Tedious Reproductive Update: Part Two.
Sorry for the two-part post, but the recounting of my appointment got longer than expected and I simply could not subject my fine readers to such a thing all in one sitting. Someone may make the point that if they are so tedious, perhaps my reproductive updates are best kept to myself, but I would have that person briskly drawn and quartered before clearing my virtual throat to continue.
Ahrrmhphrm.
So. Last Wednesday, Dr. Doctor, Scott, and I embarked on the obligatory discussion of the particulars of our upcoming IVF cycle. There was a lot of ground to cover—who gets any remaining embryos if I die, if Scott dies, if we both die, or if Scott leaves me for one of his nubile students; whether to use ICSI or Assisted Hatching; and just how overstimulated will they let me get before they call the whole thing off?
Two particularly notable things came out of our conversation:
–I will be seeing a hematologist to discuss heparin therapy for my next pregnancy, because upon further perusal of my test results, I noticed a borderline activated protein C resistance ratio (which can indicate clotting problems).
–We will be transferring two embryos on day three.
This last item represents a rather stark departure from the plan made when Scott and I first contemplated IVF, in January. Our original intent had been to transfer one day five blastocyst. Neither of us are especially enamored of the idea of twins (me because of the high-risk pregnancy and potential overwhelm of caring for two infants, Scott because he doesn’t want them to have a “creepy twin language”–obviously his priorities are in excellent order), and this seemed like the sensible thing to do. Taking our embryos to blast would enable us to choose the very best one, and ensure a reasonable chance of pregnancy. If it didn’t work, well, we’d just try again, as we planned on purchasing the shared risk program that includes three fresh cycles and all associated frozen embryo transfers.
As it happens, the things we thought we would do in a potential IVF cycle changed rather dramatically when the cycle stopped being hypothetical. The first thing to go was the shared risk program. After discussion with someone more skilled at financial management than I (which, come to think of it, could be anyone) it became obvious that this particular shared risk program wasn’t much of a deal, especially if we aren’t sure that we would stay with our current clinic for subsequent cycles. I’m not going to go into all of the financial particulars because I have a long day ahead of me and I need to stay awake for the rest of it, but suffice it to say we have enough insurance coverage not to go into debt for this cycle, but if our first attempt fails it will be quite a while before we can afford another fresh IVF.
IVF didn’t seem particularly intimidating from far away, but as it comes closer I’ve begun to panic ever so slightly, paying particular attention to my bizarre fear that the drug side effects will unhinge me and Scott will be forced to keep me in the attic all Bertha-like. IVF is a grueling process, involving time off from work and massive emotional and physical stress. Combine my nerves with the financial burden, and suddenly the pressure of this cycle seems enormous. From the far-away vantage point of January, it was easy to tell myself that the first round is diagnostic, but now that I’m within two weeks of my inaugural Lupron shot, I am consumed by a fervent, useless wish for first time success. I feel embarrassed even typing that, but there you are.
Scott and I firmly believe that a singleton birth is the most desirable outcome of an IVF cycle. If we end up with twins we wouldn’t leave one on the side of a mountain or dump it in the river with a rock around it’s middle, but we would much prefer to have our children one at a time, thank you very much. There is a perception that infertiles who get pregnant should be properly grateful, regardless of the circumstances, but I don’t think it is selfish to want to spare my children an increased risk of cerebal palsy and other disabilities. 50% of twins are born prematurely, and while the idea of completing your family with one cycle is tempting, caring for even two healthy babies at once seems horribly difficult.
But, wheedles the other half of my brain, after this cycle we will have no insurance coverage for future attempts. Can we really pin all our hopes on a single blastocyst? My pregnancy track record is not good—having had three miscarriages, it is hard to believe we will end up with two live babies. Besides, twins have their good points: one can mix me a drink while the other makes me a sandwich! One can wash while the other dries!
Unfortunately, the idea of transferring two blastocysts wasn’t much more enticing than transferring only one. There would be a much higher success rate, but in my age category, it is my understanding that we would have a 50% chance of twins. That is awfully high. Our fears of NICU stays and the increased risk for gestational diabetes and post-partum depression make it difficult for us to knowingly take such a gamble.
Reading the above six paragraphs should make it abundantly clear why insurance coverage for IVF is so important. Decisions regarding acceptable risk in infertility treatment will always be difficult, but they should not be driven by finances. Period.
For me and Scott, the decision got suddenly much easier when Dr. Doctor suggested we do a three-day transfer. I was shocked, to say the least. The advantages of day five (blastocyst) transfer have been trumpeted far and wide, and one gets the sense that nobody who is anybody transfers embryos anymore. However my clinic’s embryologist is excellent—award-winning, even—and apparently he is starting to back away from blastocysts.
Dr. Doctor highly recommended we transfer our two best day three embryos, and for once in my life, I am going to trust that someone may know more about something than I do. Transferring two embryos on day three gives us a 50% chance of pregnancy with a 30% chance of twins, numbers with which we are much more comfortable. So that is what we will do.
The fact that the decision is made doesn’t mean I will stop endlessly questioning it, obviously. Fish gotta swim, birds gotta fly, etc.
15 Comments
I sometimes question my own clinic’s decisions and expertise only because there are too many blogs to fuddle my head with stats and opinions, but I have to admit I love your embryologist.
You see, my clinic has also backed away from blasts. More studies show that embryos do better in the body, not in a dish. So if the embryos are good at 3 days, put them back. They’ll just be better blasts at 5 days in the old uterus then languishing in a plastic dish of goo.
However, knowing the negative aspects of twins, I still yearn for that “baby lottery.” *sigh*
In practice, it’s so different, isn’t it?
Your plan is actually exactly what we did for our (successful!) first cycle–we’d thought we’d go to blast, but we produced fewer eggs & embryos (9 and 5, respectively), so that all we had left on day three were two fairly good-looking embryos and several sketchy ones. They did AH but not ICSI. It did briefly result in a twin pregnancy, but ended up as a singleton. I also did Heparin + baby aspirin for the first 12 weeks of pregnancy, with just baby aspirin for the remainder–so let me know if you need tips/tricks!
Hoping you get everything you hope for on this first go!
Wow– I don’t envy you these hard decisions at all. I just wanted to comment that as a mother of twins, I often encounter people who think twins are automatically cute, without considering the difficulties of the pregnancy, the prematureness, etc.
Mine are healthy 8 year olds, and I am very blessed and I wouldn’t trade them for a ginormous piece of chocolate, but you’re right to consider all the NICU time, juggling babies, etc, because it is hard.
In the end, I guess we all get what we can handle and it turns out ok.
(Even though one twin has learned about humping pillows from his older brother which is a different issue ENTIRELY.)
But you are correct: One can wash, the other can dry. One can peel shrimp, the other can devein it. The possibilities are endless.
I think a lot of places are doing day 3 now. The best place in MA doesn’t do any blasts anymore. They don’t see an improvement and most people don’t get to blast anyway. Good luck.
WOW, Lots of decisions .. Sounds like you are doing very well and Dr Doctor and scott are taking good care of you.
I love the Jane Eyre reference!
Sounds like you’ve made an absolute ton of decisions this week. You’re right IVF should never be driven by finances but it so often is. I’m feeling bitter about that particular subject right now, so perhaps I’m being a little more vehemnt than is proper when I say how much I loathe my respresentative and senators for not standing up for this very thing. Cowardly bastards.
Good luck with the IVF. I hope it only takes once, too. It would be so lovely to see this work out for you.
Yep, that’s why you should ask your representative to co sponsor The Family Building Act of 2007 HR 2892! This was helped along by a friend of mine, so if you have any questions, let me know.
And yes, insurance sucks when you’re miscarrying too - I could have had a d&c ages ago,but didn’t want to fork out the cash. Bastards.
Like the plan and don’t worry - ivf is a piece of cake! he he. (as long as Scott knows in advance what the meds might do, and he has life insurance).
Akeeyu at “herveryown” was just writing an entry similar. And really, I don’t care what people have to say about infertility patients being ‘grateful’ for anything, even multiples. I’m naturally (which I am grateful for) pregnant with one, and I was NOT wanting twins…for all of the risks of GD, premie birth, etc. plus the financial and just general risks. However, my husband and I knew we’d be thrilled with whatever we saw on the ultrasound screen, as long as it or they were healthy.
Anyway, the 50%/30% sounds like the healthiest, best route to take…and I will be hoping and praying for the best for you!
actually, “creepy twin language” is one of the best arguments “against” (that’s not the word i really want but cannot think of a better one as it is not even 9am) twins that i’ve heard. risk to the mother can be managed, but creepy twin language? that’s out of your hands. :)
best of luck with this cycle…it sounds like you have a good plan and are in good hands.
i would transfer one. i just read an article about how dangerous twin births can be. Although, i bet you i change my mind when we do IVF. You can leave nasty messages on my blog like “YOU’RE THE GIRL WHO MADE ME ONLY HAVE ONE BABY” (ok, you’d probably write something a little more creative).
i have to add…i HATE to say this really. promise me you won’t hate me. promise me. serously, i’m not joking?
ok. so i have come to believe (and my RE agrees) that clotting creates serious implantation issues and thus, that heparin must be begun in the 2ww. In fact, my RE is theorizing at the moment that that is what is causing all of my chemical pregnancies (at least 3). There are also studies that show reduced fertility rates with people with MTHFR (what i have and what causes my clotting), untreated (i.e. no heparin), and lowered IVF success rates. I say all this to say, that you might want to explore this clotting thing further. A lot of RE’s don’t take it seriously, and there is a lot of data out there that they should. (although i hope you don’t need it in the 2ww! b/c it sucks.)
good luck.
At one hormone-drenched fourth of July barbeque at the in-laws, I saved my husband the trouble and locked MYSELF in the attic. I did make him bring me food. (Which I told him was the WRONG FOOD, didn’t he know me at all, why was everyone in the world against me?)
But I’m sure you’ll remain perfectly sane.
Wow!!! Two weeks to lupron!?!?! I’m just so excited for you. You know, not so much for the injection part as for the real deal IVF cycle with a 50% chance of pregnancy (not too shabby considering what we usually see with IUI or clomid or letrozole or other such nonsense).
Ok, enough freaking out from me. I’ll just chime in with the rest that my RE and embryologist also recommended a day 3 transfer of the best two embryos with the understanding that if the embryos looked terrible, we’d consider transferring 3. Like Jen, we did AH but no ICSI. Be aware that AH does somewhat increase the risk of identical twins, but I think they take that into account when calculating the risk of twins. We transferred two 8-cell (I think) embryos, one of which looked very good and the other of which just looked good). We ended up with a healthy singleton pregnancy on our first IVF cycle.
I’m sorry finances are weighing on your decisions, but I’m glad you’ve found a plan you’re comfortable with, more or less. Good luck!
I don’t really have anything useful to say (except DAMN STRAIGHT fertility treatment ought to be covered so we don’t have to make these huge decisions based on $$. also, hello insurance company, you won’t fork over the cash for us to do multiple IVF cycles, but would rather pay the much greater costs of hospitalization for mother, NICU costs for premature multiples, possibly lifetime of followup care…way to think ahead)…but I can’t believe your IVF is coming up so soon! hoping for only the best results for you.
Just found your blog while googling, um, “hostess dress.”
Must ask Donald and David if they have a creepy twin language. The most I’ve noticed is that they have New-Yorker-ish accents despite having been raised in Newfoundland, due to a transplanted American speech therapist during their childhood :)