an option. We decided to keep moving forward and fix anything that came our way, no matter what. Thankfully, it worked. Now we have a relatively peaceful time of it: the kids are good, and we’ve reconnected. Nevertheless I’m always aware that life is full of surprises, and I’ve learned that it takes a lot of work to stay on track. When I decided to write an article about marriage and infertility, I asked my husband for his thoughts on our infertility years. Surprisingly, he said they were "absolutely the worst years of [his] life." I

SPRING/PRINTEMPS 2013 • Creating Families

Patient’s Perspective About the Author

was shocked. I responded, "What about that time we thought about a divorce for a tiny bit, when we just seemed so stuck?” He replied with absolutely no hesitation whatsoever: "Nope. IVF was, by far, WORSE." "Really", I responded?

His final answer, "ABSOLUTELY". I guess after 18 years with this man, I still might not totally understand how hard it was for him to go down the infertility road with me. But I now know, without a doubt, that I’ll have a whole lifetime with him to try and sort it out. And try I will. ■

Charmaine Graham lives in Komoka, Ontario, with her husband Jim and their two domestically adopted children, Macarthur and Madeline. In 2005 Charmaine founded AdoptionProfiles.ca. Charmaine spends her extra time volunteering at the local family shelters, volunteering for multiple dog rescues, and is on the working board for the Children’s Health Foundation and the Graham Family EcoPark. Moved by her compassion towards people who are suffering under the various issues that accompany infertility, Charmaine coordinates infertility support groups and speaks on the subject of adoption in order to help people in Canada and the United States work towards realizing their dreams of parenting. She is always available if anyone suffering from infertility needs a listening ear. She can be reached at info@adoptionprofiles.ca.

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SPRING/PRINTEMPS 2013 • Creating Families

The LGBTQ Column

Trans People and Family Building by Gail Knudson MD, MPE, FRCPC and barbara findlay QC The idea of a man bearing a child, or a child’s mother being the child’s genetic ‘father’, contradicts strong cultural assumptions about gender and about motherhood/parenthood. However, like many other people, trans people may want to have a family. Provided that they receive appropriate reproductive counseling before they transition, this is now possible.

For a minority of trans people, Transgender people Transgender people are individuals who experience a significant degree of dissonance between their own sense of their gender – their gender identity – and other biological markers of their gender such as their secondary sex characteristics. Though we generally think that there are only two distinct and unchangeable genders and that it is a simple matter of inspecting an individual’s genitalia to determine gender, these assumptions are inaccurate. Gender is multifactorial. It involves not only the structure and appearance of one’s genitalia, but also one’s chromosomal profile, hormonal profile, and one’s gender identity, as well one’s social gender. For a minority of trans people, the dissonance between their gender identity and their body’s sex characteristics and function is so severe that they become psychologically distressed, a condition known as gender dysphoria. The treatment for gender dysphoria usually involves the alignment of gender identity with external sex characteristics. Typically, this includes hormone treatments and surgery.

Créons des familles • SPRING/PRINTEMPS 2013

the dissonance between their gender identity and their body’s sex characteristics and function is so severe that they become psychologically distressed, a condition known as gender dysphoria. Male to female (MtF) trans people, otherwise known as trans women, typically have their penis and testicles removed and then undergo surgical construction of a neovagina. Breast development occurs with a regime of feminizing hormones. Female to male (FtM) otherwise known as trans men, typically have mastectomies and surgical contouring of their chest in addition to taking masculinizing hormones (androgens). The choice to have a hysterectomy varies, as does the choice of having a surgically-constructed penis.

Standards of Reproductive Care for Trans people Transsexuals, transgender and gender nonconforming people may elect hormonal therapy and surgery to become their “gender

The LGBTQ Column implanted in his uterus.

congruent” selves. Because of the potential effects of treatment on fertility, transition to their gender congruent selves and reproduction may appear to be mutually exclusive for trans people. Until recently transition to one’s desired gender and reproduction was often mutually exclusive and seen as the price to pay.1 However, in 2013, this is no longer necessarily the case.

For all trans people considering transitioning (changing from one gender to another through hormones and surgery), an important preliminary question to ask is whether they will want to produce genetically related children in the future.

As early as 2001, the World Professional Association of Transgender Health’s (WPATH) Standards of Care for Transgender Health Version 6 included a paragraph on the need to discuss reproductive issues with trans people prior to the start of hormonal treatment. However, clinical practice has lagged behind. In a forward move, the recently released Version 7 of the WPATH SOC (www.wpath.org) now includes a chapter on fertility counseling and reproductive options.2 The Endocrine Society has also issued guidelines recommending a staged approach in fertility preservation.3

Reproductive Options For all people considering transitioning (changing from one gender to another through hormones and surgery), an important preliminary question to ask is whether they will want to produce genetically related children in the future. Some of the people who received hormone therapy and sex reassignment surgery later regretted their inability to parent genetically related children.1 Wiercxk et al. reported in 2012 that all 50 trans men in their study wished to have children.4 Trans Women A trans woman can extract and freeze sperm before transition. That sperm can later be used to inseminate either her partner, if she has a fertile female partner, or a surrogate

A trans man might choose to become pregnant if his female partner is infertile; if his partner is a trans man or a trans woman; if he is choosing single parenthood and does not want a stranger to carry his child, or simply because, regardless of gender, he has a desire to experience a pregnancy. If a trans man wants to become pregnant, the fertility issues and processes are the same as they are for any woman wanting to conceive, except that his masculinizing hormones must be discontinued and his fertility physician must coordinate treatment with his gender endocrinologist.

Legal Rights mother, if her partner is a man or if she wants to be a single parent. Sperm is frozen and stored at a fertility clinic until it is needed. Trans Men Trans men have two options pre-transition. They can either have eggs extracted laparoscopically and frozen, or they can have eggs extracted, fertilized with donated sperm by IVF, and then have the embryos frozen. The procedures are no longer considered experimental, but the cost of cyropreserving either eggs or embryos may be prohibitive.

If you are a trans person, you are entitled to fertility and reproductive technology services on the same basis as anyone else. In 1995, two lesbian co-parents won a human rights case which established that it was discriminatory and illegal to be denied fertility services because of their sexual orientation.5 Denying you fertility services would similarly be discriminatory, this time on the basis of sex. Should you become pregnant as a trans man, you are likely to be at risk of being the victim of harassment by those who view a man carrying a child as a breach of the laws of nature.

A trans man’s eggs or embryos may later be implanted either into his fertile female partner, who then carries the pregnancy, or into a surrogate, if his partner is infertile, if his partner is a man, or if he wants to be a single parent. A number of trans men have themselves carried pregnancies. Provided that the trans man has not had a hysterectomy, discontinuing masculinizing hormones may enable him to produce fertile eggs. Even if he is unable to produce fertile eggs, he can carry an embryo fertilized by material from his partner and donated material through IVF, and then

SPRING/PRINTEMPS 2013 • Creating Families

The LGBTQ Column If you are a trans person, you are entitled to fertility and reproductive technology services on the same basis as anyone else. Your care providers should ensure that their facilities are set up to accommodate your needs and that staff is trained to deal respectfully with you and your entourage. Any agency delivering services to trans people such as you should review their ‘gendered practices’: M/F on forms or gendering procedures that “sort” male and female patients. There are two choices: either remove all gender markers, and all gendered procedures, or add a non-M/F alternative. Remember to include the washrooms.

The situation in British Columbia In British Columbia, an interesting quirk of the process of a trans man having a child is that, in B.C., he will be registered at the time of birth as the child’s mother. Birth is defined as "the complete expulsion or extraction from its mother…[of a child]”. If he has a partner, he or she will be registered as the child’s “co-parent”. However, though the trans man will be registered as the child’s ‘mother’, the birth certificate will identify

him (and his partner if he has one) as ‘parent’, rather than as a ‘mother’ or ‘father’.6 (Because registration of births is a provincial matter, practice varies by province. Inquiries should be directed to the Vital Statistics Agency of the province in which the child will be born.) This means that once their child is born, they will have the choice of how to identify their social gender formally to the world as the parents of their child. The only time that trans people may run up against registration requirements of their province’s vital statistics legislation is if they use a surrogate gestational carrier. For example, because of the definition of ‘birth’ in B.C.’s Vital Statistics Act, the gestational carrier is initially the child’s ‘mother’. However, it is possible to register the intended parents instead of the surrogate mother. In some provinces that is possible to do at the administrative level; in other provinces, a court order declaring the child’s intended parents to be the parents of the child is required. At that point, the child’s birth certificate shows their intended parents, not the surrogate.

Conclusion Trans people planning families have to plan ahead in ways that non-trans families do not, to ensure that their reproductive choices are not precluded by transitioning from one gender to another. The biggest obstacles trans people are likely to face in creating families

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Créons des familles • SPRING/PRINTEMPS 2013

are not medical or legal, but attitudinal. With education, that will change. ■ Resources For further information and reproductive options: http://www.rainbowhealthontario.ca/admin/conte ntEngine/contentDocuments/Reproductive_Optio ns_for_Trans_People_final.pdf

The LGBT Parenting Connection, a project of Sherbourne Health Centre, http://www.lgbtqparentingconnection.ca/home.cfm provides information, resources and support to LGBTQ (lesbian, gay, bisexual trans and queer) parents, their children and their communities. Playful public events from skating parties, an annual Family Day Celebration each February, also offer a warm welcome to Gender Independent children and their families. Trans specific projects include a short film "Transforming Family", a qualitative study: "Transforming Family: Trans parents: Struggles, strategies and strengths", a weekend workshop for "Transmasculine People Considering Pregnancy" in collaboration with Queer Parenting Programs at The 519, fact sheets including "Reproductive options for trans people" and a wide range of ongoing work with schools, community centres, health care providers and government agencies.

Transforming Family was a community-based research project in Toronto, which explored trans parent's experiences of discrimination as well as the strengths that trans people bring to parenting. This project was led by the LGBTQ Parenting Network at the Sherbourne Health Centre, in collaboration with the Re:searching for LGBTQ Health team at the Centre for Addiction and Mental Health (CAMH). The resulting community report and a short documentary film can be found at: www.lgbtqparentingconnection.ca. This project has also led to a number of other initiatives focused on family law education for trans parents; a study focused on trans women's experiences of motherhood and a larger film project. For more information, contact Jake Pyne: jakecat@hotmail.com.

The 519 Community Centre in Toronto runs a range of programs for LGBTQ families: Queer & Trans Family Resource Programs / Events For more information about the times and dates of their drop-in programs and special events, please

The LGBTQ Column References: About the Authors 1 De Sutter, P., K. Kir, A. Verschoor, and A.

Hotimsky. 2002. The desire to have children and the preservation of fertility in Transsexual women. The International Journal of Transgenderism 6(3). 2

The biggest obstacles trans people are likely to face in creating families are not

E. Coleman, W. Bockting, M. Botzer, P. CohenKettenis, G. DeCuypere, J. Feldman, L. Fraser, J. Green, G. Knudson, W. J. Meyer, S. Monstrey, R. K. Adler, G. R. Brown, A. H. Devor, R. Ehrbar, R. Ettner, E. Eyler, R. Garofalo, D. H. Karasic, A. I. Lev, G. Mayer, H. Meyer-Bahlburg, B. P. Hall, F. Pfaefflin, K. Rachlin, B. Robinson, L. S. Schechter, V. Tangpricha, M. van Trotsenburg, A. Vitale, S. Winter, S. Whittle, K. R. Wylie, and K. Zucker 2012. Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, Version 7. International Journal of Transgenderism 13(4).

Gail Knudson is a Clinical Associate Professor at the University of British Columbia and Medical Director of the Transgender Health Program at Vancouver Coastal Health. barbara findlay QC is a Vancouver lawyer specializing in issues affecting lesbian, gay, bisexual and transgender people.

medical or legal, but attitudinal. With education, that will change. visit their web page: http://www.the519.org/programsservices/familyandchildren/familyresourceprograms

Queer & Trans Family Planning and Pre-Natal Courses For more information about the times and dates of upcoming courses, please visit their web page: http://www.the519.org/programsservices/familyandchildren/familyplanningandpre-natalcourses

Hembree, W.C., P. Cohen-Kettenis, H.A. Determarre-van de Waal, et al. 2009. Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism 94(9): 3132–3154.

Wiercxk, K., E. Van Caenegem, G. Pennings, et al. 2012. Reproductive wish in transsexual men. Human Reproduction 27(2): 483–487.

Potter v. Korn (1995), 23 C.H.R.R. D/319; aff'd (1996), 25 C.H.R.R. D/141 (B.C.S.C.)

La version française de cet article paraîtra dans le prochain numéro.

Gill and Maher, Murray and Popoff v. Ministry of Health, 2001 BCHRT 45.

SPRING/PRINTEMPS 2013 • Creating Families

Dr. Allison Case

The Doctor’s Column

I will soon begin IUI treatments and move on to IVF if these are not successful. I worry about the medications and hormones I will have to take. What are possible short and long term side effects, including weight gain and cancer?

Dr. Allison Case: One of the drugs used most frequently in IUI is clomiphene citrate. As it increases production of FSH (follicle-stimulating hormone), it stimulates follicular growth and induces ovulation in women who are not ovulating, due to conditions such as polycystic ovarian syndrome (PCOS). Typically, clomiphene citrate tablets are taken orally for five days.

You should not be too concerned about clomiphene citrate for your IUI treatments. Side effects are usually mild and well tolerated: hot flashes (in 10-15% of patients), mild headaches and mood changes. A temporary thinning of the uterine lining may occur in 15% of patients. Gastrointestinal side effects such as nausea or vomiting are uncommon. The main “side effect” is the risk of a multiple pregnancy (between 8 and 10% as opposed to about 1% in the general population) due to ovarian hyperstimulation. In 99% of cases, the multiple pregnancy will be twins.

Some women are concerned about the risk of ovarian cancer after using clomiphene. While a couple of earlier studies suggested a possible association between clomiphene use and the development of ovarian tumors (benign or cancerous), more recent research has not shown this. Note that if you have used oral contraceptives at any time in your life, this lowers your risk of ovarian cancer. In order to stimulate ovulation further or to encourage the production of multiple eggs (we want two or three eggs for IUI and around 10 for IVF), some women will be given subcutaneous injections of FSH for 10 to 14 days. These are generally well tolerated – there might be slight discomfort at the injection site – and there are no long term effects that we know of. Once again, the main risk is that of a multiple pregnancy. For IVF treatments, FSH injections are also given, but at higher doses. Many patients receive other injections as well, in particular a GNRH agonist or antagonist aimed at suppressing the pituitary gland’s function. This gland controls egg development and ovulation, among other things. (Although we do want eggs to develop, in IVF we don’t want them to ovulate before they can be retrieved.) One injection of human chorionic gonadotropin (HCG) is

given for final maturation of the eggs before retrieval. Progesterone is usually administered vaginally following embryo transfer up until the pregnancy test. If the test is positive, this is maintained for the first 10 weeks of the pregnancy. A side effect to watch for is ovarian hyperstimulation syndrome (OHSS). Patients most at risk are young women, PCOS patients, women with low BMI or who experienced the syndrome before. Symptoms are bloating, discomfort in the lower abdomen, nausea, vomiting, diarrhea, dizziness and shortness of breath. Mild OHSS occurs in about 10% of patients; severe OHSS requiring hospitalization in less than 1%. All patients are carefully monitored for OHSS and there are many ways to decrease its risk and severity. The most common side effect experienced by women taking FSH injections is some bloating and discomfort in the lower abdomen as the follicles grow on the ovaries. Weight gain is minimal, and usually due to fluid retention if it occurs. There don’t appear to be any long-term side effects such as cancer or premature menopause in women who have taken these medications. ■

Dr. Allison Case, BSc, MD, FRCSC, is currently an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Saskatchewan. She is Medical Director of the ARTUS Assisted Reproductive Technology program and Clinical Head of the Division of Reproductive Endocrinology and Infertility. She runs a busy full-time academic practice, and is actively involved in teaching medical students and residents in Obstetrics and Gynecology. Her clinical and research interests include infertility, assisted reproduction, recurrent pregnancy loss and fertility preservation.

Créons des familles • SPRING/PRINTEMPS 2013

La chronique du médecin Q:

Je commencerai bientôt des traitements d’IIU, puis je passerai à la FIV au besoin. Je m’inquiète des médicaments et hormones que je devrai prendre. Quels sont les effets indésirables possibles à court et à long terme, y compris le gain de poids et le cancer ?

Dre. Allison Case: L’un des médicaments les plus couramment utilisés pour l’IIU est le citrate de clomiphène. Vu qu’il augmente la sécrétion de la FSH (hormone folliculo-stimulante), il stimule la croissance des follicules et induit l’ovulation chez les femmes anovulatoires pour cause de troubles tels que le syndrome des ovaires polykystiques (SOPK). Normalement, la patiente prend des comprimés de citrate de clomiphène par voie orale pendant cinq jours.

Vous ne devriez pas vous inquiéter outre mesure au sujet du citrate de clomiphène. Les effets secondaires sont habituellement légers et bien tolérés : bouffées de chaleur (chez 10-15 % des patientes), céphalées peu intenses et sautes d’humeur. Un amincissement temporaire de la paroi utérine peut survenir chez 15 % des patientes. Des symptômes gastro-intestinaux tels que la nausée ou les vomissements sont rares. Le principal « effet secondaire » est le risque d’une grossesse multiple (de 8 à 10 % des cas, par opposition à 1 % dans la population en général) attribuable à

l’hyperstimulation ovarienne. Dans 99 % des cas, il s’agira de jumeaux. Certaines femmes s’inquiètent du risque de cancer des ovaires en rapport avec la prise de clomiphène. Dans le passé, des études ont suggéré un lien possible entre le clomiphène et l’apparition de tumeurs ovariennes (bénignes ou cancéreuses). Cependant, des recherches plus récentes ne montrent pas ce lien. Notez que si vous avez fait usage de contraceptifs oraux à un moment donné, cela réduit votre risque de cancer des ovaires. Afin de stimuler l’ovulation davantage ou d’encourager la production de plusieurs ovules (nous en voulons deux ou trois pour l’IIU et une dizaine pour la FIV), certaines femmes recevront des injections souscutanées de FSH de 10 à 14 jours de suite. Celles-ci sont généralement bien tolérées – il peut y avoir une légère douleur au site des injections – et on ne leur connaît aucun effet indésirable à long terme. Une fois de plus, le risque principal est celui d’une grossesse multiple. La FIV exige également des injections de FSH, à des doses plus élevées cependant. De nombreuses patientes reçoivent en outre d’autres injections, notamment d’un agoniste ou antagoniste de la GnRH, qui visent à inhiber la fonction de la glande pituitaire. Cette glande contrôle le développement des ovules et l’ovulation, entre autres choses.

La Dre Allison Case, BSc, MD, FRCSC, est professeure agrégée au Département d’obstétrique, gynécologie et sciences de la reproduction à l’Université de la Saskatchewan. Elle est la directrice médicale du programme des technologies de procréation assistée à l’ARTUS Fertility Centre ainsi que chef de clinique du Service d’endocrinologie de la reproduction et infertilité. Professeure à temps plein, elle enseigne aux étudiants en médecine et aux résidents en obstétrique-gynécologie. Ses intérêts cliniques et de recherche sont l’infertilité, la procréation assistée, les fausses couches à répétition et la préservation de la fertilité.

(Même si nous voulons que les ovules se développent, pour la FIV nous ne voulons pas qu’ils soient libérés avant qu’ils puissent être collectés.) On donne une injection de gonadotrophine chorionique humaine (hCG) pour assurer la maturation finale des ovules avant la collecte. Enfin, de la progestérone est habituellement administrée par voie vaginale après le transfert d’embryon jusqu’au test de grossesse. Si le test est positif, on poursuit pendant les 10 premières semaines de la grossesse. Un effet secondaire à surveiller est le syndrome d’hyperstimulation ovarienne (SHSO). Les patientes les plus à risque sont les femmes jeunes, celles atteintes du SOPK, celles dont l’IMC est bas ou qui ont été atteintes du syndrome précédemment. Les symptômes sont des ballonnements, une sensation de malaise au bas-ventre, des nausées, des vomissements, de la diarrhée, des étourdissements et le souffle court. Un SHSO léger affecte environ 10 % des patientes, alors que moins de 1% sont touchées par une forme grave exigeant l’hospitalisation. Toutes les patientes sont suivies de près en rapport avec le SHSO, et il existe de nombreux moyens de réduire les risques et la gravité du syndrome. Les effets secondaires les plus courants chez les femmes recevant des injections de FSH sont les ballonnements et la sensation de malaise au bas-ventre lorsque les follicules se développent sur les ovaires. Quand il survient, le gain de poids est minime et est dû habituellement à la rétention de liquide. Il ne semble pas y avoir d’effets indésirables à long terme tels que le cancer ou une ménopause prématurée chez les femmes qui ont pris ces médicaments. ■

SPRING/PRINTEMPS 2013 • Creating Families

The Naturopathic View

Natural Conception by Judith Fiore, ND

In the midst of the complex world of medical fertility treatment, natural conception can seem to be something that was tried and can never be attempted again. For many couples, there is a feeling of “been there, done that” when asked about conceiving without medical help, and during an IVF cycle it is not unusual for a couple to abstain altogether from sexual intimacy. But when a couple is taking a break between rounds of treatment, and sometimes it can be a break of several months, there is often the hope that there might still be a chance of conceiving naturally. This is an opportunity to re-connect with one another when you are free of the stress associated with undergoing a cycle of fertility drugs and procedures. There can be issues regarding sex and intimacy if you have come to rely on the fertility clinic’s help in trying to get pregnant. You

Créons des familles • SPRING/PRINTEMPS 2013

When a couple is taking a break between rounds of treatment, and sometimes it can be a break of several months, there is often the hope that there might still be a chance of conceiving naturally. may rarely make love or maybe you have stopped having sex altogether. There may be emotional and psychological issues with trying to get back to being intimate on a regular basis. Males, in particular, may feel pressured to perform. If intercourse is only attempted when ovulation is expected, the man may feel he is only wanted for the sperm he can

produce, and as a result there may be problems with maintaining an erection. If these are issues that are concerning you, there are natural ways to improve your health and consequently your mood and your sex life. If you are planning to take a break of at least three months or longer, nutritional changes, supplementation, and lifestyle changes can have an impact on the quality of your eggs and sperm. In addition, you may find you are feeling healthier, your mood is elevated, and your love life has improved. And even if you are planning a shorter break, it’s always a big help to seek out ways to optimize your health and all the good things that come with that. However, if you and your partner have been dealing with intense emotional and psychological issues, you may need to seek professional help. A reputable therapist can put your situation into perspective and help you both discover a healthier relationship.

The Naturopathic View Nutrition

encouraged to incorporate the following lifestyle changes:

With trying to conceive naturally, it is especially important to make sure that you are covering the nutritional basics for good health and fertility. Eat lots of fruits and vegetables as these are the primary sources of antioxidants in the diet. While supplements are helpful, you can’t beat fruits and veggies. A general rule of thumb: eat at least two fruits daily and make sure that vegetables make up at least 50% of your plate at lunch and dinner. There will be days when it’s difficult to get in this amount of fruits and vegetables, but if you can follow this recommendation at least five days out of seven you should see a big difference in how you feel and hopefully see improvements in your fertility as well. In addition, it is best to consume moderate amounts (roughly 25% of meals) of lean protein choices. Lean cuts of meats (grass-fed is best), chicken, and turkey are good options.

• Watch your caffeine intake. One small 6-oz. serving of coffee per day is usually okay, but many people are now stopping for 12 to 16-oz. cups of java. This could be affecting your fertility adversely. For a healthier caffeine boost, try green tea.

Eat lots of fruits and vegetables as these are the primary sources of antioxidants in the diet. While supplements are helpful, you can’t beat fruits and veggies. Limit fish to once per week. It has also been found that reducing saturated fat in the diet leads to better fertility. Aim to eat vegetarian proteins at least three times per week. Vegetarian protein choices are beans, legumes, chickpeas, tofu, tempeh, or seitan. For added protein and healthy fats, raw nuts and raw seeds are excellent choices. They can be sprinkled on salads, on your morning oatmeal, or eaten as snacks. Keep portions to about ¼ cup. Avoid low-fat dairy, as it’s better to have regular fat dairy products such as 2% milk. However, this doesn’t mean you are eating high-fat dairy products every day. Keep higher fat dairy foods to a maximum of two 4-oz. servings weekly. In other words, a serving of Haagen Daz is okay once or twice per week.

Lifestyle A healthy lifestyle is an important part of any plan to conceive naturally, and you are

• Keep alcohol to a maximum of three drinks per week. If you are drinking more than that, and if you find yourself drinking alcohol on a daily basis, it’s time to take a good hard look at this and resolve to reduce your drinking. You may even find it’s best to cut out alcohol altogether. • Don’t smoke. Even a few cigarettes per day can interfere with your attempts to conceive. This goes for both men and women. If you’re having a tough time quitting, see your doctor for advice on how to reduce your addiction to cigarettes. • Get plenty of sleep. This means at least seven hours nightly. For some people, it could be more. We are learning that for the best health and vitality, eight hours of sleep will give most people the benefits of improved health and cognitive function. If you are burning the midnight oil, take an honest look at your lifestyle and determine what needs to change so that you can get to bed at a reasonable hour. • Exercise. Move your body at least four times per week for a minimum of 20 minutes, enough to raise your heart rate and create a bit of sweat. This is great for your circulation, your waist line, for managing stress, and your fertility. Find activities that you really enjoy and make time for them. Even just putting on some uptempo music and dancing around your living room until you are sweaty is great.

SPRING/PRINTEMPS 2013 • Creating Families

The Naturopathic View

Ovulation and Intercourse Timing With natural conception, it is, of course, important to know when ovulation is happening. Knowing this allows you and your partner to make love around this time in your cycle. Most women are aware of the changes in their bodies when they are nearing ovulation. Cervical mucous is more abundant, and often takes on the classic egg white appearance. You may or may not experience increased libido at ovulation. While this cannot be generalized to all women, in my opinion, having a strong interest in sex at ovulation is a positive sign of good health and fertility. Ideally, cervical mucous changes would be all you need to tell you when it’s best to have sex. But for some of you, determining your ovulation time may take a bit more work. Tracking cervical mucous in combination with the first morning temperature, also known as basal body temperature (BBT), is considered to be a fairly accurate way to determine ovulation time. The thermometer can be placed under the tongue or in the centre of the armpit (axilla). Most thermometers will beep once the reading is complete, and the temperature is

Cervical mucous

recorded on the corresponding day on the BBT chart. (See the accompanying sample chart.) It can take a while to get into the habit of taking a BBT every morning, as it has to be done upon waking, before getting out of bed. (I’ll often suggest to patients to put up a sign with “BBT” written with glow in the dark marking pens, next to their alarm clock.) Once you are adept at charting when you are nearing ovulation, you and your partner can plan to make love in the days leading up to ovulation, as well as the day of ovulation. The standard recommendation used to be to have sex every second day or so, but now what is considered more important is not to miss the day(s) when the cervical mucus is abundant. Abundant cervical mucous means you are

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Créons des familles • SPRING/PRINTEMPS 2013

secreting plenty of vaginal fluid with the consistency and appearance of egg white. It could be clear or it could be a combination of clear and white. You’ll know you are ovulating if your temperature drops on the day of ovulation and then rises by 0.5 to 1.0 degrees Celsius the next day. Keep in mind that if you are planning to have sex when you see the temperature rise, you may have missed your ovulation. If taking morning temperatures and charting doesn’t appeal to you, there are a number of ovulation testing kits on the market. These kits monitor luteinizing hormone (LH) which is the hormone that will peak just before ovulation. The main drawback is that the testing strips are expensive. I will often recommend that a couple use the testing kit for at least two cycles. The egg white type of cervical mucous should coincide with the LH peak, and once you’ve seen this happen for two cycles you can be fairly confident about tracking ovulation by just noting the appearance of the cervical mucous. You should also be aware that you may ovulate one month on day 14, but on day 18 or later the following month. There could be a number of reasons for delayed ovulation, including traveling or facing a stressful situation, and it can

The Naturopathic View earlier or later than the actual ovulation time during your natural cycle. Believing that ovulation is set for day 12, for example, may result in missed opportunities for conception if it turns out ovulation is actually taking place on day 16 or later of the cycle.

I believe this is due to improving circulation. Diets high in animal fats are being implicated in heart disease. One of the first signs of coronary artery disease in males is ED. Therefore it is a simple step to consider eating vegetarian to prevent coronary artery disease and ED.

Additionally, if you are noticing that cervical mucous is not that plentiful, then itâ&#x20AC;&#x2122;s a good 4HIS IS THE SIZE THAT WAS SUBMITTED AN ACTUAL BUSINESS CARD SIZE 4HNutritional IS IS THE SIchanges, ZE THAT WAS SUBMITTED AN ACTUAL BUSINESS CARD SIZE idea to use a fertility friendly lubricant. There supplementation, and lifestyle are two lubricants on the market, one is Prechanges can have an impact on seed and the other is Zestica Fertility. Both are the quality of your eggs and formulated to mimic the more alkaline pH of W E L L N E S S C E N T RE sperm. In addition, you may find cervical mucous. In Canada, it is somewhat difficult to get Pre-seed, but Zestica Fertility is you are feeling healthier, your sold in most Shoppers Drug Marts. Whichever mood is elevated, and your love product you choose, a lubricant that helps life has improved. sperm to stay alive and increase chances of natural conception could be the additional aid you need. Itâ&#x20AC;&#x2122;s also important to create a spermbe a normal occurrence during a womanâ&#x20AC;&#x2122;s friendly environment: vaginal sprays and reproductive life. I will encourage you to simdouches as well as scented tampons and artifiply trust your bodyâ&#x20AC;&#x2122;s signals, chart as best you ) CAN EITHER STRETCH THE WHOLE THING TO COLUMNS LIKE THIS )can, CAN EIfocus THERmore STREonTChaving H THEa W HOLE TsexHING TO lubricants COLUMNshould S LIKEbe Tavoided HIS as they might cial and satisfying endanger sperm survival. ual relationship with your partner. In fact, research into frequency of intercourse and best pregnancy outcomes shows that making love WE L L N E S SThe C ELast N T R EWord several times weekly is much better than just I am not a sex therapist, but I have counselled having intercourse when you think ovulation is couples on love-making when they express conimminent. You might say â&#x20AC;&#x153;practice makes percern about libido, maintaining erections, and fectâ&#x20AC;?! sexual positions. I have learned from my Learning your bodyâ&#x20AC;&#x2122;s signs leading up to ovulapatients that libido and issues with erectile dystion and charting your temperature during function (ED) are often improved with a your natural cycle is also important if you think healthy diet and lifestyle. In fact, patients who you are ovulating on a certain day based on adopt a mostly vegetarian diet seem to have the previous fertility treatment cycles. When taking best OR JUST THE BACKGROUND LIKE THIS OR JUST THE BACKGROUND LIimprovements KE THIS when it comes to libido. fertility medications ovulation may happen This also appears to be true for males with ED.

When I am asked about what sexual positions are the best for conception, my answer is always the same. The best positions are the ones where the couple is enjoying sex. Usually this means adopting sexual practices that do not put a strain on the muscles and the skeletal system. I would also advise that after intercourse, you do not immediately get up. Try to relax and stay in a laying down position for at least 20 minutes.

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I hear of women who after sex are advised to lay for a half hour with their bottoms propped up by a bunch of pillows, or with their legs positioned high up against a wall. Gravity does help to keep the seminal fluid around the cervix. But if holding this position is putting undue stress on your body, then donâ&#x20AC;&#x2122;t do it. Being close to one another after sex, holding each other, cuddling, talking, and laughing together probably offers the best opportunity for sperm to get to the waiting egg, in my opinion. I think being relaxed and happy is the kind of environment natural conception is most likely to take place in. Add to this good nutrition and lifestyle, and my hope is that your chances of baby-making success will be as strong as your health and your libido. â&#x2013;

About the Author Dr. Judith Fiore, ND, is a Doctor of Naturopathic Medicine and Natural Fertility Expert, who has been focused on fertility care for individuals and couples for over a decade. She currently practices in Toronto, Ontario, in close proximity to several downtown Toronto fertility clinics. She is also writing a book on how to safely and effectively integrate natural therapies with medical fertility treatment. For more information on Dr. Fioreâ&#x20AC;&#x2122;s fertility practice, please visit her website: www.naturalfertility.ca.

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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, and whatever you deem important. You can also ask questions about anything related to fertility, and our experts will be happy to answer.* Write to us at info@iaac.ca

Ask an Expert

I am a regular employee (not part of management) at an Ontario nursing home. I

have great difficulty getting time off to undergo fertility treatments and have received

Le coin des lecteurs Le coinfeedback desfromlecteurs Le coin lecteurs very negative my employer. Is infertility officiallydes recognized as a disease Le coin des lecteurs Le coin (it is bycoin the Worlddes Health lecteurs Organization) and Le do I have any legaldes rights orlecteurs recourses? Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs A : Randy Slepchik: Le coin des lecteurs As a legal counsel working primarily with unions, I will address this situation for a unionized employee. The first step for an employee is to submit appropriate medical documentation to their employer speaking to their need for treatment. If the employer is not willing to reasonably accommodate such treatment, the employee should speak with their union representative who may be able to address this matter with their employer. If the employer unreasonably denies the accommodation, the union may very well launch a grievance alleging discrimination and a breach of the employee’s human rights.

protect employees from discrimination on Human Rights grounds. As my colleague Anatoly Dvorkin mentioned (see page 67), the employer is required to accommodate an employee’s disability “up to the point of undue hardship”. In a unionized workplace, it is important to note that the obligation to accommodate a disability also falls upon the union. For example, a union may have to overlook seniority rules with regards to shift scheduling if the employee undergoing fertility treatments requires specific shifts or more time off than he or she would normally be entitled to under collective agreement rules for seniority.

Readers’ Corner Under Human Rights law, infertility has been recognized as a disability, not in the practical sense, but for the purposes of triggering an employer’s obligations under Provincial & Federal Human Rights legislation. These laws

Randy Slepchik is a workers’ rights lawyer with Jewitt McLuckie & Associates in Ottawa. He advises unions and workers on all aspects of labour, employment and human rights law. He can be reached at rslepchik@jewittmcluckie.ca or 613-594-5100 #249.

* N.B. These articles ought not be relied on for legal advice, and cannot take the place of consultation with a lawyer.

Créons des familles • SPRING/PRINTEMPS 2013

Readers’ Corner

A : Anatoly Dvorkin:

attending medical appointments to deal with infertility issues.

affirmed that this means that persons with disabilities must be accommodated by employers to the point of undue hardship. The most important question becomes whether infertility is a disability within the meaning of the Code. On this point, there are court decisions which affirm that infertility is a disability. As such, an employer has a positive duty to accommodate an employee dealing with infertility to the point of undue hardship (although what that means practically will vary with each situation and depend on several factors).

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 Whether you are part of management and whether infertility is recognized as a disease are irrelevant. What matters is your employment contract (if any), the number of employees at the nursing home, its policies (if any) with respect to personal leave or “sick days” and whether infertility is a disability.

However, I understand that fertility treatments may require that an employee be absent from work for more than 10 days in a calendar year and that many employees work for employers that employ fewer than 50 employees.

Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs Le coin des lecteurs LeAn coin des lecteurs Le coin des lecteurs LeIn Ontario, cointhe employment des lecteurs employee who is not entitled to personal relationship is govLeernedcoin des lecteurs emergency leave under the ESA should look to by legislation, including the Employment LeStandards coin desand thelecteurs his or her employment contract, which will often Act (“ESA”) Ontario Human stipulate how much personal time or “sick days” Code (“Code”), as well as the Common LeRights coin des lecteurs an employee is entitled to take off from work Accommodating an employee does not necessariLaw. The ESA sets out minimum standards for conditions of employment while the Code prohibits discrimination against disadvantaged groups. According to section 50 of the ESA, if your employer regularly employs 50 people or more, you are entitled to an unpaid leave of absence not exceeding 10 days in a calendar year for personal illness, injury or medical emergency (known as personal emergency leave). If your nursing home fits in the 50 employees or more category, the question then is whether infertility qualifies as an illness, injury or medical emergency. Although the analysis may differ from province to province (or territory), I expect that it would not differ greatly, perhaps with the exception of Quebec.

Although I am unaware of any court decisions dealing with this question, the Ontario Ministry of Labour’s Guide to the Employment Standards Act provides some guidance. It states that “All illnesses, injuries and medical emergencies of the employee … will qualify an employee for personal emergency leave.” Generally, employees are entitled to take personal emergency leave for preplanned (elective) surgery. Although such surgery is scheduled ahead of time (and therefore not a medical "emergency"), surgeries performed because of an illness or injury will entitle an employee to personal emergency leave.

In my opinion, an employer of 50 or more employees would be faced with an uphill battle if it tried to prevent an employee from utilising the personal emergency leave for the purpose of

each year. If there is no written employment contract, the employee should investigate whether the employer has a policy dealing with time off work for personal reasons. In the event that no such policy exists and the parties did not enter into an employment contract (or if the employment contract is silent on this issue), the employee should speak with the employer about the employer’s policy and seek to obtain the employer’s consent to his or her taking time off to attend medical appointments and to recover from any procedures. If an employer refuses to allow an employee any or sufficient personal time or “sick days”, the employee may have to resort to using his or her vacation time. Likewise, an employee who is entitled to personal emergency leave under the ESA but requires more than 10 days off work may have to resort to using vacation time for the additional days off.

ly entail providing a leave of absence; rather, depending on the situation, it may mean a temporary reassignment to a less stressful role or fewer hours or more administrative assistance. What is clear, however, is that it would be contrary to the Code for an employer to be disrespectful, marginalize or penalize an employee undergoing fertility treatments as this would amount to discriminatory behaviour contrary to the Code. Similarly, an employer that has a policy regarding time off work for “sick leave” or personal time must apply that policy equally to all employees whether the employee requires chiropractic care for a disabling back injury or fertility treatments.

Readers’ Corner

The above analysis is just the starting point. Perhaps the essential consideration is whether the Code requires employers to allow employees undergoing fertility treatments sufficient time off work to attend medical appointments, recuperate from procedures and/or simply avoid stressful situations which may impact the success of the treatments.

Under the Code, in the context of employment, everyone has the right to be free from discrimination because of disability or perceived disability. The Supreme Court of Canada and other appellate courts throughout the country have

In short, if you are undergoing fertility treatments, you likely do have rights that you can assert if your employer is not cooperative or worse still, giving you negative feedback for the sole reason that you require some time off work for undergoing medically necessary procedures. As there are numerous factors that will affect your rights, you should be sure to consult a qualified employment or labour lawyer before taking any steps. ■ Anatoly Dvorkin is one of the founding partners of D2Law LLP, a multi-service law firm in Toronto, Ontario. Anatoly’s practice includes employment law, corporate/commercial litigation and business law. He can be reached at anatoly@d2law.ca or 416.907.2188.

SPRING/PRINTEMPS 2013 • Creating Families

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Readers’ Corner

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Readers’ CornererReader Readers’ CornerReader er Readers’ Corner Readers’ CornererReader Readers’ Corner Readers’ Corner 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 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 et tout ce qui vous paraît important à signaler. Vous pouvez aussi poser toute question liée à la fertilité et nos experts seront heureux de vous répondre. ** Écrivez-nous à info@iaac.ca

R : Marie-Ève Crevier: La loi québé-

coise sur les normes du travail prévoit spécifiquement qu’une personne peut s’absenter en tout 26 semaines sur une période de 12 mois sans salaire pour cause de maladie si elle a à son crédit trois mois de service continu pour l’entreprise où elle travaille. Pour exercer ce droit, la personne doit aviser son employeur de la situation le plus tôt possible. Si des absences répétées sont à prévoir, l’employeur peut exiger un document médical attestant les motifs invoqués.

L’employé(e) dans cette situation ne peut être sanctionné(e), c’est-à-dire que la personne ne peut être congédiée, suspendue ou mutée à un autre poste. Si l’employeur contrevient à ces règles, l’employé(e) peut porter plainte devant la Commission des normes du travail – c’est cependant la Commission des relations du travail qui entendra sa cause. La Commission met à la disposition des plaignant(e)s des avocats qui les représentent gratuitement. La personne peut cependant se défendre seule, ou embaucher son propre avocat si elle le

Une lectrice nous a posé une question qui pourra intéresser tous les employés obligés de s’absenter du travail pour suivre leurs traitements de fertilité. L’avocate montréalaise Marie-Ève Crevier y répond dans l’entrevue ci-dessous.

Q : Je travaille dans le milieu de la santé (je ne suis ni syndiquée ni cadre) au

Québec. J’ai beaucoup de difficulté à me libérer pour suivre mes traitements de fertilité et je reçois des commentaires très négatifs de mon employeur. L’infertilité est-elle reconnue comme une maladie (elle l’est par l’Organisation mondiale de la santé) ? Ai-je des droits ou des recours ?

désire. Il y a enquête au préalable car la Commission veut d’abord s’assurer qu’il y a matière à plainte. Il est important de noter que très peu de décisions ont été rendues en matière d’infertilité, de sorte que le droit reste à construire à cet égard.

Me Marie-Ève Crevier exerce au cabinet Schneider & Gaggino, à Dorval, au Québec. Elle est spécialisée en droit du travail. On peut la joindre à mecrevier@sg-avocats.ca ou au 514 631-8787 poste 223.

Il semble que, dans votre cas, il soit surtout question de harcèlement psychologique au travail. Si vous désirez porter plainte, le processus est le même : vous devez porter plainte auprès de la Commission des normes du travail, et c’est la Commission des relations du travail qui entendra votre cause, après enquête.

Readers’ Corner

Si la personne vivant ce type de situation est syndiquée, elle doit d’abord contacter son syndicat, qui vraisemblablement déposera un grief, et c’est un arbitre de grief qui entendra la cause. Il examinera dans un premier temps la convention collective pour vérifier si elle prévoit une situation de ce genre. Si ce n’est pas le cas, la Loi sur les normes du travail primera, car une convention collective doit prévoir des normes au moins égales à ce que prévoit la Loi des normes du travail. ■

**N.B. Ces articles sont publiés à titre d’information et ne peuvent remplacer une consultation avec un avocat.

SPRING/PRINTEMPS 2013 • Creating Families

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