Monday, August 31, 2009

Visiting the U.S. Consulate

Being the first road trip with the baby, preparation took longer than we expected. I woke up at 6:00 to feed the baby. Then packed – carseat, diapers, formula, water, bottles, wipes, change of clothes, extra swaddling cloth and changing mat (towel).

We had also called ahead to schedule the appointment (and rescheduled it multiple times). The consulate tries not to schedule more than one passport/CRBA application per day, and they said they're currently doing about three surrogate related applications per week. When we made our first call, they had openings within about a week. Although you schedule the appointment, you still pull a number when you arrive.

We had hired Asha to be a day nanny on this trip – she’s both a trained nurse and has helped other surrogate couples through the consulate and FRRO – and she was great. Nice to have someone that can efficiently take care of the baby, especially when he pees in the middle of a change in the consulate as you're trying trying to answer their questions about your paperwork. (Asha can be reached at ashamj70 at gmail dot com or +91 97657 45028). If you use another day nanny, make sure she brings her passport in order to get into the Consulate.

We got to the Consulate at 9:30 AM, pulled a number, and were pleasantly surprised to see that we were number 37 and they were already on 35. 9:30 put us at the tail end of the Monday morning rush since the consulate opens at 9:00. By about 10:00 we were about the only ones there. (I never did figure out if our appointment gives us the ability to cut in front of everyone - at some other embassy's and consulates it does, so it would be worth asking).

Passing through security to get into the consulate was a bit like airport security. You can’t bring any electronics in (phones, computers, cameras) – they even asked me to leave an extra SIM card I had in the outside lockers. You can bring baby products and paperwork in. Any kind of liquid is dicey – we got the thermos with water in (maybe they didn’t notice it buried in the baby bag), but didn’t get the disinfectant hand cleaner in. Past security there is a water cooler.

First task was to feed the baby, since by the time we got into the consulate it was feeding time again. Then waited a few minutes for our number to come up.

We had pre filled out the Consular Report of Birth Abroad (CRBA) and Passport applications (including 2 2x2 passport photos) and filled out an SSN application while we were there. We are both U.S. citizens and did gestational surrogacy with our own genetic material. Based on that we didn’t have to prove much presence (I think 1 day) in the U.S. For this situation, the supporting paperwork that the consulate asked for was:

* Passports
* Original Surrogacy contract and 2 copies (bringing the copies helped, they gave us the original back)
* Birth Certificate
* Letter from Hospital (Hirinandani for us)
* Letter from clinic (Rotunda for us)
* Marriage License (We brought an original which they gave back)
* Records from clinic (we didn’t have medical records themselves, but showed print outs of some of the test results and updates that had been forwarded to us during the process)

A note: do read the letter you get from the clinic. The first draft of the letter we received obviously came from a template because it had many errors including:

* the wrong retreival date,
* indicated we used an egg donor,
* said a female baby was delivered, and
* said the baby was born healthy and fine although he spent 15 days in the NICU for respiratory distress syndrome

Any of these errors could have raised eyebrows at the Consulate and could possibly put us on the path of requiring a DNA test. So we requested a new copy of the letter. Good thing it wasn't time critical and we weren't planning to visit the Consulate that day.

In our situation (married, both U.S. citizens, baby genetically both of ours), we did not have to do a separate affidavit of presence. We’ve traveled overseas quite a bit, so in the “traveled overseas box” of the CRBA, it was okay to just put “various”. This was because we each only had to show 1 day presence in the U.S.

Coordinating with the Mumbai consulate (it is Rachel right now) to know what paperwork was required in our situation certainly helped speed the process, and arriving with the paperwork filled out, having baby photos when we arrived, and having all of the above documents in a single pile to hand over, helped speed the process as well.

We then did a quick oath affirming that the statements and documentation we provided were accurate.

After paying $150 by credit card, we left the consulate by about 11:30. Because our baby had spent 16 days in the NICU, the consulate was kind enough to grant us an emergency Visa, which was available for pickup the next day/morning (on the way to the FRRO).

The consulate says they currently look at the “body of evidence” to determine whether or not a DNA test is required. In our situation, a DNA test was not required, which saved us time (a week for the test to turn around) and money (close to US$1,000). (Note that for U.S. citizens, Rotunda has DNA test kits from Universal Genetics which you can use if required. This saves the time and cost of having a test kit mailed to India, if you need one.)

Rachel, who works at the consulate and who I emailed and spoke on the phone with many times, was extremely helpful. Definitely gets an A+ for customer service. It is because of frequent emails and correspondence with her and her team that we were fully prepared going into the consulate and that the process went smoothly. In this case, it was a pleasure to deal with one of our government organizations.

When I had spoken to Rachel earlier, she did recommend scheduling the DNA test and the visit for passport/CRBA documents on separate days in situations where both are required. We decided to do the passport visit first, which then helped determine or confirm whether the DNA test was required.

Released from the NICU

After 15 days in the NICU at Hiranandani, our baby was released. He went through a pretty standard progression for lung problems, starting with a ventilator/respirator, moving to Continuous Postive Air Pressure (CPAP), and then to a hood, and finally off the hood.

While in the NICU, there were usually 4 to 7 other babies there. The doctors and nurses definitely have experience dealing with pre-term babies. I've never been in any other NICUs anywhere, so I can’t comment on the equipment or processes.

During that time he had two pediatricians – Dr. Sanjeev Ahuja and Dr. Bijal Shrivastava. Both were very good. Although busy and rushed, they both answered our frequent questions and helped manage our anxieties. We shared progress updates with our friends, including home pediatrician and an obstetrics nurse, neither of whom suggested anything different than what the doctors were doing.

One comment – the visiting hours for the NICU at Hirinandani are limited. Officially, visitors are allowed from 5:00 pm to 7:00 pm. Mothers are allowed to visit more often, usually because they are nursing. On the one hand, this restriction limits interaction with your newborn. On the other hand, it does keep germs out of an area with infants that need every chance they can get.

And the proof is in our now healthy baby. When we visited the U.S. consulate, they said he certainly didn’t look like he’d spent 15 days in the NICU and that he was also the only baby they’d seen with his eyes open – he was looking at them, eyes wide open, while we were there.

Saturday, August 15, 2009

Baby arrives 5 weeks early...the rushed trip to India

Baby decided to arrive 5 weeks early. We got a call at 11:00 PM congratulating us on a healthy baby boy, and I flew at 7:00 AM the next morning. My first night of no sleep in a very, very long time. I’m sure many more to come. Spent most of the night packing and making sure the place would be okay while we’re gone (it will). My wife and I were in different cities, so we traveled separately and I arrived first.

The baby was in the NICU and on a respiratory, which nobody mentioned to us before I physically talked to the pediatrician. Because the baby was born five weeks early, it’s lungs were underdeveloped. The doctor calls it Hyaline Membrane Disease which is the same as Respiratory Distress Syndrome.

Many things to relate, but in largely chronological order…

After landing, I call Dr. Kadam who basically says to goto the hospital and get a room. Which is about what I expected. Nothing about the baby being in NICU (which I didn’t know yet).

On this trip, I didn’t have a driver lined up at the airport. Good news – there is a counter where you prepay for a taxi, the very last thing you do before you exit the airport - about 2 yards from the airport exit (oh, and there are about 6 currency exchange counters here if you need them, although ATMs are pretty widespread outside as well). They quoted me 230 Rupees for a ride to Hiranandani in an air conditioned taxi, which seemed reasonable compared to all my other taxi rides. I then went outside and had to find the taxi parked among a large throng. Some guy helped me find the taxi, I gave him a 30 Rupee tip, he asked for dollars. I left it at 30 Rupees.

On the way to Hiranandani, the taxi driver stops for gas. This doesn’t happen in very many countries. But, as I looked at the queue of taxis waiting for gas, several others had passengers. So I guess it’s not uncommon either. More interesting, my taxi used CNG (compressed natural gas), not petrol. When I was taking a picture of the CNG filling process, my limited English speaking taxi driver gestured me not too use the phone and made an explosion sound and hand gesture. I then saw a sign that said to turn off your mobile phones while filling (in addition to not smoking). Overall, it was more like filling up your propane tank (for your bbq grill) than filling up your gas tank. This smallish taxi took 170 Rupees worth of CNG. I have no idea how far that would get him. And the line of cars waiting to get a fill was long. We probably waited 15 minutes.

Of course the traffic was bad. And, the taxi driver didn’t know where the hospital was once we got to Powai. I realized this when he asked me if he should go straight or turn right. (This actually happens frequently in India, although usually the taxi or rickshaw driver stops and asks someone.) That’s when I started paying attention. Fortunately, there were enough signs to basically find the hospital, along with one quick stop asking a friendly person on the sidewalk to confirm we were on track. We were on the right track the whole time. I never did figure out if the taxi driver could read the signs or not.

The taxi driver said “tips” when we arrived. Since aside from the detour he’d done a good job, I gave him a tip of about 150 Rupees. I mean, how can he be living on a 1 hour trip that cost about US$5. With the tip, it still cost less than having someone pick you up at the airport. Although the taxi was probably 20 years old, so less comfortable (but more local) than arranged cars you’ll get picked up in.

The hospital is a hospital and not a hotel. They haven’t caught on to the Thai medical tourism thing. So, not surprisingly, there’s really no concierge to help with your luggage. They do a security check of your baggage before you go inside, although it’s a bit cursory, and you’re not going through a metal detector (like you would at the Marriot).

Good news, we got a room at the hospital. I had no idea if this would be easy or not. I think we got lucky, someone was just checking out of a suitable room. We got the Single plus room. Turns out to be a hospital bed and meager couch (that’s the second bed) for about 4500 Rupees a night. And it looks exactly like a hospital room. Two can sleep in the room, although one is sleeping on the couch. Filling out the paperwork to get a room was about 45 minutes. Had to prepay a deposit of 25,000 Rupees for the room. The room wouldn’t be ready for an hour, so they asked me to wait. I asked where I could leave my luggage, and there really wasn’t any place. I ended up leaving it under the information person’s counter.

Neesha, who’s in charge of “public relations”, also came out and said hi. The best I can figure, “public relations” means “customer service”. She said the hospital could help with the birth certificate. Seems there’s a new guy in charge at the municipality, and a “rushed” birth certificate now takes around 10 days, rather than the previous 3 days. Well, that will make for a longer stay. I wanted to learn more about the best (fastest) way to get birth certificates. She said she’d stop by my room later in the day to discuss further. More on that later.

So, as I walk by the nurses station they amazingly know who I am because they say the surrogates name as I walk by. One of the nurses shows me the room and gives me the disinfectant to use before holding the baby. I’m pretty sure I asked if they were going to bring the baby, but I’m in the room and waiting for the baby for a half hour when I go out and ask the nurses when they’ll be bringing the baby. They have an attendant walk me down to the NICU. The nurses (sisters) there say I can’t see the baby until I’ve talked to the pediatrician. I’m then walked over to the pediatrician (Dr. Bijal, is nice but is at times rushed like everyone else) who tells me the baby is in the NICU (which I’d sort of figured out since they took me to the NICU), had excessive grunting (a form of breathing difficulty when born) and is on a respirator to make sure he’s getting enough oxygen. I ask a few questions and wrote down the big words for later Internet research.

Dr. Bijal asked where we were staying and I said here at the hospital. She seemed pleasantly surprised, which told me not everyone does, and that she thought it was a good idea (at least for us).

Then I go back to the NICU, wash my hands, put on a gown, put on a mask, put on a hair net, put on sterile slippers, disinfect my hands again, and finally go in to see the baby.

Poor baby. Tubes going in and out, mostly for food and air. I look at all the machines. Trying to decipher the numbers. Heart beat around 170, a bit high. Oxygen absorption at 98%, seems good. Breathing rate erratic jumping between 50 and 90, not so good. Some kind of glucose at 9.5 (mls per hour?). And the respirator set at 36% Oxygen. Two other babies. I feel sad for the other baby’s parents as well.

I then head off to report to the family. I’d learned that there are publicly (free) computers on the 1st floor in the health check area. So, I can gmail folks. It turns out the machines are locked down so I can’t get photos/video uploaded through the USB port or any other method that I can think of. Nor can I connect my laptop straight into their LAN. The folks were nice enough to call one of the IT guys, who came down after 20 minutes, logged in as an admin, bluetoothed the files over, and made them available for me. Now that was good service. Although I don’t think I can do that every day, or even ever again. More on email/Internet access later.

Also worked on getting a local SIM card for my unlocked phone. Good news, you can get SIM cards. Bad news – you seem to need ID and a sponsor to get one. So, I got an Aircel SIM card. Probably the wrong thing to do as it turns out because they’re still new in Mumbai, and the hospital doesn’t have top-up cards. Oh, and the sales guy’s friend is now my local sponsor after providing him a tip ($5). During the process we also had to leave to get a photo, which was also required for the SIM card. It took about 24 hours to get activated.

With the room, you get meals. Choices are India, Chinese and Continental/Western. And, they’re not bad. We went for the Indian food – it’s actually pretty good. I’m sure the locals find it much too bland – it is not spicy. Western breakfast had omlette, bread, corn flakes and papaya. Indian lunch was soup (spinach, I think – a bit bland which means it was probably healthy), chicken (not masala, but something like that), dhall, some other kind of naan (I get them confused), yogurt, a sweet cream-of-wheat like desert, and an Indian vegetable dish. Indian dinner was soup (don’t remember which kind) and three dishes – a vegetable, a dhall (lentils) and a meat (chicken) along with desert, fruit cup and naans. You’re not in the U.S., so if you need Western sized servings, you’ll need more food. If you’re fine with normal sized servings, you’ll be fine. One set of meals comes with the room (breakfast, lunch, dinner). You can special order a second set which seems to cost about 180 Rupees per day. Quite a deal.

Talked to the Dr. Bajil in the evening, who seemed to indicate that the baby wasn’t improving as fast as she’d like, but that the lung situation was relatively mild and we didn’t need to rush anything. This seemed to confirm some of the Internet research which seemed to indicate it often takes a few days to get a baby of the respirator.

Being exhausted, I fell asleep early and woke up early.

Well, the bathroom still didn’t have the towel I’d asked about the night before. It did have something the size of a dish towel, which was enough. They’d also given me soap, tooth brush and shampoo. Kind of hotel-like in that regard.

I decided to go see the baby at 7:30 in the morning. That’s when I learned there are visiting hours, and they’re 5:00 PM to 7:00 PM. Which I guess makes sense. But they also said mothers could visit outside those hours, but fathers could not. Disappointing. But, with some sweet words, they were kind enough to let me in (I won’t be able to do that again either). I tried to be helpful and hold our baby boy while he was trying to pull the tubes out of his mouth, marveling at what was before me. Our baby boy.

I had my questions for Neesha and called her about nine. She said she’d stop by my room in a half hour. Two hours later she appeared. I am not currently cut out for the India sense of time and wasn’t so happy. She knows Prashar, who is the other guy that can do birth certificates, and says it will take the same amount of time either way. Among other things, I also asked her about the wifi that the brochure I got at check-in talks about. I’d been trying to connect, but wasn’t working on any of my three wifi enabled devices. She called IT. Their line was busy so she gave me their number and asked me to call them back. I call them in a few minutes, and they say they’ll be down in 15 minutes. After 45 minutes of no-show, I start calling. Busy and no answer. At an hour and fifteen minutes I get through to them again, and they they’re waiting for the outsourced wifi company to call them back before doing anything (such as visiting my room as they said they would). I told them I’d been waiting for them and they told me they were sorry.

Then a mystery visit by the nurses. “Please go down to the NICU now”. Since I’ve been in the room for about 4 hours, they probably could have called me directly. They wanted me to sign paperwork to give consent for an umbilical catheter. Like most places in the world, the paperwork I sign says that I’ve been fully briefed on what they’re going to do. I hadn’t, so I asked several questions. They were satisfactory enough, so I signed. Then the NICU folks told me I had to go settle the bill.

Since billing is largely by pre-payment, I had to get caught up on payments. So, more money for the Surrogate’s stay (probably at US$4,000 for her four stays total, including delivery), but haven’t paid anything for the baby’s stay yet.

And that’s where we are so far…

Sunday, August 9, 2009

Communications during the pregnancy

Although with several bumps, our surrogate’s pregnancy seems to be progressing well. It is difficult being so far away from our baby in many ways. The most anxiety-provoking is trying to understand the results of each pregnancy check-up and steps that will be taken to mitigate any irregularities identified.

Doctors in the U.S. have figured out and resigned themselves to the fact that people do research on the Internet and come in informed (sometimes misinformed, but most doctors say overall much more informed) and ask many questions. In the late '90s when patients first started visiting doctors with their Internet research, some doctors found it helpful (patients were more knowledgeable) and some found it annoying (the patients were more questioning, questioning their knowledge and authority). With lower Internet penetration, India is still in the earlier phases of this transition and some of the doctors do lean toward finding it more annoying.

Surrogacy complicates the situation. If it’s your own pregnancy, you talk to the doctor when you have your check-up. With surrogacy, the doctor has to communicate with both the surrogate and the remotely located intended parents. We are emailed reports of the check-ups, often with very short updates. More often than not, we have to chase to receive these in a timely manner. And chase to see whether the surrogate went to her scheduled appointment (monsoons sometimes cause cancellations, kind of like a snow day). And chase to understand the results of the reports. The level of initiative in proactively providing intended parents updates and interpretations of the reports is just at the lower threshold of acceptable. The emails we receive are typically short. This, of course, means we need to review and interpret the reports ourselves.

In reviewing the reports, it seems that our pregnancy is having it’s share of irregularities, but nothing terribly severe. What is frustrating is that we seem to discover these issues, rather than being told about them. Some of the irregularities include:

Amniotic fluid levels. An early June test indicated an amniotic fluid level of 20 and had “mildly high” written next to it. The amniotic fluid is the nourishing and protecting liquid that surrounds the unborn baby during pregnancy. Since the doctors didn’t mention anything to us, we asked them about this. As a result of our asking, the surrogate was scheduled for a followup check. No asking...probably no follow-up check. Interestingly, some Internet research shows that 25 is actually the cut-off for mildly high amniotic fluid. So, 20 probably is okay. It seems that the cause of high AFI levels is usually unknown, although since the baby swallows amniotic fluid, high levels can be indicative of swallowing or digestive problems.

Gestational diabetes. Because of the high amniotic fluid, we had the extra doctor visit. During this visit in mid-June, gestational diabetes was discovered, which resulted in the visit becoming a 2 week hospital stay. This basically means there is high blood glucose (sugar) in the surrogate’s blood. It’s apparently getting more common (3 to 10% of pregnancies according to Wikipedia) for women to have gestational diabetes which puts the baby at increased risk of being large for its gestational age (which can cause delivery complications), having low blood sugar and even jaundice. We seem to have caught this reasonably early and our surrogate was immediately put on insulin.

T4. At the same time we got the bill for the above stay, we got more reports and tests that were done during the stay. One late June report showed low T4 levels. HELLO! Was anyone going to tell us? The thyroid creates T3 (serum tri-iodothyronine), T4 (thyroxine) and TSH (thyroid stimulating hormone). T3 is a reservoir for T4, so my non-medical assessment is that T3 may be more important. But the available literature seems a bit fuzzy. T3/T4 seems important for brain development. By reading the invoice, we see that our surrogate was given/prescribed Thyronorm 25mcg tablets, which are Thyroxine. So, it seems that action is being taken to address the low T4 levels. Good on the action side, bad on the communication side.

Our mid-July updates showed blood sugar within normal ranges and T3/T4/TSH levels in normal ranges also (although T4 is still at the low end of normal). These were the first follow-up tests we received after the late June diabetes and T4 discoveries. The email content was:

Please find attached the blood reports of [surrogate name] for your reference.
Please note that these have already been checked by Dr. [doctor name].

Yup, no mention of whether levels were high, low, or whether they need to continue to be monitored. Follow-up phone calls are mandatory.

Our early August updates show AFI levels still mildly high at 25. Research seems to indicate there really isn’t much one can do.

Well, we’re focusing on identifying everything we need to bring with us to India in order to bring our baby home. Mid September is the due date! And hoping none of the above issues cause major complications...