I’m still in disbelief despite this news update from a few hours ago, which goes into more detail regarding the octuplets and the way that they were conceived. According to this story, these babies were conceived through a frozen embryo transfer. I guess at some point, my skepticism will have to give way, but up until now, I still had a strong leaning towards believing that this was not through IVF but rather through ovulation induction with either IUI or intercourse.

I highly questioned the fact that these were through IVF for two types of reason – hard medical reasons and human nature reasons. The hard medical reasons are based on the unlikelihood of someone having enough embryos to transfer that they could have eight successfully implant. Many people don’t realize that you don’t always transfer two embryos and get twins or transfer three and get triplets. Rather, if we transfer three, we may get zero, one or two babies. Rarely (but it certainly happens), we transfer three and all three take. It’s mathematically even more improbable to transfer eight and get eight. It would be more likely to imagine transferring, say 14 embryos and having eight take. However, this second scenario, while mathematically more likely is even MORE unlikely from a human nature viewpoint, because it is hard to imagine any physician eager to transfer eight (let alone fourteen) embryos under these circumstances.

Our phones were ringing yesterday with inquiries from reporters fishing for information, asking if we could comment on which RE did this. In all honesty, I have no idea which RE was involved in this case. My colleagues and I have been privately tossing around a lot of conjecture regarding certain of our colleagues, but we have no real proof. I have been flooded with questions regarding this case, but since I don’t have any inside information, I’ll focus my commentary on providing science to answer some what-if questions.

How many embryos would you have to transfer in order to get eight embryos to implant?
This is a question that can only be answered with probabilities and not with certainties. It is akin to asking how many free throws must a basketball player shoot in order to sink eight of them? The answer is it depends. It depends on the skill level of the player and it depends on how the luck factor played out. In yesterday’s post, I worked out the calculations for a few scenarios. If we start out with an assumed 60% chance of implantation per embryo and eight embryos being transferred, the odds that a perfect eight out of eight would take is 1.68%. This is not impossible, but it certainly improbable. However, let’s say that these are top quality embryos from a very young woman who already has proven IVF success, then we might really really stretch things and give her a generous estimate of 75% chance of implantion per embryo. Bear in mind that even if a woman is in her 30’s today, transferring frozen embryos that were created and frozen back when she was in her 20’s give her the same fertility potential today as if she were still in her 20’s. This is why we are excited about the prospect of someday helping women who wish to delay childbearing while still preserving their fertility at the same level as when they were younger. This can already be done, but there are practical limitations of cost and of the fact that the eggs would have to be fertilized in order to optimize their survival and later usefulness. Anyway, if we assume a 75% chance of implantation per embryo, then the chance of a perfect eight out of eight taking would be 10%. So if this pregnancy was indeed from a FET, it is more probable that greater than eight embryos were originally transferred in order to end up with the eight which took.

There was some talk that this patient was actually paid to do IVF. Is that possible?
Egg donors are routinely paid to participate in IVF. The big difference is that the donor does not retain possession of the embryos. Rather, the embryos are transferred into another woman who will be the rightful mom to the baby. There are instances where a shared cycle is done so that one woman donates eggs, retains some of the embryos for herself while relinquishing some to a sponsoring couple. The eggs would typically be fertilized with different sperm respectively (ie the husband of the recipient woman and the husband of the donating woman. I’ve not heard of a case where the donor was both paid and given some of the eggs.

Would it be possible for an insider, say an employee of a fertility program, to pull this off without the consent or knowledge of the doctors?
This was a question posed to me by the KCAL news team. I expressed my opinion that it would not be probable that an untrained technician, nurse or medical assistant could have secretly pulled this off. Even if the embryos were originally created with a legit IVF cycle, I don’t think anyone could have singlehandedly, or with an untrained accomplice, thawed the embryos and performed a transfer that would have resulted in eight babies. It’s conceivable that they could have tried, but it probably wouldn’t have worked. Again, if this indeed was an IVF case, there almost certainly were doctors involved.

Do doctors ever refuse to do IVF on patients or do they accept anyone who has the money?
Haha. I had to add that last part, because a lot of the cynical comments out there on the internet express anger at the doctors who did this, citing the ever-popular complaint of corporate greed as the motivation for them performing this procedure. I’ve even come across some remarks stating that the“three moronic smiling doctors” should have their licenses taken away. I guess that reader did not realize that those doctors pictured in the news are the delivering perinatologists, who had nothing to do with the initiation of this pregnancy. They were the heroes who were forced to save these babies.

We RE’s do sometimes refuse treatment to patients, based on medical unsuitability, age or suboptimal life circumstances. I’ve taken care to always do so tactfully. One example was a woman who wanted to do IVF using donor sperm without her husband’s knowledge. Despite my offer to discuss this jointly with her and her husband, she was very angry at me for refusing to do it. As it turns out, there are some natural checks and balances that prevent some inappropriate candidates from doing IVF. For example, if a financially unstable single woman wanted to have babies so that she could get better welfare benefits, she would run into the problem right away that she could not afford the IVF. There is no shortage of women who want to get pregnant even though they may lack the maturity, finances or life stability to provide for a child. We get phone inquiries at our office from women asking if we would accept their Medi-Cal. On my Google report, I noticed the other day someone who hit my site after searching “gubermint paid fertility treatment”. So yes, while we do at times turn away paying patients, we have a tricky balancing act, because there have been instance of RE’s being sued for refusing to provide services, for example, to gay couples.

How does HIPAA protect this woman’s right to privacy?
HIPAA only applies to “covered entitities”, such as her doctors, insurance companies, etc. It does not apply to her friends, family or to strangers, including reporters. On the news, we have seen the crews near her house, interviewing neighbors. The patient’s father was stopped and interviewed by news crews. There is no absolute legal restriction to this, as the reporters are doing their jobs providing information to a hungry public, but there are certainly moral restrictions, that often are self-imposed. For example, this morning, one of my patients who knows someone who knows someone at the schools of the six older children, told me that there were news crews at the kids’ schools. Is that a little too much?

When I first heard about the octuplets who were born earlier this week, my first theory of how this came about was that somebody went to Tijuana, bought fertility drugs, injected herself indiscriminately without medical supervision and then went on to have sex. According to the latest updates, this may have been a result of IVF. This news comes as a huge shock for several reasons.

In the first scenario I described, it is feasible to think that somebody injected herself with medication, unmonitored and unaware of exactly how many follicles she was developing. Therefore it would be more understandable that she subjected herself to the risk of octuplets when in fact, she thought she had much fewer eggs. However, if it is true that these babies are a result of IVF, that brings up many questions.

It’s one thing to post flyers announcing a party at your house and then being surprised when 100 people show up. It’s entirely another thing to send out 200 personalized invitations and then being surprised when 100 people show up. In other words, when you take fertility drugs and have an insemination or just have sex, you might not know how many eggs are actually growing. You would need to monitor using ultrasound to get an idea of how many eggs there could be. Even if you did monitor and count the follicles, it’s still uncertain how many eggs will physically wind up in the right place. With IVF, it’s an entirely different matter. In this case, an exact number of embryos are transferred right into the uterus. Therefore, in order to have eight, someone would have to deliberately and knowingly put eight or more embryos into uterus. Why? That’s the big question.

One of the most important decisions in IVF is how many embryos to transfer. In general, the more embryos you transfer, the higher the chance of success, but also the higher the chance of multiple gestation. The goal is to maximize the chance of having one or two babies. Zero is not good. Three or more is certainly not preferred either.
In order to understand the thought process that goes into deciding how many embryos to transfer, let’s use a deck of cards as an example. Pretend that you have a well-shuffled stack of 1000 cards and you were told that in each deck, some cards are green and some cards are red. You are then given a very specific deck of which exactly 50% were green cards and 50% were red cards. And then you are told that for every green card you draw, you get one baby. For every red card you draw, you get nothing. Now you are asked. “How many cards would you like to draw?” If you decide to draw just one card (ie put in one embryo) then you have a 50% chance of coming away with nothing and a 50% chance of coming away with a single baby. The math is simple on that one.

Let’s say however, instead of drawing one card, you decide to draw two. Now, you will wind up with a 25% chance of no babies, 50% chance of one baby and 25% of twins. This is a very popular choice for many couples. The exception would be couples who are very much against having twins. Then they would be more conservative and prefer only transferring one. On the other extreme, couples who are very aggressive may prefer to put in three rather than two. What happens in this case if we put in three?
Chance of zero babies: 12.5%
Chance of one baby: 37.5%
Chance of twins: 37.5%
Chance of triplets: 12.5%
By putting in that third embryo, you have reduced the chance of a completely failed cycle from 25% down to 12.5%. You have lowered the chance of a single baby from 50% down to 37.5%, and you have raised the odds of twins from 25% to 37.5%. You have also increased your risk of triplets from zero to 12.5%.

When people ask me “How many embryos should I transfer?”, my answer would be “It depends.” It depends on how aggressive you want to be. What do you fear more? A completely failed cycle? Or a cycle where you end up with more than twins. It also depends on what is the estimated % of success for each embryos, ie what % of cards are green? The final variable is “What actions are you prepared to take in the event of getting quadruplets or more?”

So let’s take what the news has reported regarding these octuplets. This is a woman, supposedly in her early 30’s with a history of having six children on her own. Those are fairly favorable condition. Let’s say that the embryos in question were blastocyst embryos and that we estimate (generously) that each embryo has a 60% chance of becoming a baby. If you were to transfer eight embryos that each had a 60% chance of becoming a baby, then what are your possibilities?
Chance of zero babies: 0.07%
Chance of one baby: 0.79%
Chance of twins: 4.13%
Chance of triplets: 12.39%
Chance of quadruplets: 23.22%
Chance of quintuplets: 27.87%
Chance of sextuplets (6): 20.90%
Chance of septuplets (7): 8.96%
Chance of octuplets (8): 1.68%

Just to clarify, what I have just listed are the predicted outcomes if you put in eight embryos, each with a 60% chance of “taking”. As you can see, there are a few odd things. When you put in eight, the odds of all eight taking are actually quite low at 1.68%. So when the patient’s family member said they were surprised that all eight took, that has a teeny bit of validity. However, that validity flies out the window when you realize that even though the chance of all eight taking is small, the chance of four, five, six, or seven taking is cumulatively 80.95%. So how can anyone justify putting in eight embryos when the odds of quadruplets or more is so overwhelmingly high.

We also can infer from these calculations that if this truly was IVF, then it’s quite possible that even MORE embryos than eight were transferred so that eight actually took.

OK, for the sake of argument, let’s say that whoever made the decision on transferring so many embryos felt in his heart that each embryo only had a 25% chance of implanting. Would that justify putting in so many embryos? Let’s do the calculations…
Chance of zero babies: 10.01%
Chance of one baby: 26.70%
Chance of twins: 31.15%
Chance of triplets: 20.76%
Chance of quadruplets: 8.65%
Chance of quintuplets: 2.31%
Chance of sextuplets (6): 0.38%
Chance of septuplets (7): 0.04%
Chance of octuplets (8): 1 out of 65,536!

In this case, it’s a bit more reasonable, but still very very risky given that the chance of quads is 9% and the chance of triplets 20.76%. But if this were the case, then this octuplet birth would really be a miracle in mathematical terms because it would have really defied the odds.

We don’t have all the facts and it’s well possible that the family members providing the new information were mistaken or just not telling the truth. In any case, we in the RE community are waiting a little nervously to see how this all plays out. Our fear is that the powers that be will seize this extreme case use it as an opportunity to put draconian restrictions on physicians in this field, despite the fact that the majority of us have not been careless.

In the US, it is against the law for somebody to sell their kidney or other organ. This is clear, even if getting a kidney could well be the difference between life or death. It’s true even if the recipient is eager to pay and even if the potential kidney donor is rational, intelligent and voluntarily willing to make the exchange with no coercion.

This is certainly one of the most complex ethical dilemmas in medicine and although the law is simple and clear-cut, the overall ethical answers are not so clear cut.

Two recent news stories bring this issue up for discussion. One reporting an increase in egg and sperm donor applicants and one reporting about people turning to internet sites such as Craigslist to solicit organ donation.

In contrast to kidneys and other organs, when it comes to the donation of sperm and eggs, the law in the US is different. Egg and sperm donors are regularly paid for their participation. Technically, an egg donor does not sell her eggs. At least that’s the official spin. She undergoes injections and a medical procedure to enable her eggs from that month to be removed. This is what she officially gets paid for, not for her eggs per se. But no matter how you label it, the fact is the recipient couples pay her with the intention of using her eggs to help themselves have a baby.

So for kidneys and other organs, it is illegal in the US for there to be any financial compensation given to the donor. For eggs, it is legal in the US, but it is illegal in other countries, such as in the United Kingdom.

Kidney donation and egg donation have some key fundamental differences. Kidney donation is done to save a life. Egg donation is done to voluntarily conceive a baby. A kidney donor loses half of his/her potential kidney function. An egg donor loses only surplus eggs from THAT month, which were going to be wasted forever anyway. The same goes for a sperm donor. However, the sperm and egg donation have social repercussions in that afterwards, there could be a child walking around with the donor’s genes that he/she will never know. So keeping those in mind, let’s look at the different arguments.

PAYMENT SHOULD BE ALLOWED TO GIVE INCENTIVE FOR PEOPLE TO DONATE:
- “It is sheer agony to watch my wife waste away day by day. The dialysis is barely keeping her alive. I’ve read stories of how life greatly improves after a successful transplant and I wish for her to have her once-happy life back again. We have been on the waiting list for over a year and we’ve already pleaded with all our family and friends. Of the few that offer, none have been a match. Yesterday, I saw someone on Craigslist offering to donate a kidney in exchange for money. The money in my retirement account is worthless to me in the future in comparison to what it could do now to save my wife. Yet, I am afraid I will have to risk breaking the law if we make an under-the-table arrangement.”

ALLOWING PAYMENT FOR ORGANS IS UNFAIR TO THOSE WHO DON’T HAVE THE MEANS TO PAY:
- “My wife has been on the waiting list for a kidney for a year now. We are on welfare, because neither of us work and we just don’t have the financial means to purchase a kidney. We are so thankful that kidneys can not be bought, because otherwise, it would be unfair for the rich people to jump ahead of us in line. By making it not about money, then it is fair for everyone, rich or poor. The decision of who gets to live should not be based on ability to pay”

- “My cousin was ready to donate his kidney to me. Then he heard that other people were getting thousands for their kidney and he decided he longer wanted to give me his kidney. Instead, he wanted to shop for the best offer instead. I don’t make enough money to pay him and therefore, I am losing the kidney that I was entitled to. It should be illegal for someone to offer money.”

PAYMENT WILL RESULT IN MORE OVERALL DONATIONS, THEREBY BENEFITTING THOSE WHO ARE WAITING FOR ORGANS:
- “There is no doubt that money talks. Look what’s happened to the number of sperm and egg donor applications with the current drop in economy. There are not many people lining up to volunteer their kidneys today. If there were financial compensation, the number of willing donors would skyrocket. So let’s say there are 10 rich people and 10 poor people waiting for kidneys and at the current rate of new donors, 1 rich person and 1 poor person would be saved by getting a kidney. Now let’s say that the rich people are allowed to offer a reward for donated kidneys as long as they help subsidize kidneys for the poor. As a result of this policy, all 10 rich people get kidneys as well as 5 of the poor people. While this is still biased in favor of the rich, the overall number of people saved is much higher.

OFFERING TO PAY FOR ONES BODY PARTS EXPLOITS THE POOR:
- “Can you imagine all the people who are so desperate for money that they will be forced to donate a kidney just to survive? It is cruel and inhumane to turn our bodies into replacement parts”

IT’S MY RIGHT TO DO WITH MY BODY AS I WISH:
- “I work a minimum wage job. I have always dreamed of of going to Hawaii, but there’s no stinking way I can ever afford it. I’m more than willing to give up a kidney in exchange for a chance to realize my dreams. I know that there’s a 5% chance that I will have problems and regret it, but I’m willing to take a little hope for my life in exchange for no hope at all. With the money, not only could I go to Hawaii, but I could also go to Europe and do many other things I could never have done otherwise. I would also have something leftover to give to my children to help brighten their future.”

COUNTRIES WITH MORE RESTRICTIONS HARM THOSE WHO NEED THE DONATIONS:
- “In England, there is a severe shortage of egg and sperm donors. Couples are resorting to drastic measures in order to find the help they need in order to have babies. More and more, couples are coming to the US and to other less-restricted countries in order to do their cycles that require donor eggs or donor sperm.

DONORS ARE TAKING A RISK AND SOCIETY COULD END UP BAILING THEM OUT:
- “Look. If somebody donates a kidney and is left with just one remaining. Then, they go spend all the money they got. What if something happens to their remaining kidney and now, my tax money or my insurance premiums will go to pay for their needed medical care. That’s certainly not fair to burden society just so that those people can have more spending money.”
- “Then what about someone who donates altruistically for no money compensation. If something happens to their remaining kidney, doesn’t society face the same burden?

Where do I stand? I see the arguments of both sides because, well there are some good and bad things associated with either a free policy to accept payment for donating or a restricted policy banning financial compensation. Because there are good arguments in favor of and against the restriction of paying donors, I don’t agree with the government’s black-and-white policy of just saying NO to every case. There needs to be some flexibility with reasonable checks and balances against abuse. A blanket ban is not the best for everyone involved.

17 February update:
Here’s a story about how things are in China.

I ran into a fellow RE at the hospital we eventually came around to discussing the news of the octuplets who were born yesterday. Our initial reaction was like a fishing expedition for gossip with each of us asking the other “Do you know who the RE was? I wonder if it was so-and-so.” We both said “It wasn’t me.” Neither of us knew, but it’s likely that in the next few days, we’ll eventually hear more of the details.

Although I know zero specifics of the case right now other than what was reported in the news, my professional opinion is that I’m more than 99% sure this involved injectable fertility drugs. This doesn’t necessarily mean that this was the work of an RE. Some general OB/Gyn’s also prescribe injectable gonadotropins. In fact, I’ve also heard of cases in which patients went to Mexico, procured the drugs and self-medicated without a doctor’s supervision.

My medical curiosity springs up with two immediate questions. How old was the mother? How many follicles did she have? What was her infertility history? If forced to speculate, I would venture to guess that she is not over 35 and that there were at least twenty follicles and that this might have been her first treatment cycle.

Hopefully, the public is not misled by this into thinking that all octuplet pregnancies will have this good of an outcome. On the contrary, there has only been one other time in history, where there were surviving octuplets. On another note, I hope the public is not misled into thinking that this type of high-order multiple pregnancy is a common occurrence when taking fertility medications.

Patients sometimes ask, “Is fertility treatment painful?” It’s a reasonable question. I know that before I personally undergo any medical procedure, I would want to know that. To better answer this question, I’ve taken an informal survey of my patients who did IVF and asked them to share about their experiences. As can be expected, there were a range of answers. However, the overall agreement, with a few rare exceptions, is that the physical pain associated with their IVF cycle was minimal. By the way, note that we’re talking now only about the physical pain, not the financial and emotional pain (if the cycle fails).

There are several potential sources of pain during an IVF cycle. The first starts out way before the actual egg retrieval. In preparation for the egg harvest, it is standard to take injectable medications to help develop the eggs. These are done with small needles and modern injection pen devices. Almost everyone dreads the first injection just out of fear about the unknown, but after the initial anxiety is over, most women report that the injection pain is nothing. The needles are tiny and go in fast and easy. Compare this to if you had diabetes. In that case, you would be injecting yourself with similar needles many times a day.

The next potential source of pain comes as the eggs develop, when the ovaries start to enlarge, causing bloating. This is a very real phenomenon, and there’s little that can be done about it other than to limit the number of eggs that we grow. Of course, this is a tradeoff, because if you only have 4-5 eggs, the pain and bloating are minimal, but your success rate is going to be decreased. This is the part most women hate, but in reality, most women with a well-controlled stimulation don’t even experience any real pain, but merely significant bloating, which itself can be quite uncomfortable. This discomfort can extend well into the week after the egg retrieval.

The third phase where there could be potential pain comes on the day of the egg retrieval itself. Knowing full well that the eggs are removed by piercing a thin long needle through the walls of the vagina into the ovaries, many women anticipate great pain on that day. But in reality, the pain is zero during the procedure, thanks to the wonders of modern anesthesia. In our program, we have anesthesiologists on hand for every retrieval in order to keep our patients pain-free and breathing normally with normal heart rates and normal blood pressures throughout the case. Some places around the country still do their retrievals without full anesthesia. While this is a cost savings, on the surface, there is a price with regards to patient comfort and the ability to successfully harvest each egg. Way back during my training at UCLA, we used to do these cases under sedation-only and it added to the difficulty of the egg retrieval when patients would occasionally twitch or move. It’s not that hard to aim a needle into a follicle, but it becomes way trickier when your target is moving.

Either three days or five days after the eggs are retrieved, the embryos are transferred back into the uterus. The transfer itself is almost painless, but it is as uncomfortable as a Pap smear.

After the retrieval, patients begin on progesterone, which is an injection, but different from the stimulation medications. Since it is an oil-based injection, the needle is larger and therefore more painful. The opinion on this is variable with some patients reporting a lot of pain while some find it quite tolerable. The ones who really find it unbearable have the option of taking their progesterone in other non-injection forms, such as with vaginal creme or vaginal suppositories.

So in summary, with regards to physical pain, while IVF has the potential to be painful in a few phases, in actuality, there is minimal pain for most patients.

However, nine months later, there is the much greater pain of childbirth and the postpartum period, which far surpasses any pain of the IVF cycle. The consolation is that this great pain is followed by the reward of motherhood

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This article makes a lot of sense. People make the best decisions and take responsibility for their actions when they are held accountable.

If your car breaks down or gets damaged, then you are responsible to get it fixed. That’s why people actually care about driving carefully and performing routine maintenance. Imagine a world where government paid for unlimited cars for you. If your car breaks down, they will pay for the repair or a replacement at no cost to you, even if it’s your fault. If this rule were put into place, I can guarantee you that people would be a lot less diligent about getting oil changes and I can guarantee you that people would care a lot less whether their car got a dent or not.

In the case of universal healthcare, suppose that I choose to smoke and eat a lot of junk food. Now I get fat and my lungs get dirty. If I get diabetes, a heart attack or lung cancer, my personal tragedy and misfortune doesn’t affect only me. It also affects those of you out there who are diligent about watching your weight and diligent about avoiding cigarettes, because you will have to pay for my medical care.

There are two ways to try and fix this. Either make each person responsible for their own health. Smokers, by virtue of a higher risk of lung cancer, would pay higher health insurance premiums. Healthy individual who are less likely to need expensive healthcare woud play lower premiums. We already have a system like this in place for auto insurance. If you have five accidents and four speeding tickets on your record, you are going to be paying more for insurance. The second way to try and fix this is what they are doing in Japan (as cited in the article) - putting restrictions on the lifestyle of the people to whom you are providing the free healthcare.

Is this really what we want?

This is a continuation of my previous post with my opinions regarding the new California laws that go into effect for 2009.

Mobile homes: Requires, at time of sale, all mobile homes and manufactured housing to have smoke detectors in all rooms designed for sleeping and to have seismic braces on gas-fired water heaters.
I have smoke detectors in my home, but that was by my choice. Hmm, I don’t have any Radon detectors and I certainly hope I’m not forced to get some.

National guard: Authorizes a state employee who is a member of the National Guard or reserves to receive government benefits for four additional years, if they were ordered to serve on or after Sept. 11, 2001, as a result of the war on terrorism.
It’s a nice gesture, but again, who is paying for this? This could be potentially very costly for the state of California.

Oil drilling: Permits development of additional oil reserves beneath submerged lands of the Wilmington oil field.
I don’t know enough about the details, but offhand, I would like to have more American oil sources and rely less on OPEC.

Pets: Provides for enforcement of “pet trusts” set up by animal owners to pay for continuing care of their pets after the human owners die.
I’m all for this. People should have a right to show love for their pets. Personally, mine are not getting a penny from me.

Phone cards: Requires refund within 60 days to any holder of a card if the provider’s services fail to operate in a commercially reasonable manner. Also mandates that phone-card firms maintain a toll-free customer service telephone number.
It’s odd that there should be a specific law to state this. I thought this was a given. Any business should be held to a standard that if they don’t deliver the services they promise, then the consumer has the option of a refund.

Press freedom: Prohibits discipline of high school and college journalism advisors for the content in a student newspaper.
The way I read this, it’s giving freedom to school journalism advisers when they themselves give freedom to their students who are doing the writing. So I support this.

Privacy: Makes it a misdemeanor to use radio waves, without consent, to remotely read another person’s identifying information. The measure is in response to the practice of having personal identification information included on government-issued identification cards that can be read with radio-frequency identification devices.
This blow for personal privacy is very important, but will be difficult to enforce.

Real estate: Allows the state Department of Real Estate to suspend or bar a person who has committed a violation of real estate laws.
What’s the point of having a supervisory board if they don’t have the power to discipline someone who violates the law anyway? This should have been another given and not requiring a separate law to state the obvious.

Schools: Allows Los Angeles Unified School District and other districts to continue tapping state funds even as they withdraw from a program to fund multitrack, year-round schools.
I honestly don’t know what this is all about. Can somebody explain it to me, please?

Senior homes: Assisted-living homes are required to show potential customers their history of rate hikes, tell local prosecutors about suspected abuse and plan for emergencies such as blackouts.
If this is a move towards more transparency, I agree with it. Consumers choosing a home for their loved ones should be armed with adequate information on which to base their decisions.

Smoking: Allows the state director of the Department of Mental Health to prohibit the possession or use of tobacco products on the grounds of state mental hospitals.
Remembering what I learned in medical school about the high prevalence of smoking among psych patients, this could well cause a few riots.

Spousal abuse: Prohibits jailing of alleged victims of domestic violence for refusing to testify against their abusers.
I realize many domestic violence victims call for help when they are imminently threatened, but then are caught in a quandary about leaving their abuser, so they refuse to testify. I don’t profess to know the answer to this complex problem. I would be open to hearing the views of those who work in this field whether jailing of the victims is or is not helpful to the overall situation.

Tax breaks: Allows taxpayers to exclude forgiven mortgage debt from their incomes for state income tax purposes.
I don’t know too much about this and this would be of no personal benefit, but you know me. I’m generally in favor of lower taxation for everyone.

Taxis: Allows local agencies to disconnect the telephone service of a taxicab operator that fails to obtain proper permits and insurance if other enforcement remedies have failed.
The role of the government is enforcement when people violate the rights of others. So if a taxi operator failing to obtain permits and insurance constitutes a violate of other people’s rights, then giving more ammo for enforcement agencies to do their job is a good thing.

Teacher crimes: Includes “no contest” pleas in the definition of convictions when the Commission on Teacher Credentialing decides whether to suspend or revoke teaching credentials.
If I read this correctly, prior to this law, teachers accused of violations could opt to plead “no contest” and then not be held accountable for those incidences when decisions are made to revoke their credentials. This law closes that loophole. Good.

Toll roads: Allows local transit agencies to create carpool lanes that can be used by lone motorists willing to pay a toll on stretches of the 15 Freeway in Riverside County and portions of the 10 and 110 freeways in Los Angeles County.
If this end up easing traffic, then I’m all for it. People should have more choices.

Used cars: Allows police officers to impound vehicles of anyone cited for acting as a car dealer without a license.
I don’t know what it entails to obtain a car dealer license.

Veterans: Requires the state Department of Veterans Affairs to develop plans to reach out to National Guard members or veterans returning to California from combat, and assist them in obtaining a screening for post-traumatic stress disorder and traumatic brain injury. Another law authorizes, after local approval, veterans whose vehicles display one of a number of special-recognition license plates to park free in metered spaces.
I profess to having limited knowledge regarding the prevalence of PTSD among National Guard veterans. My reading is that this law goes beyond just rendering the standard care to veterans, but instead pushes the limit towards hand-holding grown men and women and assisting them in just getting screening. It is already controversial whether or not the label of PTSD is overused as a way to tap into money from the government.

Wave pools: Requires operators of wave pools at amusement parks to increase safety steps, including assignment of lifeguards, provision of life vests and restrictions on children shorter than 42 inches.
All operators of public venues should take responsibility for the reasonable safety of participants. Whether or not these arbitrary guidelines constituted a good balance of safety and individual choice remains to be seen.

Overall, my personal views are founded on a healthy respect for other people’s freedoms and rights. In general if we were to ask if our lives today would be made better by more government control and less individual freedom or less government control and more individual freedom, I think it’s pretty clear where I stand. The balance needs to shift back towards the middle, or our standard living will stop growing or even go backwards, while the standard of living in China and India continue to improve for their people.

If you think your life has already been overrun by an obsession for fertility, you might be interested to know that it can always get worse. Apparently there are people out there who want to get text messages reminding them when to have sex. There is no medical proof that the timing established by this service is even accurate. By the way, I am not endorsing this in any way, shape or form. Reading about it might be good for a laugh, though.

After just one glass of wine the other night, I had a strange dream. It provided the inspiration for this post.

Imagine the journey for a baby as being like a race. The runners begin at the starting point, staring up into the distance at a road that stretches as far as the eye can see. The runners are told that their baby might be waiting for them somewhere up the road. It could be near. It could be far. Or it could be not at all. The runners can make the choice of when they wanted to start up the road, but the longer they waited, the farther away their babies might get moved. So one by one, couples made their decision to start walking up the road. The luckiest couples walked a few hours and came upon their babies right away. They rejoiced, took their babies into their arms, laughed about just how easy it was and left the road to enjoy a brand new life with their child. The rest of the couples congratulated them and continued walking. Some of them had to walk for a long time, but just as they were tiring out and almost giving up hope, they arrived at their babies. They, too, took their babies into their arms and breathed a sigh of relief that they were able to finally reach their goal. They gave thanks and were much more grateful than the first couples, but they realized that they still had it pretty easy. The remaining couples continued walking and walking and still, no baby. Some of them decided that they would remain patient and just keep walking, for as long as it took. Others quit the race and gave up in exhaustion, sadly resigning themselves that they would never be united with their baby. Still others decided in frustration that this was not working, so rather than keep walking, they stopped and rented horses. Now they were galloping along at about five times the speed of the walkers. For about half these couples, this strategy worked and they reached their baby. They realized that had they kept walking, they probably would have eventually reached their baby anyway, but it would have taken years. They were glad they took the horses instead because they were able to get there much sooner and even had time to get back on their horses in the future to go for a second or third baby. However, not all the horse riders met with success. Some of them kept riding and riding and still didn’t see any baby in sight. A few of these gave up, returned the horses (after all, feeding them was getting a bit expensive) and went back to walking. Still others got fired up and decided to look for better alternatives. They found out that they could rent cars. Now, they were roaring down the road at 70 mph and most of them happily reached their babies, but only after covering a huge stretch of distance. Of course, there were still some couples who had walked until they had blisters on their feet, rode horses until their butts ached and drove and drove until they could no longer afford the car rental and still, never reached their baby. Fortunately, not too many people fell into this category. The irony of it was that some of these couples could have reached their baby, if only they had decided to drive cars a little bit sooner. But by the time they decided, it was too late.

In reality, the pursuit of a baby is a lot like this silly story. Trying to get pregnant naturally is like walking. Doing low tech treatment, such as IUI’s and fertility medications is like riding a fast horse. Doing high tech treatment such as IVF, is like driving an even faster car. Back in ancient times, everybody walked. If they couldn’t reach their destination by walking, then they were out of luck. Then, as civilization advanced, some people could afford horses and were able to get where they wanted much faster. As the years have passed, in countries like the US, people now drive cars everywhere. True, just as there are still some underprivileged countries where cars are but a wishful luxury, for some people in the US, infertility treatment, especially IVF, is out of reach. Over the years, the effectiveness of IVF has skyrocketed and the prices have come down well ahead of inflation, but it still all comes down to a choice of where to spend your earnings. So. Do you keep walking? Do you try getting on a horse for a few months? Or do you go all out and start driving?