Appendix A–Infertility Treatment Options

There are many infertility options available to you, including some that will preserve your genetic connection to your child. Not all options for infertility will work for all couples, which is why it’s important you consult with your fertility counselor and reproductive endocrinologist about which options are available for your particular situation.

In general, here are the several options for infertile couples available today:

FERTILITY DRUGS
Usually, the first infertility treatment that couples undergo is fertility medication. When a couple first has trouble conceiving naturally, their physician will usually prescribe them fertility drugs aimed at stimulating ovulation, thickening the uterine lining, increasing sperm count or other methods designed to increase the chances of conceiving. Talk to your reproductive endocrinologist to discover which fertility drugs might be right for your infertility options.

MEDICAL PROCEDURES FOR INFERTILITY
If fertility drugs do not enable a couple to conceive naturally, their reproductive endocrinologist or fertility counselor will usually suggest medical infertility options, otherwise known as assisted reproductive technology (ART). Again, which medical procedure will be best for you will depend upon your own situation, but here are some of the more common ways that conception is assisted medically:

In vitro fertilization (IVF): Perhaps the most commonly known ART method, in vitro fertilization involves the harvesting of sperm and egg cells from each partner. Then, the gametes are combined for conception in a laboratory dish. Once the embryo develops, it will be transferred into the woman’s uterus for implantation. After it successfully implants, her pregnancy will likely proceed just as any other pregnancy would.
Intrauterine insemination (IUI): If the harvesting of egg is not needed, a physician will usually recommend IUI. In this procedure, sperm is collected from the male partner, “washed” to remove seminal fluid and then inserted directly into the uterine cavity to increase chances of conception.

Intracytoplasmic sperm injection (ICSI): This treatment is the part of the IVF process where a single sperm is inserted into a retrieved egg. It’s usually used in cases of male infertility problems.

Assisted hatching: To increase the chance that an IVF-created embryo will implant in a woman’s uterus, some medical professionals use the “hatching” technique. This method makes it easier for an embryo to “hatch” out of certain layers of protein and then implant.

Gamete intrafallopian transfer (GIFT): Like IVF, the GIFT process harvests egg and sperm from intended parents. Instead of fertilizing the egg in a laboratory dish, however, this method mixes sperm and egg and then implants them into the fallopian tube for fertilization.

Zygote intrafallopian transfer (ZIFT): The ZIFT process is similar to the GIFT process, although the egg is fertilized before transfer to the fallopian tube.

SPERM, EGG OR EMBRYO DONATION
If the egg or sperm of an intended parent is not viable for a healthy embryo-creation process, gamete donation may be the next path to take. This way, intended parents can preserve at least one parental genetic connection to their child even if both parents cannot be genetically related to the child.

In addition to cases where parents’ sperm or eggs are not healthy enough for IVF, gamete donation is used in cases of same-sex family-building — lesbian couples will need a sperm donation and male couples will need an egg donation (as well as a gestational carrier, which you can read more about below). Gamete donations may also be used to avoid passing along a genetic disease for which one or both intended parents are a carrier. For people in these situations, an egg, sperm or embryo donation is the best of the infertility options available to them.

Like with other options for infertile couples, a reproductive endocrinologist will be able to tell you whether a sperm, egg or embryo donation is necessary or could be useful for your situation. Fortunately, there are many sperm, egg or embryo banks from which to find a donation, and intended parents can have the choice of an anonymous or identified donor. They can also choose important characteristics, like IQ, eye color, hair color, medical history, etc.

Before you choose to use a gamete donation, it’s important to talk to your fertility counselor about the potential challenges of doing so, including your future child’s identity as a donor-conceived child. Only once you are comfortable with these should you move forward with this ART process.

SURROGACY
For those parents who cannot carry a child to term themselves (either due to medical reasons or because they are a single male or gay male couple), surrogacy may be the answer. In this family-building method, an embryo is created by the intended parents (from their own sperm and egg or with a donor gamete) and then transferred into the uterus of a surrogate, who will carry the child to term for them. For intended parents who believe that becoming parents is more important than actually being pregnant, surrogacy is the best way to preserve a genetic connection to their child.

There are technically two kinds of surrogacy — gestational and traditional — but most surrogacy professionals today will only complete gestational surrogacies, where the surrogate is not related to the child she carries. Even in gestational surrogacy, the process is an emotional one, and both intended parents and surrogates should be prepared for the physical and emotional challenges that will await them.

To learn more about the surrogacy process, contact a surrogacy agency today or take a look around our website. While surrogacy may not be one of the infertility options that’s best for everyone, it may be possible for you.

ADOPTION
One of the more popular options for infertile couples is adoption, through which parents bring a non-genetically related child into their family. Adoption has changed a lot over the last few decades, and many are surprised at how positive an experience it can be for all involved. There are a couple of different paths if you choose to pursue adoption:

Private domestic infant adoption: In this adoption process, a pregnant woman chooses to place her child for adoption. She chooses the adoptive family, creates a relationship with them and is able to be a part of her child’s life as they grow up through open adoption.
Foster care adoption: There are many children in the foster care system who are eligible for adoption after their parents’ reunification plans have failed. Many of these children are older and may have special needs, but the foster care adoption cost is generally the least expensive of all adoption processes.
International adoption: While the options for international adoption are dwindling, it is still possible to adopt from certain countries other than the U.S. Children adopted internationally are usually older or have special needs, and the wait time for international adoption can be long.
It’s important to remember that adoption is not a “cure” for infertility, as it does not bring a child into your family that shares a genetic relationship with you. However, for those intended parents who believe that raising a child is more important than having that genetic relationship, adoption is the right path to pursue.

LIVING CHILD-FREE
Finally, one of the last options for infertility is choosing to live child-free. This is a serious decision to make — and only one that should be made after serious consideration by both members of an infertile couple. While this is certain one of the least popular options for infertile couples, there are some who choose to go this path.

Many times, when people choose to live child-free, it’s because they have already spent many years and funds trying to have a child of their own with no success. Rather than go through that process again, they decide that they can be happy living without children. They may have the joy of children in their life through nieces, nephews and neighbors, and they decide that missing out on the joys and pitfalls of parenting is not a huge loss for them.

Before you and your partner make this decision, it’s important that you talk it over in detail. A fertility counselor can also help walk you through this discussion.

DECIDING WHICH INFERTILITY OPTIONS ARE RIGHT FOR YOU
Because there are so many options for infertile couples, how do you decide which one is right for you? One of the best resources in this decision is your fertility counselor, who can not only inform you of the medical options available in your situation but also the practical and emotional requirements of each infertility option, including the differences in cost for each one. Intended parents should also consider speaking with a financial advisor before selecting a family-building option.

With the proper preparation and research, you can have the child you’ve always dreamed about through the family-building method that’s best for you. Every couple’s situation is different. Even if you’re not sure if surrogacy is right for you, you can get in touch with a surrogacy professional today to get more information about your infertility options.

References

surrogate.com, “Intended Parents, What are your infertility options today?”;

Appendix B–Prenatal Care

1st Trimester
If you haven’t yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don’t cause infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don’t pose any serious risks for pregnant women or their babies. Vaccination can help pregnant women build antibodies that protect their babies. If possible, people who live with you should also be vaccinated against COVID-19.

Whether you choose a family doctor, obstetrician, nurse-midwife or other pregnancy specialist, your health care provider will treat, educate and reassure you throughout your pregnancy.

Your first visit will focus on assessing your overall health, identifying any risk factors and determining your baby’s gestational age. Your health care provider will ask detailed questions about your health history. Be honest. If you’re uncomfortable discussing your health history in front of your partner, schedule a private consultation. Also expect to learn about first trimester screening for chromosomal abnormalities.

After the first visit, you’ll probably be asked to schedule checkups every four weeks for the first 32 weeks of pregnancy. However, you may require more or less frequent appointments, depending on your health and medical history. In some cases, virtual prenatal care may be an option if you don’t have certain high-risk conditions. If you and your health care provider opt for virtual prenatal visits, ask if there are any tools that might be helpful to have at home, such as a blood pressure monitor. To make the most of any virtual visits, prepare a list of questions ahead of time and take detailed notes.

During these appointments, discuss any concerns or fears you might have about pregnancy, childbirth or life with a newborn. Remember, no question is silly or unimportant — and the answers can help you take care of yourself and your baby.

2nd Trimester

If you haven’t yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don’t cause infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don’t pose any serious risks for pregnant women or their babies. Vaccination can help pregnant women build antibodies that protect their babies. If possible, people who live with you should also be vaccinated against COVID-19.

Your prenatal appointments will focus on your baby’s growth and detecting any health problems during the second trimester of pregnancy. Your health care provider will begin by checking your weight and blood pressure. Your provider might measure the size of your uterus by checking your fundal height — the distance from your pubic bone to the top of your uterus (fundus).

At this stage, the highlight of your prenatal visits might be listening to your baby’s heartbeat. Your health care provider might suggest an ultrasound or other screening tests this trimester. You might also find out your baby’s sex — if you choose.

In some cases, virtual prenatal care may be an option if you don’t have certain high-risk conditions. If you and your health care provider opt for virtual prenatal visits, ask if there are any tools that might be helpful to have at home, such as a blood pressure monitor. To make the most of any virtual visits, prepare a list of questions ahead of time and take detailed notes.

Be sure to mention any signs or symptoms that concern you. Talking to your health care provider is likely to put your mind at ease.

3rd Trimester

During the third trimester, your health care provider might ask you to come in for more frequent checkups — perhaps every two weeks beginning at week 32 and every week beginning at week 36.

Like previous visits, your health care provider will check your weight and blood pressure and ask about any signs or symptoms you’re experiencing. In some cases, virtual prenatal care may be an option if you don’t have certain high-risk conditions. If you and your health care provider opt for virtual prenatal visits, ask if there are any tools that might be helpful to have at home, such as a blood pressure monitor. To make the most of any virtual visits, prepare a list of questions ahead of time and take detailed notes.

If you haven’t yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don’t cause infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don’t pose any serious risks for pregnant women or their babies. Vaccination can help pregnant women build antibodies that protect their babies. If possible, people who live with you should also be vaccinated against COVID-19.

Also, one dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine is recommended during each pregnancy — ideally during the third trimester, between weeks 27 and 36 of pregnancy. This can help protect your baby from whooping cough before he or she can be vaccinated.

You will also need screening tests for various conditions, including:

Gestational diabetes. This is a type of diabetes that sometimes develops during pregnancy. Prompt treatment and healthy lifestyle choices can help you manage your blood sugar level and deliver a healthy baby.
Iron deficiency anemia. Iron deficiency anemia occurs when you don’t have enough healthy red blood cells to carry adequate oxygen to your body’s tissues. Anemia might cause you to feel very tired. To treat anemia, you might need to take iron supplements.
Group B strep. Group B strep is a type of bacteria that can live in your vagina or rectum. It can cause a serious infection for your baby if there is exposure during birth. If you test positive for group B strep, your health care provider will recommend antibiotics while you’re in labor.
Your health care provider will also check your baby’s size and heart rate. Near the end of your pregnancy, your health care provider will also check your baby’s position and ask about your baby’s movements. He or she might also ask about your preferences regarding labor and pain management as you get ready for delivery. If you have specific preferences for labor and birth — such as laboring in water or avoiding medication — define your wishes in a birth plan. Review the plan with your health care provider but keep in mind that pregnancy problems might cause plans to change.

As your due date approaches, keep asking questions. Knowing what to expect can help you have the most positive birth experience

References
mayoclinic.org, “pregnancy week by week.”;

Appendix C–Can Diet Prolong Life?

Earth’s longest-lived people follow what author Dan Buettner calls blue-zone diets.

What’s the secret to living an extra 10 years? It’s never one thing. Rather, it’s a set of environmental factors that reinforce each other and that keep people reflexively doing the right things and avoiding the wrong things for long enough not to develop chronic diseases. For the past 20 years writing for National Geographic, I’ve identified and studied the world’s longest-lived areas, which I call blue zones. These places—Okinawa, Japan; Sardinia, Italy; Ikaría, Greece; Nicoya, Costa Rica; and the Seventh-day Adventist communities in Loma Linda, California—have the most centenarians and the highest middle-age life expectancy. Why? Residents live purposeful lives in walkable settings that keep people naturally active and socially connected. And they eat a diet that’s largely plant-based whole foods.

In 2019, as the COVID pandemic set in, photographer David McLain and I hatched the idea of searching for an American blue-zones diet. Thinking that our great-grandparents may have eaten similarly to people in the original blue zones, we searched for dietary surveys conducted in the early 1900s. To our dismay, we found that our own ancestors (who immigrated from northern and central Europe) brought their cows, pigs, and pickles with them.

Determined to find what food traditions other cultures, Indigenous and immigrant, had brought to the American table, we crisscrossed the country to find people who could tell us about these foods.

Here’s what we discovered: There is another American diet, one that could actually increase your life expectancy by up to 10 years and, in some cases, reverse disease. It’s not a fad diet invented by a South Beach doctor, a paleo diet marketer, or a social media influencer. This diet was developed by ordinary Americans, is widely affordable, is sustainable, and has a lower carbon footprint than a meat-heavy diet. Most important, it is hearty and delicious, developed over centuries by fusing flavors from the Old and New Worlds in ingenious and uniquely American ways.

We start in New England, looking at the traditional foods of the Wampanoag Native Americans. Their ancestors played a role in history in 1621 when they encountered recently arrived colonists. One man, Tisquantum, taught colonists how to plant corn, a local food. Carolyn Wynne, a Mashpee Wampanoag elder and Otter Clan mother, and her friend, food anthropologist Paula Marcoux, re-create an early 17th-century meal for us using typical Wampanoag foods.

As Wynne cooks over an open fire, she seems to be impervious to the heat. In the coals, she roasts squash stuffed with hazelnuts, dried blueberries, and maple syrup. In a pot off to the side, she boils nasaump, a cornmeal soup. In a third pot, she poaches pumpkin slices in sassafras tea. Though the Wampanoag hunted game and collected mussels and oysters, 70 percent of their diet came from plant sources.

Marcoux tends cast-iron pots hanging over another fire. In one, there is bubbling msíckquatash, a Wampanoag staple stew of hominy, beans, and squash, which Marcoux gussies up with green beans, onions, and herbs. The Wampanoag might also add Jerusalem artichokes, acorns, chestnuts, and walnuts (the nuts sometimes powdered to serve as thickeners). “My particular obsession with history affords me the fun of networking with long-dead cooks in their long-gone kitchens through archival and archaeological sources,” Marcoux says. “It’s a thrilling privilege to conjure their wisdom through fire.”

On the other side of the United States, at the northern tip of Hawaii’s Big Island, we see another version of Native ingenuity on the farm where Scott Harrison’s family has been cultivating native plants for three generations. It abounds with produce eaten here for hundreds of years: sweet potatoes, bananas, pineapples, papayas, mangoes, and breadfruits. In a neatly tended patch, Harrison reaches into the shallow water and extracts a taro plant, holding it up like a trophy: “You can eat the leaves like spinach and boil the stalks like asparagus,” he says. “Mostly we survived off of the root, which we mash into a paste that we eat every day.”

To the west, on the island of Oahu, in suburban Honolulu, 95-year-old Ruth Chang is preparing lunch. “I cook every day,” she tells me as she minces root vegetables. “Once you stop, you lose it.”

Chang’s demographic may be the longest-lived on Earth. Chinese American women living in Hawaii enjoy about 90 years of life expectancy, and the diet of Chinese Americans living there supports such longevity.

Since Southeast Asians began arriving in Hawaii over 170 years ago as agricultural workers, each ethnic group has introduced its own flavors and ingredients. The Chinese brought leafy cabbage, soybean products, and teas. The Japanese, miso and their own version of tofu. The Filipinos, tender tips of many plants such as squash and pumpkin. This melding of foods and cooking techniques has made Hawaii the place to experience Asian fusion cuisine that’s primarily plant based.

African Americans living in the Deep South have a long tradition of eating blue-zones-type foods. What began as a largely plant-based West African diet morphed with local Native American and European influences to produce a unique and vividly delicious cuisine. Dietary surveys going back to the 1890s indicate that most foods eaten by southern African Americans were vegetables and grains. Aside from salt pork added for flavor, animal products played a minor role.

On a steamy morning in Charleston, South Carolina, we’re in chef-historian BJ Dennis’s home, huddled around a pot of okra soup. Okra, garlic, onion, butter beans, tomato, thyme, searingly hot Scotch bonnet peppers, and the splendid funk of fermented benne (sesame) seeds fuse New and Old World flavors. My first bite delivers a tsunami of umami followed by eye-watering heat and a blush of pure happiness. (These are the world’s happiest places.)

Dennis is on a mission to bring back the cuisine of his rice-growing ancestors. Captured from places such as Senegal and Liberia, his forebears were brought to the Low Country of South Carolina and Georgia to cultivate Carolina Gold rice. Because of their expertise, some of the enslaved Africans were allowed gardens where they grew African staples and local ingredients. “We took the rustic soul of the Africans and the Native American techniques and made this special mash-up,” says Dennis.

The traditional West African diet consisted mostly of greens, root vegetables, black-eyed peas, okra, benne seeds, herbs and spices, and cereals like millet; meat was eaten only occasionally. When captured Africans were shipped to America, the plants and seeds of their homeland foods came with them. They entered into cultural exchanges with Native Americans, who shared some similar farming practices and food staples; both cooked with corn, sweet potatoes, and local bean varieties. The result was a blended, innovative cuisine.

On another day, in Texas, we’re with chef-historian Adán Medrano as he destroys the myth of Tex-Mex cooking. In his Houston kitchen he stirs a savory posole in one pot and in another a tomato-stewed rice, both dishes flavored with the Texas Mexican trio of garlic, cumin, and black pepper.

“Greasy, cheesy Tex-Mex food was largely an Anglo invention,” Medrano tells me. “Our traditional enchiladas were not slathered with cheese. We fill ours with carrots and potatoes.”

Born in San Antonio, in south-central Texas, Medrano, 74, grew up eating cactus, beans, corn, chilies, potatoes, onions, mushrooms, portulaca, amaranth, various berries, and occasionally game. These were the authentic foods of Texas Mexican cuisine, a far cry from Tex-Mex culinary corruptions like chicken fajitas or extra cheesy quesadillas. These types of whole, plant-based foods are also typical of other Latin American cuisines.

~ ~ ~

As we traveled the United States, we found the historical diets of these Indigenous and immigrant cultures being interpreted by a new guard of chefs and food pioneers. As they re-create traditional dishes, they are not only opening a treasure trove of largely overlooked culinary genius but also offering new expressions of the standard American diets—which may actually help us get that extra 10 years.

Conversely diet can also shorten your life expectancy. If you’re eating like a typical American, you’re probably going to die prematurely. This year more than 678,000 Americans will die from diseases or conditions associated with what they eat. These include common conditions such as high blood pressure, high blood sugar (type 2 diabetes), and high cholesterol. Collectively, we’ll spend more than four trillion dollars on health care, 20 percent on diseases linked to unhealthy diet choices, according to one study. It’s been estimated that we lose at least 13 years by eating a typical U.S. diet.

This may not come as a shock when you consider that each year the average American consumes a total 264 pounds of beef, veal, pork, and chicken; 123 pounds of sugar and caloric sweeteners, including some 39 gallons of soda pop; 16 gallons of milk; and more than 40 pounds of cheese, some of which tops our annual 46 slices of pizza. Seventy percent of our calories come from processed foods, containing thousands of artificial food additives, many of them known to cause cancer.

References

nationalgeographic.com, “This American diet could add 10 years to your life.” By Dan Butler;