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I mentioned that today’s guest is a friend of mine, we’re in a writers group together, but I’m gonna walk her in just like I walked in everyone else so Hi, thanks for coming on the show. Can you introduce yourself Ariel and tell us where you’re from?

Ariel: My name is Ariel, and I am from New York City and now live in California.

P: Lovely. Thanks so much for coming on. I read the maternity labyrinth. I knew you have quite a story. There’s a lot going on. I mean, that’s a that’s a perfect title. It is. It is a tricky thing to make it through. Let’s start before the beginning. You have siblings, right?

A:  Yeah, I have two younger brothers.

P: Did you grow up thinking I definitely want a family. I want a big family. What were you thinking?

A: That’s good question. I guess I assumed I would have a family. I not necessarily big I think I probably assumed I have I don’t know two kids. I didn’t get married till I was in my mid 30s. So at that point, I think having a big family was less likely in my mind. But I mean, my mom had three super easy pregnancies, easy deliveries, no issues got pregnant easily. So I just assumed you know, it would have happened when it happened.

P: You’d walk into it kind of in a straightforward way like your mother. Yeah. around that age. I had my first kid of 32. So around that age, I feel like when people are starting to have kids and are you like aware of what’s going on with your friends, is anyone having a trickier time or it just that doesn’t have much resonance for you because in your own family, it went well. 

A: I definitely had some friends who had miscarriages in the first trimester. And I have one good friend from Boston who definitely had a really hard time. She had multiple miscarriages and they did IVF. So I had friends who had some fertility issues, and I definitely seen friends.

 With IVF. 

P: So it was somewhere in your universe, but you didn’t think it was on your path. And so now let’s start at the beginning. Remind me Was it easy to get pregnant? 

A: It was very easy to get pregnant. 

P: Okay, good. Okay, good.

A: So that was the what was so bizarre about it was like once I got pregnant that easily because I was worried I was in my mid 30s. So I thought, you know, maybe it’s not going to be as easy as it would have been a few years earlier. And I got pregnant easily. I thought, wow, this is this is gonna go fine.

P: And you found out with like, a home kit. Yeah, that’s fun. And that’s an exciting day in your house. 

A: Yeah, no, I was I remember being stunned, right. Frankly, my husband couldn’t believe it either. We really thought it would take at least you know, the good five months or whatever. And so I think it was like, second month I tested and there was it was it was fast and easy. 

P: Wow.  Well, that’s a good story. You know, I think all of us walk in thinking that’s how it’s gonna happen just because that’s the story you get when you’re a teenager. So I’m glad it was true for you and it’s true somewhere, and then that pregnancy develops and then I know that you run into trouble with that, but I’m not sure about the timing.

A: Yeah, so so everything was going smoothly. I had amnio everything was fine. I had the level two ultrasound and I can’t remember if it was around 20 weeks or something. Everything was great. And at that point, I thought you know, it’s gonna be smooth sailing from here on in because I sort of passed all these markers and I felt fine. And I was it was in 24 and a half weeks pregnant and I was just it was night I was just reading in bed and I went to the bathroom and a bloody clot came out. And so I tried to be rational and calm and I mean, I just felt fine and I wasn’t bleeding continuously. So I got all my trusty pregnancy books. And we’re in then about anything like that because it was way past miscarriage time. And so I wasn’t having contractions I felt fine. So I kind of sat and waited

P: Wait a minute, wait a minute…So this is I feel like I would hit the panic button immediately because 

A: Well, I think because it was at that point it was so it is it didn’t fit any bigger. Like I had no idea what like I was completely out of my mind that I could possibly be Miss Karen because it was I was 24 and a half weeks pregnant. I was six months pregnant. So like at that point, it’s not a miscarriage. 

P: Like it just no no, I agree. It’s I agree it just meeting is like enough to it’s not like I felt weird, right? It

A: it wasn’t like continuously bleeding. That’s what was strange. And then I think part of it may have just been the way I don’t know if the way I was raised but I generally I had never I’ve never heard that in my entire life has been in the hospital. The only sicknesses I’ve ever had are like you know, a cold what happened? Nothing. Like my I think my mom is sort of joke like she is the antithesis of the Jewish mother that she is like, she’s the type like if you tell her to do well, she’ll tell you to go shrug it off like not a worrier. We were not rewarded for sickness. It was sort of like go to school and get over it. So it was like the furthest thing from my mind. I’m generally I’m moderately athletic. I felt fine. So I could not imagine that something could be going wrong. And then I had like everything looked fine and all the tests. So I thought, you know, who knows? Then I started having contractions.

P: and you knew that they were contractions. You knew what they were? 

A: Well, I mean, again, I started rationalizing, thinking, Oh, they can be Braxton Hicks. It’s about the right time. And again, you know, looking at all my books and nothing made sense. And so I tried to go to sleep and it got worse like the contractions were bad. So I called my doctor the middle of the night and she said go to the hospital now. 

P: are you in NY for this?

A: No, I was in here in California, California. Okay. So she said, Go now and I’ll meet you there. And she told me later that she almost hesitated to tell me that because I sounded so calm, which is nice. I went to the hospital and I was in full labor. I mean they checked me out I was fully dilated. And I mean, they had to deliver the baby there was nothing they could do. Like once you’re dilated like that…so when the doctor arrived, they decided to do an emergency C section because 24 and a half weeks is a dicey time like there is a decent chance the baby could survive, but it’s not. Not not ideal, but I guess she wanted to do whatever she could to, you know, to see if the baby could learn if no vaginal delivery would not have

P: so vaginal deliveries like too much pressure on the baby.

A: So they did an emergency C section. And when the baby was born, I mean, she was crying like it was she was born alive and they took her immediately to the NICU. And basically she survived for three days and the thing that I believe develops last is the lungs. 

P: Yeah, 

A: so the lungs were just not and once that started with just sort of snowballed, like that affected with the brain and then there was bleeding and it’s like there was just no way.

P: Yeah, I mean, you it sounds like it was so out of the blue that you didn’t even get the chance to take steroids for a day or two or anything. Like that, because it happens so quickly. I’m So sorry.

A: You know, it was seriously like I mean, I’m even at the time I barely reacted because it was I couldn’t cry. It made no sense. It was surreal, truly. And, you know, no one could figure out what like they did. Test. There was no there were no genetic issues. There were no one could figure out why. So after that, 

P: something kicked off, Labor’s what that means, right, something 

A: Well, that’s interesting. So my professional medical theory. Yes, I mean, in my mind or the way it felt because I wasn’t doing anything. It wasn’t like I was running a marathon. I was seeing getting rejected, right. So in my mind, it felt like there was some chemical thing. Miss something not wired right. That told my body to go into labor at the wrong time. However, I did I went to see a high risk specialist and he said that I have an incompetent, incompetent cervix, not a diagnosis, I can name I really appreciate

P:  I was gonna say, in this community of writers, we have to come up with a different name That’s so dumb and and just why why in 2020 like 15 years ago, why?

A: It’s like an accusation…So anyway, but he said that it wasn’t definitive because you basically have to go into preterm labor twice for them to be sure of that and there was also like, again, my mom never had any problems. It does tend to be something that sometimes runs in families. I wasn’t particularly large. 

P: today. We’re lucky to have Dr. Filthy Rich on the show. She’s a professor at Intermountain Healthcare and adjunct at the University of Utah. And medical director of MFM, obstetrical ultrasound services. So I feel like the cervix is the unsung hero of pregnancy. And I think people don’t necessarily understand exactly what’s going on with their cervix. Maybe you can walk us through the role of the cervix in pregnancy.

Dr. Feltovich: So the cervix is just an amazing structure. That cervix is one of the critical pregnancy tissues that performs a diametrical opposite function during pregnancy it’s job for most of pregnancy is to remain long and firm and closed but for pregnancy to occur normally, and allow vaginal delivery at the end of it, it has to go completely opposite by the end of pregnancy. It has to be completely soft and completely dilate and open for normal events to happen and the same is true of the other reproductive tissues. The uterus needs to stay quiet and calm through most of pregnancy but at the end contract strongly for things to go normally, and the membranes also have to stay quiet and intact, and only like break open to allow the delivery at the end. And these structures are all talking to each other all the time. There’s a lot of evidence about, cellular communication between them. The problem is that it’s just such a remarkable transformation that these tissues undergo throughout pregnancy, that there’s just really not much known about it. Not nearly enough known about it. 

P: So let’s talk about Ariel. I’ve shared her story with you…and Of course after such a devastating outcome, We want to know why. Why did this happen? So the doctor she goes to see says that maybe she has an incompetent cervix, but it has to happen twice to get that diagnosis. I wonder she’s got no family history. She doesn’t have a high BMI. All the obvious things are not in play. So I’m wondering what the risk factors are for preterm labor. Do we think there’s some chemistry issue at play for spontaneous preterm labor with no obvious trigger?

Dr. Feltovich: So first of all, I’d like to react to the term incompetent cervix. I never use that term. I feel like it’s pejorative and it kind of Yeah, it is. And it it sort of imply some sort of personal blame on the patient and their own body or blame on their cervix or, you know, something else that just isn’t fair and isn’t correct. So, I actually use the term cervical dysfunction because there there are certain people whose for whatever reason, those reproductive tissues that are supposed to stay intact and strong and have the molecular scaffolding within them stay intact until the very end of pregnancy for some reason in some people that that isn’t the case. And there are, multiple different reasons for it. There are certain things that precipitate or increase the risk of preterm birth and a lot of it is sort of a chicken and an egg problem. So, bleeding can be both a symptom of cervical dilation. And for Ariel, it kind of sounds like that was the case because she had some, some bleeding and passage of sounds like some mucus and clot and then she had contractions right after that. But bleeding can also be the precipitator of events. So for instance, women who have bleeding during pregnancy, especially continued bleeding, heavy bleeding, bleeding, in the second trimester are at increased risk for preterm delivery, because there’s just something about that bleeding that that irritates tissues and sort of messes with their extracellular matrix, you know, the scaffolding and in the membranes and the cervix that that give it its, strength, it’s biome biomechanical properties, and it’s never clear which thing comes first. Right? It’s a real chicken and the egg thing. Same thing is true with another precipitator of preterm delivery, which is preterm rupture of membranes when that when that bag of water around the baby breaks too early. And same thing is true with cervical dysfunction where the cervical structure just kind of breaks down. So What’s tricky about this is that all three of those things have to happen, right? The cervix has to disappear become soft and dilate, the membranes have to break and the uterus has to contract in order for a fetus to deliver. And he more we learn about it, it seems like those things don’t need to happen in any particular order. So the cervix to go back to Ariel’s problem has long been thought of as the kind of gatekeeper of pregnancy and it is, you know, it’s like sort of the common denominator of all these processes, right. It’s sort of the final step, because you can be contracting, your water can be broken, and unless that cervix opens and shortens the fetus won’t deliver. So it’s kind of thought of as a gatekeeper. For a long time people thought the cervix was just sort of a bystander in the process of parturition, which means, you know, pregnancy and delivery. And then for a long time, people thought it was sort of controlling the event. And there are various different theories on that. The truth is, nobody really knows except that it is 100% clear that all of the pregnancy tissues are involved, and they are all chattering with each other all the time. One important thing for somebody like Ariel to know, is that two thirds of spontaneous preterm births are unexplained, two thirds of them and this is revealing of the real paucity of understanding we have about the process. Many women have zero antecedent history of anything going on until they’re minding their own business laying in bed one day and they pass a clot. So that is a very, very common story. And why this I think, is so complex, is that take Ariel story, she passed a clot and had some bleeding. 55 0% of women will have bleeding during pregnancy. You know, mostly during the first trimester spotting or you know, something like that. But the problem is that there’s this event that can herald a very serious outcome, like what happened to Ariel is also very normal in pregnancy. Same with contractions. You know, people talk about the Braxton Hicks contractions or many of us call those preterm uterine activity without preterm labor. And in fact, we understand so little about preterm birth and why it happens. That the diagnosis is actually retrospective, which means if someone’s having contractions, and I say 32 weeks, which is preterm 37 weeks is term 40 weeks or someone’s due date, but if someone’s having contractions at 32 weeks, I will tell them, you know, I don’t know if this is preterm labor or not. It depends on what happens if you have all these contractions and deliver before 37 weeks, it was preterm labor. If you have all these contractions and deliver at 37 plus zero or later, it wasn’t preterm labor.

So the picture is just so complex because all of the things that normally happen for a pregnancy to occur in the right way, which is cervix, changing contractions, breaking water, even bleeding is really normal. All of those things can also be completely abnormal and results in a traumatic outcome. So very, very complex. 

A: None of it really fit or made sense. 

P: Right.

A: So he basically said, you know, if I get pregnant again, they would do a squash community sewing up your cervix and put me on full bedrest.

P: How do we walk away from this and I can fully imagine that it cannot be processed in the moment, but now Is it is it 15 years old now? How long ago was this? 

A: This was 2002 

P: Okay, so 20 years ago, yeah, almost.

You would say it’s processed now or we just we don’t touch it.

A: It’s it’s pretty much processed. I mean, I mean, I think to some degree, you never get over something like this, but I 

P: agreed

A:  totally about it. I mean, I’d say at first I was just not like totally shocked. And I mean, we we decided we try again because the doctor said he thought it was I mean he couldn’t make any promises, obviously but he thought I had a cat remembered statistics, something like an 80 something percent chance of carrying to term or at least to a safe time. So this second time, it took me a little longer to get pregnant. I think it’s about seven months and then I got pregnant and then I did CDs because they can do it earlier than amnio and everything was fine and then did the start class and I think around 13 weeks, went on full bedrest

P: What are you doing in your life at this point? This is a huge thing to ask.

A: The timing worked out well because I was teaching and I had this or collage seriously the day after school ended in June sometime and then did not plan to return the following year and then was on bed rest we made arrangements which was complicated like the bed rest rules are just so weird because he wouldn’t give me definitive answers. Like we had a second story in our house or our bedroom was so I said, Well, can I go up the stairs to go to bed and he basically said once a day, like it seemed a little arbitrary. 

P: Yeah, 

A: so I basically hung out all day on a sofa and our den which was right next to the kitchen, and he told me I could get up to use the bathroom

P: one thing that’s frustrating about incompetent cervix is all you’re doing is naming the fact that your cervix open too early, but 1000 routes probably lead to that outcome. So I don’t know what you’ve identified at all except for the most obvious thing. So I’m wondering like how bedrest will resolve whatever force is confusing your cervix?

A: That’s an excellent question. Well, I believe they think it’s more of a structural issue, not a chemical one. So I think he saw it as putting less weight or pressure on the cervix. So you’re supposed to lie on your side, not even your back, which is mentally uncomfortable. Yeah. And basically just minimize the amount of weight and pressure you put on your cervix. I mean, I think there’s, this is a controversial treatment. I got a second opinion. I went to another expert in San Francisco and she said the same thing. I think it was almost like for lack of a better remedy. I mean, they just end fitness has bad side effects.

P: I took this issue of bedrest to Dr. Feltovich.

When you describe the complicated dance between the uterus and the cervix and the membrane and all the chemistry that must be going on to have those things communicate, it’s not I understand bedrest for that since we don’t know. We don’t know what’s causing the preterm labor. 

Dr. Feltovich: bedrest. Yeah, it does nothing. You’re exactly right. I mean, I think in in previous days, people recommended it because it makes sense that if you’re like laying there doing nothing, that things should be better. But in actuality, that is not the case. There’s tons and tons and tons of data to suggest that bed rest only results in an increase in blood clots differently than people. And it doesn’t. It doesn’t prevent preterm birth at all. I tell my patients, you know, you could be climbing Mount Everest or laying in bed and if your water’s gonna break, your water’s gonna break so, live your life and I think there’s an element of people including doctors feeling like if you suffer a little bit, chances are your outcome will be better and bed rest just precipitates anxiety makes people crazy, right? So I think there’s some element of that but in fact, the American College of Obstetricians and Gynaecologists completely agrees with you and two years ago, put out a publication that we call them practice bulletins for providers that said there’s no reason for bed rest. Stop it. Wow. Yeah, that there’s some role for bedrest in women with hypertensive disorders, you know, high blood pressure disorders, but not for prevention of preterm birth because it flat out doesn’t work. So I’m really glad you brought that up, because there’s still a lot of misinformation out there about bedrest.

P: I can’t remember in like, early 2000s I mean, you certainly didn’t have the internet stuff you have now right? I feel like Netflix was still like, send away the DVDs and get it back.

A: Yes, we did. But I did have Netflix was sending us I saw a lot of movies. And it was hard though. Yeah, my husband was working so like he would leave. Like all I had to do was basically just get it. I didn’t cook or anything. I had a couple of friends who’d come over but I mean it was it’s lonely. It’s also just physically uncomfortable to be like, you know, to lie in one position for hours on end. It’s awful.

P: And like you feel responsible like if only I lay the right way. Yeah, all worked out. Right. Which even though that doesn’t entirely make sense.

A: And then when I was monitored it also like the ultrasounds they would try to measure my cervix and through the ultrasound, and he would tell me things like it was always long and closed. Everything looks fabulous. And sometimes it was longer. I was like it’s growing. I mean, it was ridiculous. Like, the tests aren’t even accurate.

P: She said one thing that was frustrating is she had been going in to get her cervix measured, measured, measured, measured, and she was saying every time I got it measured it gave some different reading. And I understand that that measurement means that this is what your cervical length is in this very moment. But she was wondering how predictive that is.

A: It’s a little tricky, you know, measuring the cervix after somebody has had a sore claws like that’s a whole separate area. But if you think about just cervical length in general, it is the best biomarker that we have currently, for preterm birth prediction and a biomarker is a metric of discrete measurement that can’t be done in a standardized fashion that actually gives you information. So it is really the only biomarker we have for prediction of preterm birth, which makes what I’m about to say next, even more pathetic, which is that its predictive value is close to flipping a coin. So yeah, so there’s definitely there’s a very well established inverse relationship between the length of the cervix in the middle of pregnancy like between 16 and 24 weeks or so. And eventual timing of delivery. So that people that have a cervix, that is what we call short. And by the way, there are various definitions of short but the most accepted definition of 20 is 25 millimeters or less,

P: since everybody’s body is different. I wonder why you wouldn’t take a measurement of the 20 week and then make it a percentage. So

Dr. Feltovich: that has also been looked at, okay, and another definition of a short cervix is a cervix that is…What we work on is developing non invasive ultrasound waves called quantitative ultrasound to do things like measure how fast an ultrasound wave goes through a tissue, because that’s directly related to it softness. So I work with brilliant people at the University of Wisconsin Medical Physics Department, my main collaborators, Tim hall there and he’s a well established quantitative ultrasound physicist and we have so many brilliant during your faculty and trainees that we work with there and at Columbia and Duke University and we just have this big group of really invested caring people with brilliant minds turned on this problem or I’m just that person in the lab group that goes and says this is a terrible problem, please fix it. So what what all these people in our labs are coming up with is ways to look directly at properties like tissue stiffness and the structure like how organized is that sort of college and microstructure in the cervix in the membranes? And we have found that the cervix has a wide range of stiffness property and the length at the beginning of pregnancy does. These are small studies. Small studies, but it seems pretty clear that the normal sort of x changes in stiffness by about four to 6% per week, there is a predictable stiffness decrease in normal pregnancy. You’ve just said it makes so much more sense that you basically figure out where a particular person is starting and predict from there rather than just say, well, here’s this number that kind of fits most people. And eventually, we and many other people that are doing pregnancy research, hope that that’s the case hope that we can do modeling and sort of a precision approach to pregnancy.

A: Anyway, so that went on I was monitored heavily and the this time into my 23rd week of pregnancy. I then went to the bathroom and my waterpark and I mean this was with all that. So so again went to the hospital and at that point, I was like basically rolling my eyes because I obviously knew what was coming. And it also tells you that the tests they do like like the ultrasounds they measure your cervix like at that given moment. Yeah, this was a few days later. So yeah, it doesn’t it’s not predictive in any way. It’s just they see at that time,

P: I had a kind of wait and see aspect to my pregnancy too. And I kind of I kind of appreciate it, at least for today. I know that things are okay. Even though I could go home and it could all fall to pieces right? Did you have any comfort from the actual ultrasound in the moment or you were like this is worthless? 

A: Well, at the time, I believed that they were giving me good news. It was only after when I went into labor A few days later, which clearly showed that and then, at that point, I just felt like I had lost faith in sort of modern medicine and my body like I just felt like no one knows anything.

P: There’s a lot of unknown. So obviously your cervix doesn’t have to open for your water to break because you have a collage.

A: No, but I think it tore through part of it. Like I seriously like first for the stitches. Wow. Yeah. I mean, me and my cervix is highly like I don’t know, it also made me think like it has to be something chemical. Because I wasn’t doing anything. There was no weight on my Surface. Yeah. And I wasn’t like someone who was enormous when they were pregnant, like the baby was not huge. So it just made no sense and I mean, I haven’t seen multiple doctors since then and specialists and ask them about about like it being triggered by something chemical and they will roll their eyes and I’m not kidding. looked at me like I was asking an idiotic question. still contend that is not

P: Agreed. Agreed. That seems crazy that they’re not willing to at least entertain there might be something here we don’t know. Since bedrest is not the answer. So this seems very stressful. You know, when your water broke, there’s there you can’t they can’t maintain the pregnancy anymore right

A: now. Well, but I mean, it was awful. So what happened was so when my water broke, the umbilical cord came out as well. So that meant the baby could not survive. So they also did a vaginal delivery even though I was told in no uncertain terms by my doctor that it had to be a C section. It was a T cut. It would be dangerous to deliver any other way second time, but they said because the baby was so small it would not be a problem, which would turn out to be correct. So at least that delivery was easy. Because the C section was a nightmare too I was excruciatingly painful for six weeks. We can’t do much of anything. So this was easy in terms of the delivery part. But the baby was stillborn because the umbilical cord had come out…

T

P: Did you know it was the umbilical cord like did you find it and they found it Okay, good.

A: Yeah. So

P: So that seems again, unbelievably hard. And yeah,

A: it was also surreal in the I think because it was easy delivery. I mean, I came in, like in the early evening I can’t remember at dinner time and they I left the next morning in the hospital. And the only reason I stayed overnight is because it was essentially I mean, there was no like they said, I mean because there was no baby. Like, I could just go home I was fine, which was also crazy. Like, it’s just like, 

P: the whole thing is  crazy, and I’m guessing you’re on like labor and delivery work. 

A: Yeah. Which was awesome. Well, they were I do have to say Stanford’s credit, they both times they gave me my own room, but the C section. And that’s, they were I mean, they were very set for the C section. I was there for four days and they were very sensitive to the fact that they were not going to put me in a room with someone with a newborn. And this same time also I was just there overnight that they gave me my own room and I noticed they put something on the door I couldn’t see what it was it was some sign for the doctors or nurses making clear that there was no baby so like not to ask me awful questions. So So I at least they they seem to do that. Well.

P: Well good. I’m glad for that. And then I can imagine it’s are you thinking like we’re I guess we’re not going to have kids or we’ll adopt or like how do you what?

A: So at that point, well, when we talked to a doctor before I’d asked him about this and he said like if this didn’t work and he said there was another kind of cert clash I can’t remember they call it something else where they I can’t they saw you up like I don’t know if it’s like part of your universe. It’s a much more involved procedure. And you’re, like, again, risky, there was no way I was doing that. And I didn’t really have much faith in anything working at that point. At that point. We were talking adoption. And then my doctor had mentioned that she had had a patient who would use a surrogate. So she told me, you know, she contacted the patient and asked him it’s okay if I talked to her. So I talked to this patient and was willing to entertain and in my mind, I remember surrogacy when I grew up. I was a child, but I remember the very Mary Beth Whitehead case, and it was a huge thing in the news. And basically she carried the baby for another couple, but it was also her egg. And then when the baby was born, she wouldn’t give it up. Oh, this is what I remember, at least. The whole notion of surrogacy seemed insane to me. And that’s really all I knew about it was that story that I remembered.

P: But let me ask you a question about you knowing you I feel like you’re not someone who is super attached to the idea of pregnancy like it has to come from my body, right? You don’t care

about that? 

A: No, not really, but I definitely and at that point, it was clear like I had no problem getting pregnant. So that part I could do. It was the caring part I couldn’t do which is why surrogacy seemed like the perfect solution. Right? That’s why you couldn’t use our sperm and egg and someone else’s, basically. Yeah, but yeah, so that part I and I, my experience has been pregnant are so negative at this point, that was nothing like that. I was romanticizing accounting, but it still it made me very nervous. Like, you know, I don’t I didn’t know enough about it. I didn’t like my mind. I thought Who on earth would do this and I didn’t understand the legal issues. involved. So we looked into it and the person I talked to had a very positive experience both with her surrogate and the agency shoes. So I called the agency she had used in LA has, for whatever reason, many service agencies. We all seem to be there and I was really impressed with the people I talked to. And then we did look into adoption too. And I taught a cow for adoption in California is quite complicated, actually. Most of it’s done through private lawyers, not through agencies and I talked on lawyer who I really didn’t like very off putting so and then my husband was much more in favor of surrogacy than adoption. So we started kind of doing most of our research on in that direction. And so that was another very lengthy process.

P: It there’s no easy way to have a child right there’s no no easy path there. I guess unless you’re like 18 or something. I interviewed a midwife who was a surrogate. Her argument for why she wanted to be a surrogate was that I could do this pregnancy thing pretty easily. And it’s such an amazing thing to give to someone else. And I totally agree with that. And I was like, Oh, I guess if it were easy for me. I could see how that would be an attractive thing to like, make money on the side and do something for someone else. So I think it’s like attractive. If you find that person. It sounds like what the first person you work with. 

A: She was fabulous. Yeah, no, they were she was great. Like and that was true of like the people we talked to and interviewed with but they were lovely. They really they all had easy pregnancies. They like doing it. It was like a good deed they could do for someone else. They were mostly people who really cared about family. Yeah, the agency was great. They screen people. Well, I mean, it took a long time, you know, to match us all that. So the surrogate we worked with at first had four kids of her own two Singleton’s and twins, and she was just lovely, warm and like common sensical and just easy to deal with. They thought that I’d be a great candidate because I had no problem getting pregnant. They thought oh, this will be a snap. But meanwhile, also I was turning 40 And so like, who knows what was going on with my fertility at this point, it wasn’t going to be getting any better. So we did IVF. Basically, we ended up doing four rounds of IVF and each time I produced insane number of x for like a four year old, like, minimum of like 18 Like it’s like unheard of. 

P: I remember reading that and thinking holy crap. This is a I hear so many stories about people who do IVF and they end up with, you know, after day three or four when they form the embryo and they’ve checked it out they end up with like one or two. 

A: I always had a bunch of times and like obviously some of them were not good, but it was like that was not a problem and and then we got plenty of decent embryos each time. And each time the surrogate first was a two time shooting and pregnant third time she got pregnant with four quadruplets. And I was like, This is insane. It was like Octomom story.

P: That’s that seems scary. And in your book, I was like,

A: No, we couldn’t make this stuff up. It was crazy. The doctor was very aggressive to like he put in a ridiculous number of embryos each time because he kept perceiving me it was like he couldn’t fathom that. It wasn’t that I wasn’t there for fertility reasons. Yeah, we kept like putting in ridiculous amount of it was not good. So anyway, like before, basically we would go down each week with like her for the ultrasounds and each week was like then there was one less and finally the last week there were none and they had to do a DNC It was horrible.

P: So it was just sound like emotionally challenging in a totally different way. 

A: it was awful like, just like you’re sitting there staring at the screen because like no one’s knows what’s going to come and they ultrasound and you could like that time I would look at the doctor’s face as he was and you could tell he was horrified. And then I asked her around she didn’t get pregnant and then we decided we would try to use donor egg and see what happened with that, because the doctor kept blaming me in my ancient texts, that I had to be the problem and meanwhile, the one thing about our surrogate is she was very overweight. And and that is a factor. I mean, yeah. And I had asked about that when we first met her and my doctor didn’t think it would be a problem because she had had four kids no problem. So we then had to find an egg donor, which was another incredibly lengthy, crazy process. We did that and we had some great embryos and so they implanted a couple in our surrogate and she was pregnant, got pregnant, and they could tell two heartbeats, but one seemed pretty weak and the other same time. And then again, after a few weeks, the one that was weak, didn’t survive, but she didn’t miscarry. And then the second one was not looking so good, and then again on the ultrasound, not viable. So that was when we decided this is like I kept emailing him and saying, What is going on? And he kept proposing things like putting our surrogate on different medications that she Oh, I know what it was. She was pre diabetic, maybe. Like he wouldn’t just say this is not working out find a new surrogate. He went through that. I had to flat out say to him, if you knew what you knew today about our surrogate, would you recommend I work with her and he just wrote back? No. She told me this like two years ago,

P: totally. And there’s so much gray area that right

A: Yeah, and I’d say that particular placement we use that place because it was within a reasonable distance to our surrogate house. But it was kind of an Idea Factory. It was not. It was a private clinic. It was the office was always jam packed. You never got any you never felt like they cared about you. It wasn’t I don’t know. I mean, it sounds like there are a bunch of different considerations you have to keep in mind like ease of access for the service, right, which is important because you mean she had to go there quite a bit. So we then had to find a new surrogate which was also awful because I you know, we had become close and I felt terrible. I mean, I basically, you know, ruin two years of her life and you know, she had her own life and family as well, like it was terrible. So the agency found us a new surrogate who would carried like she seemed like a surefire bet she had carried twins full term. They were like a powerhouse for another couple years before. Plus she had had to have her own kids. So we used we had frozen embryos from the previous round. So we use that lb changed. Fertility Centers. Which was a huge, like, night and day. This was USC. The difference was amazing. Like, just at my intake, I guys spent two hours talking to the doctor. He was lovely like he it was just a very different experience. So she got pregnant on the first round. But nothing easiest thing on earth. And I mean, at this point, I was a nervous wreck and could not possibly believe in any control.

P: When I read the book, I was amazed by your tenacity because there’s so much hope put in every single attempt that anyone makes ever and to the IDF seems fairly grueling, right. There are a lot of aspects to that you taking drugs and the shots and all that stuff. And all of it is building building building to the implantation and then the next ultrasound and there’s so many points at which things can go right or things can go wrong and it’s just it’s a lot

A: I that’s interesting that you said tenacity, but I felt like I’d started something and you can’t finish like I was going to see this to the end of it killed me it was like I had people ask me that. I think one of my cousins said like, Why on earth are you doing this? And it was like I felt like I had something to fix. And I and it also just sort of snowballs. Like, once you get started, it’s like you can’t you almost can’t stop. Once we had the embryos. I’m like, well, we may as well use them.

P: And that’s totally true. But it’s not costless for you right? I can You can see that you’re when you read the book, like you’re suffering through all of this. On the one hand, I totally relate to the I’m going to see this thing through I’m this is my goal. I want a kid and this is how we’re going to do it. And on the other hand, it’s just, it’s like expensive, right in terms of emotional capital. 

A: Yeah, no, it was awful. I mean, I I would definitely say I not the same person. Right. Yeah. And yeah, I mean, it affected me in profound ways. Just like I mean, the whole pregnancy. I mean, seriously until our daughter was born. I did not believe that this was going to happen even after the first trimester when we were basically we were done with the fertility center like after three months. You then go on to your regular OB I still was not convinced this was gonna work. 

P: Oh, my God, I would have wrapped the surrogate and bubble wrap. 

A: Well, that’s the funny thing is like, first of all, she lived in LA and I live in Northern California. So we felt like I could monitor her noise in my place to do everything right. And she’s also she’s very low key easygoing, which I think is probably great, but for me, that’s inconceivable to me how you could be so relaxed. So it was hard for me to have to sort of let go and just trust her. It’s not like I know her well, but you know, everything was fine. And the irony of all this was that in the end, our daughter was a week late. Wow, that killed me severest.

P: So how. So how does all that work? Like how does it work for the bird? It sounds like you’re going down there fairly frequently for all the ultrasounds to be involved. Yeah, and et cetera, like you I needed a bunch of medical help to get pregnant and stay pregnant. And it’s, it’s so not what I pictured to involve all these people in my pregnancy. What it is like a different route to that same outcome. So how did it work for the birth? Like what’s the plan and

A: we made plans ahead like we knew we had visited the hospital with our surrogate ahead of time and the hospital and clearly worked with surrogacy before we were warned ahead of time to avoid certain hospitals, particularly Catholic ones who are not so okay with this. So we went down to LA. We were there for about a week we like we went down after her due date because her daughter said no way on earth is she ready yet or giving birth any day? So we stayed in a hotel and was pretty much waiting with our phones on all the time. Basically, when the doctor said he was inducing her, we then moved to a hotel like right next to the hospital, and she called us early in the morning and we went in and then he was born like two hours later. Wow, we were in the delivery room.

P: That’s awesome. That was gonna say is it’s weird to be late. This is her fourth pregnancy. Right. Kind of want to? Yeah, of course. But I’m glad that the birth was fairly straightforward. Yeah, no,

A: it was, I mean, easy fast. And her I mean, she said they did limit the number of people that could be in there. It was my husband. And I And then her mom, and that was it. And it was again great. They didn’t very they were very sensitive. You know that she had, you know, some like there’s some decorom there. My husband is not suiting like it was it was done very appropriately. As soon as our daughter was born, they handed her to me. It was they, they really did a great job. And then they we had a room in the hospital they gave us that’s awesome. I know. They were amazing. So we all stayed overnight and then the next day we drove back home to our house, with a baby. 

P: And a surrogate just says goodbye and that’s it. 

A: Yep. So she stayed overnight also, just to make sure she was okay. And she went back to her family and she was 15 minutes away from the hospital. But, you know, we’ve been in touch with her. You know, we sent pictures. It was surprisingly the surrogacy relationship worked out very well, like we were friendly and got along well, but I don’t think there was any indication that we were necessarily going to be best friends for life. But I think, you know, I think she wants to know that our daughter is fine and things are okay. And you know, that’s that’s really the extent of it.

P: I do think it’s probably surrogates are similar to NICU nurses, where it’s like special people who select into that work and so they’re able to have kind of the right kind of bond with someone who they who they give this gift to. 

A: Yeah, no, she, I mean, I’m forever grateful to her. She you know, what you’re in for life. And, and she, you know, she did a great job, like, there was, our daughter is healthy and fine. And so.

P: So that’s amazing. And you guys get home and what’s that like?

A: Well, that I mean, this is where we’re going to talk about how I feel like I’ve been profoundly changed like, I’m like, I think like my mom, I was never someone to get worried about sickness or anything like that. And then, like, that was a huge change. Like, my daughter would so much it’s like sneeze and I’d be ready to call 911 Just like I would assume the worst of everything just get much more nervous high strung about particularly things that I’ve never ever been like before.

P: Well, that totally makes sense, right? You’re you have had these shocks. So now you understand how things can go and that’s kind of that’s terrifying, right? It’s there’s no, that seems like a legitimate response to experience. 

A: Yeah, I would say though, it took years before I kind of realized, you know, she’s basically she’s likely to be okay. But that was a huge difference, I’d say are a huge impact that this had on me.

P: And did you guys take turns fingered at you know, when she was an infant, or how did all that go? 

A: I’d say why I couldn’t nurse and we’d looked into that it would have meant taking more hormones, which not doing any work, but because of that it meant my husband could get up for the night. That was quite nice. That’s super nice. And she was a huge baby. She was big and hearty because she was a week late also. So it meant like she generally slept better through the night faster, and she didn’t need to find a ton of weight fast. So that was also nice. That’s awesome.

P: I mean, you’ve had time to process all this stuff that has happened. What advice would you have given to younger Ariel? What would you tell her to have made her path any easier?

A: That’s a good question.

P: I mean, I think most people learn partially how you did through your own experience. With pregnancy. That is like a giving up of control. And I’m imagining while you’re talking about the surrogate, you have to give up control even more. It’s not even your body, right. It’s not, which is a hard thing to hard thing to do. 

A: I don’t know what advice I’d give. This isn’t advice, but expect the unexpected, which is kind of cynical, but I felt that I was cocky about my pregnancies but the first time but I after a certain point, I felt like what could go wrong? Yeah, like after I asked the first trimester and so it’s hard for me now like when I like even after shortly after that time, friends who were you know, more or less my age who got pregnant and they were just relaxed. And I had one friend, you know, she ran part of a marathon I had, like I was just thinking and they were very self confident and everything turned out fine. But I mean it’s still mystifies me like I still I’ve gotten less so now but at that time, like I would see women, you know, pregnant women, whatever at the gym or biking or doing and I just thought how and I assume with most of them, everything was fine, because I think my situation was also on the extreme end and it’s by no means common. Yeah, all combination of things. And it’s it’s also hard, like, people who don’t know what happened, ask them about pregnancy and I don’t want to give advice to anyone because, like I said, I just was I don’t want to scare people or horrify them again, it’s not what happened to me. It’s not typical by any means. So

P: I’m not sure what to do with the scary part. I mean, a lot of people talk about oh, I don’t want to talk about my preeclampsia because it will scare people and I’m not sure that’s the right frame only because it is what it is. This is what pregnancy looks like in all its many forms. It’s not all rainbows and butterflies. I think that’s a pervasive story, but not necessarily a pervasive experience.

A: Yeah, no, I think you’re right. I mean, it’s interesting, but in terms of when I was looking for agents for my book, and a lot of them would say things like it’s too much of a downer. People don’t want to read that they want you know, much more optimistic story.

P: I mean, I think your story is amazing that here you are with a 50 sheet 15 or 16 shall be predictive team soon. Yeah, like a you with a 15 year old. This is an amazing story. I think I you know, all the things that you went through, you know, show that it can be done.

A: At the same time. I remember people would ask me, which still shocks me shortly after she was born if I was gonna have another one. I’m not doing this because I also realized that it took five years basically to have one. Yeah. And I knew all the possible things that could go wrong. Doing this again, but people were stunned like they thought because I had a healthy child that somehow erased everything that had preceded it.

P: Yeah, or they can’t imagine what it felt like to do although the everything that came before. I think it’s an amazing story and amazing to have a teenager now. Right? 

Maybe because Ariel and I know each other. The end of the episode sort of got away from us. We started talking about things unrelated to pregnancy. So I’m gonna end this episode with two more insights from Dr. Feltovich about the culture around specific issues in women’s health. Everyone I’ve spoken with, patients and doctors suggests that they don’t like the term incompetent cervix and I’m wondering how we change the name. How does that happen?

Dr. Feltovich: These things happen slowly medicine is very, very, very slow to change. But I don’t hear the term incompetent as much as I used to, even though it’s in the ICR diagnostic codebook has it in there because it’s just it’s been a term for more than 100 years. Some people think it’s better to call it insufficient cervix. And I guess that’s slightly better, but I don’t like that one, either, because lots of tissues can function or dysfunction and it just seems kind of non pejorative. So how do we change that? I guess, like we change everything else, just talking about it and whenever we publish on it, talk about cervical dysfunction. We had a paper some collaborators and I a number of years ago in which we talked about how incompetent wasn’t the right term, and I guess we just slowly talk about it and speaking of talking about things, I think the culture around preterm delivery really needs to change again by talking and you know, sisters talking to sisters and friends and mothers and neighbors and, and talking on blogs. And podcasts. And you know, all of this because I think that one very common misperception

really needs to change again by talking and, you know, sisters talking to sisters and friends and mothers and neighbors and, and talking on blogs and podcasts and you know all of this because I think that one very common misperception that ties into terms like incompetent cervix is some sort of accountability for that. As if we as patients have any control or as if there’s something the matter with our bodies and you know, I don’t think I have ever in my multi decade career, done a consult on a patient with a history of preterm birth. Who has not cried when I’ve said and what part of this do you think is your fault or you know, what are the things coming up around the, you know, because they don’t talk about it. People are scared to say, What did I do? You know, so in my clinics, we just hit that nail on the head, we say, Okay, you’re gonna think you’d like like, let’s say Ariel had come to my clinic after her 23 weeks P prom, right? Yeah, I would say all right, you’re gonna think 100 things over the next few days. It’s just it’s the mind is a very, very busy place. And anxiety, and fear, are very, very strong emotions, and they kick things up in your brain, right? You can’t control them. And so we always talk about how there there are 100 things that are going to come up you know, like, that day when you’re throwing up and you’re like, oh my gosh, why did I want to be pregnant? This is awful. Or like, you know that those glasses of wine you had before you knew you’re pregnant, or you know what, whatever else it is, there’s the mind is just a very busy, active place. And let’s pick those things up. But none of them are true, because the truth is that you could be laying on the street doing meth cocaine, you know, like mainlining, crud your whole pregnancy and not have a preterm birth, like you could be really doing things that aren’t good for your body and not lined up with a preterm birth. So culpability is the word I was like. culpability. Yeah, they’re just there, isn’t that and so, a really important thing. That I hope people like you disseminate and communicate to people is that there really is no shame or blame in this. Doctors. Experts don’t even understand what causes it, but we know what doesn’t cause it. And what doesn’t cause it is women doing things wrong. Yeah. Yeah.

P: If only it were that easy, right. Then you just say, don’t walk downstairs.

Dr. Feltovich: Right. And that is exactly that is exactly what I tell people. I say. That’s exactly what I tell people. I’m like, I wish there was like, I wish I could say, Yeah, thing ABMC that’s what you did. So don’t do those again. Right? But they’re just there. There isn’t that. And so there’s a whole component of classy care. That’s not about the uterus at all, but it’s about self care. And self love, and gentleness and understanding around real uncertainty over biology. And, yeah, and really letting go, self judgment and the judgment of others.

P: such wise words to live by…Thanks again to Ariel for sharing her story. And thank you to Dr. Feltovich for teaching us what the current state of understanding is about preterm labor, and what the future might look like. If you liked the show. Feel free to like and subscribe and share it with friends. We’ll be back soon with another story of overcoming