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The American Fertility Association’s Monthly Newsletter

August 2, 2007

Carolyn Berger, LCSW

Conquering Birthmother Fear
By Carolyn Berger, LCSW

New adoptive parents love nothing more than telling their “Adoption Story,” and people considering adopting never get tired of listening to it.

These stories generally begin with the adoptive parents’ difficulties trying to conceive a child and end with the day they met their baby. When the story is about a domestic adoption, one of the first questions people ask is, “Weren’t you worried that the birthmother would change her mind?” followed by, “Are you in contact with her?” These questions tend to be asked in the hushed tones people a generation or two ago used to reserve for “Does your child know she was adopted?”

“Birthmother fear” is so entrenched in our culture that many pre-adoptive parents immediately opt for international adoption, which places the birthmother far away and therefore, they think, much less likely to show up on their doorstep. These fears are fueled by newspaper headlines such as those earlier this year when Allison Quets of the U.S. fled to Canada with her biological twins after she had placed them with an adoptive couple in North Carolina. “Fugitive Mother Vows to Fight” blared The Ottawa Citizen last January. The fact is, scenarios like this rarely happen.

What does happen, though, is that sometimes birthmothers--and birthfathers-- change their minds sometime during the process of planning an adoption. The reasons are as varied as human nature. They can range from electing to terminate the pregnancy to marrying the birthfather to getting the family support raising the child. For some it’s a slow realization process, for others it hits them just before the birth. Note well, though, only a very small number of birthmothers –experts say fewer than one percent -- choose to contest the adoption after she has relinquished parental rights and the baby has gone home with the adoptive parents.

One of the best ways to overcome birthmother fear is to understand it. Step into the birthmother’s shoes for a moment. According to the Evan B. Donaldson Adoption Institute’s 2006 study “Safeguarding the Rights and Well-Being of Birthparents in the Adoption Process,” voluntarily placing a child for adoption is exceedingly difficult for the vast majority of women traveling this path. For most, it is a step that causes deep pain and reverberates through the course of their lives, even when they make the choice in a self-determined manner.” Yet, according to the study, approximately 14,000 birthmothers follow through on their adoption plan each year. (Go to www.adoptioninstitute.org/publications and look under “Birthparents” for the complete study.)

When a birthmother begins to consider placing her child, she is invariably coping with a sense of impending loss and pre-adoptive parents are often in the midst of grieving over the loss of the biological children they could not have. Pre-adoptive parents can begin to view a birthmother as someone with the power to take their pain away and replace it with joy. The birthmother can, and often does, become feared because of her ability to “withhold” the baby and create a new loss for the pre-adoptive parents.

With emotions running high, a birthmother and pre-adoptive parents can become adversaries in the course of planning an adoption. Dawn Smith-Pliner, Executive Director of Friends- in- Adoption, an adoption agency in Vermont, encourages all the adults to put their needs aside long enough to recognize their common goal: “They all want to make a plan that will enable the child to grow into a healthy child and a healthy adult.”

The vast majority of adoption professionals believe that open adoption, where connections among birthparents, adoptive parents and adopted child are maintained, is in the best interest of the child.

Creating and fostering an open adoption takes hard work on the part of birthparents and adoptive parents. For this reason, Smith-Pliner encourages birthparents coming to her agency to get counseling for support and help with their decision-making. Lately, she has noticed a new trend: Adoptive parents, too, are seeking counseling—often because the social worker conducting the adoption home study is recommending it. Counseling can provide them with the opportunity to discuss their fears about adopting and begin to manage them before stepping into what can be an emotionally turbulent process.

Ronnie, 45, the adoptive parent of 6-month old Zach, describes the fears she experienced two years ago when she and her husband Ben, also 45, decided to adopt. She was exhausted from infertility treatments when she approached adoption, and angry, too, that she could not conceive a child. She found the whole concept of adoption anxiety provoking. She worried about all the possible glitches. It would take years for her adoption agency to find a match; the birthmother would push for too much involvement with the child; or she would fall in love with the baby only to have the birthmother change her mind.

Today, Ronnie is able to smile at her fears, saying that she has come 180 degrees in her attitude toward birthmothers and open adoption. How that happened will make a wonderful story to tell Zach one day. Like many good adoption stories it begins with a twist of fate, and ends with transformation and joy: It was already snowing when Ronnie and Ben dashed up to the hospital where Zach was born. Before they knew it, the roads were closed and they realized they were snowed in. The hospital was filled to capacity and with nowhere to go Ronnie, Ben, the birthmother, Jen and Zach suddenly found themselves spending the night in Jen’s hospital room. In those tight quarters birthmother, adoptive parents and baby Zach got to know each other very well. Ronnie’s fears about Jen and her own life as an adoptive parent dissolved. This adoption was going to work!

While Ronnie and Jen made a schedule about how and when they would be in contact, they trust each other enough to use it flexibly. They know that they will be there for each other in a practical way—if, for example, Jen develops a medical condition that could be passed down to the baby she will alert Ronnie. Both women know that the baby will grow up having a relationship with his birthmother as well as her family. Zach will know his own adoption story—including where he came from and why he was placed for adoption—opening the way to a greater sense of self-acceptance and a solid identity.

Ronnie has just one regret about her son’s adoption: She believes her “ birthmother fear” cheated her of the days of happy anticipation she might have enjoyed leading up to Zach’s birth.

Sometimes a birthmother and adoptive parents develop a relationship that unfolds seamlessly. Carmela and Stephen, who adopted with the help of an independent adoption attorney, met Roxanne over the Internet. Roxanne already had a child and knew that she could not parent another. The first time Roxanne and Carmela met, Roxanne knew she had found the person she wanted to parent her unborn child. Carmela says it was like a blind date where both people “just clicked.” Carmela and Steve made it clear from the start that they wanted Roxanne to feel sure about her decision and would understand if she should change her mind.

She didn’t. When Maribelle was born six weeks early, Roxanne had the couple by her side and give Carmela the honor of cutting the chord. Roxanne gave Carmela and Steve a pink teddy bear for Mirabelle. Carmela gave the birthmother the baby’s hospital bracelet and footprints, one of two sets she had the hospital make.

Over the last two-and-a-half years, the relationship continued to expand with Carmela viewing Roxanne as a familiy member. Still, knowing that adoptions inevitably bring challenges, Carmela and Steve belong to an adoptive parent support group.

Maybe it’s not possible to conquer birthmother fear—the baby the birthmother is carrying is too important to her and the adoptive parents to allow for that. Perhaps managing birthmother fear is a more realistic goal. And by getting to know the birthmother as a person rather than our personal baby-maker, we may come to understand and maybe sympathize if she has a change of heart.

But if the adoption goes as most do, open conversations between adoptive and birth parents will give them a chance to deepen their mutual appreciation and celebrate the child they all want to see grow up happy, healthy and fortified for life with a strong sense of self and family.

This is the first of four articles devoted to domestic adoption. Future articles will focus on domestic adoption (independent and agency), transracial adoption, and adoption through foster care.

The AFA invites you to join adoption attorney Suzanne Nichols for an Online Educational Session on Domestic Adoption, Tuesday, August 14, 8 to 9 pm ET.

Carolyn Berger, LCSW, is Adoption Coordinator of the AFA. She has two sons, one biological and one adopted domestically. She experienced birthmother fear, survived a birthmother’s change of heart, and thinks about her son’s birthmother every day.

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SINGLE EMBRYO TRANSFER: THE VIABLE OPTION
By Christine Briton-Jones Ph.D. and Mark Surrey M.D.

Mark Surrey M.D.

Christine Briton-Jones Ph.D.

The goal of reproductive endocrinologists using assisted reproductive technology (ART) has always been to increase the chances of achieving a healthy live singleton birth for their patients. It was an elusive goal until recently.

In the earliest days of ART, the failure rate for treatment cycles ran high because, typically, no oocytes were retrievable. If luck was smiling, maybe there was one but more often than not that single egg never fertilized. Under the circumstances, it was hardly surprising that single embryo transfers yielded very disappointing pregnancy rates, particularly if calculated by the number of cycles that ended with no transfer at all. It stands to reason, then, that multiples weren ’t much of a concern.

By the 1980s controlled ovarian stimulation regimes developed. That provided the opportunity for multiple ovarian follicles to develop to maturity and to control the endogenous luteinizing hormone (LH) surge which often led to ovulation and loss of oocytes prior to retrieval. During this period of successful and reliable oocyte retrieval and concomitant rapid increases in the pregnancy rates for each treatment cycle, a new dilemma emerged. Since greater pregnancy rates were achieved with the transfer of more than one embryo, i.e., often the all the embryos available for transfer, it now became commonplace to transfer of three or four embryos became commonplace. That led to a surge of multiple pregnancies.

Perinatologists pointed accusing fingers at reproductive endocrinologists for their apparent lack of regard for the complications of multiple pregnancies. Indeed, the late 1980s became synonymous with quadruplets, the 90s identified the reality of the serious consequences of triplet pregnancies. At the dawn of the 21st Century, the focus is on twin pregnancies--once passed off as acceptable – and the health, financial and social costs they bring.

There is a solution. Long held views that the transfer of a single embryo would surely lead to pregnancy failure persist, despite dramatic advances in both medical and laboratory technology during the 1990s and early 2000s. It ’s time for perception to catch up with reality.

Single Egg Science
An important vehicle for rapid improvement in success rates for assisted reproductive treatment was the development of sequential culture. The current view embryologists take is to develop the philosophy of a culture system rather than culture media. By analyzing and addressing potential stresses to gametes and embryos at each stage of growth and differentiation, embryo culture has become more standardized and efficient around the world. We now have a reliable system in which to grow viable embryos to the stage at which they would normally be entering the uterus. Compared to the standard practice of transferring embryos after two or three days of culture, when in vivo they would still be held within the fallopian tube.

An interesting observation that accompanied the technique of blastocyst culture was that only approximately sixty percent of morphologically good quality embryos progressed to the blastocyst stage. During this time the technique of pre-implantation diagnosis (PGD) for chromosomal aneuploidy was being applied to ART. Independent studies using the technique of comparative genomic hybridization (CGH) compared the ploidy status of all forty-six chromosomes within all cells from donated day three embryos. These studies identified that seventy percent of morphologically good quality embryos carried chromosomal aneuploidies. More recent studies have confirmed that embryos that are aneuploid are less able to form blastocysts. However, the same studies showed that while blastocysts are much more likely to be chromosomally normal than a day three embryo, this was not absolute. Embryos with a single chromosome aneuploidy are quite capable of forming morphologically good quality blastocysts.

It’s A Matter of Choice
The dilemma for today’s reproductive endocrinologist is no longer …will I obtain an embryo for transfer but rather …which embryo should I transfer? Culturing embryos to the blastocyst stage is a good strategy to identify which embryos are most likely to implant. Blastocyst culture in combination with PGD for aneuploidy screening is a robust strategy for selecting which embryos have the best chance of achieving a pregnancy. With such powerful embryo selecting strategies at our disposal many clinics around the world are changing their practice to transfer one embryo only.

The United States lags behind most developed countries in the move to elective single embryo transfer (EST). Despite conclusive reports of the health risks to mother and babies and the enormous financial costs of twin pregnancies being widely known few clinics in the United States routinely perform EST. Countries which offer considerable financial aid to patients undergoing ART such as Belgium and Australia have introduced financial incentives for patients to choose to transfer a single embryo and to cryopreserve additional embryos for future treatment cycles. These governments have found that this investment is balanced by the reduction in costs associated with the high neonatal intensive care treatment needed by many twins. As the ART cycles in the United States are largely funded by the patients themselves it is important to educate our patients to the safety and relative cost efficiency of EST compared to a common misconception of wishing for twins and therefore form a family in just one treatment cycle. A common belief held by ART practitioners is that patients will never accept transferring a single embryo and indeed would rather transfer three or more to ensure the highest chance possible for a pregnancy in this cycle. While this is a reasonable observation it is also clearly showing a lack of education of our patients in both the advances in ART that makes SET a viable option and the serious risks of a twin pregnancy.

Today’s ART clinics have the power of PGD for aneuploidy screening combined with blastocyst culture which bring EST pregnancy rates to the same levels of those for two or three embryos being transferred but eliminate the high health, social and financial burdens associated with multiple pregnancies.

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Support Line: 888-917-3777. Fax: 718-601-7722. www.theafa.org