CD5 - The Deep Under Belly of IVF

Not many people know what IVF is, a lot of people chalk IVF up to being something as simple as insemination, aka, the turkey baster approach.

It is an understatement to say that IVF is more complicated than that. I won't go into the medications, injections, swollen ovaries....I won't even go into the number of ultrasounds, blood pricks, appointments and tests. No, today's topic has been keeping me up the past three nights. Today's topic has me scouring the internet for hours on end, with all the key search words, joining like-minded communities and talking to other women in similar situations. Today's topic, I found out, is not one you'll see frequently across IVF forums, it's one that's often not talked about aloud, especially to others, mainly because "it's so personal".

Well, I've not kept much personal on here, so I'll continue that trend by being very transparent on this topic, even letting my thoughts and eventual decision play itself out in front of your eyes, and so it is.

Today's Topic: How many embryos to transfer back into my uterus.

It wasn't long ago when I started this IVF journey, however it feels as though it's been months and months. I've learned so much in such a short time. Learned about my hormone levels, about the different stages of life, about statistics in my own country and others, learned the stories of dozens of women, learned lessons in the tiny nooks and crannies of other's experiences. When I started this journey, as naive as I was at the time, I had gone in thinking "Of course I'd transfer back two." This was the best chance for pregnancy, right?

Twin Pregnancies
Then it hit me. Twins. Two babies. Two vaginal births for the price of one (if I was lucky, C-section rates skyrocket for twin births). Two breastfeeding munchkins, two car seats, two slings (?), two pairs of everything. Two different diapers to change, two lives to parent and teach and guide....at one time.

The thought is overwhelming. And I've learned on the internet that for an infertile couple like we are, that to admit such a thing is looked down upon. There is a great blanket theory of 'beggars can't be choosers' out there in the IVF community. Basically, you're lucky to get one, getting two is like hitting the jackpot, don't you agree - and if you don't, then what are you trying for?

It's really easy to say "Oh, she might have twins, how cute and what a blessing", and "Oh, did you hear so and so is having twins?" and go on in life and thinking nothing of it. But the truth of it is, is twin pregnancies are often complicated, are often draining on the mother physically, mentally, emotionally (not saying pregnancy in itself wouldn't be that way) but oftentimes doubly so. Twin pregnancies are often considered high-risk, babies often arrive earlier than the 40 weeks and homebirth plans become riskier and uncomfortable for me. I know there are some women out there that can go on to have a low risk twin pregnancy and birth at home with no problem. I don't believe this to be the standard however, and this makes me scared. I don't want the typical hospital birth with medical interventions impeding my ability to experience a wonderful day. But I also don't want a twin birth that I'm not confident in, and find myself surrendering to the medical community for fear of losing my babies or my own life.

Sounds silly? These thoughts are plaguing me. I feel like I'm making this huge gambling decision with God, with life, with whomever or whatever. I feel like I'm making a deal with the devil in some aspects, I feel like there is a lot on the line.

Selective Reduction(SR)
This is a nice way of saying 'abortion'. Basically, if I transferred back two or more embryos, or somehow a single embryo split into two different embryos, I would have the opportunity to "reduce" a triplet to a twin, or a twin to a singleton. First I must say, that I agree with having this choice and ultimately it is the woman's choice. However, because it is a choice, it is a burden. I suppose this topic in IVF could also be considered controversial and 'personal'. A lot of doctors say SRs aren't abortion because abortion ends a pregnancy and SR does not end the pregnancy. I'm sure you can see how this topic would be painful. In the midst of all the excitement and hub bub for being pregnant, a couple now faces the decision on whether or not to rid of one or more beings - facing such heartaches of life at once, like birth and death, and loss, and gain - all of it so painful, so private, so not talked about.

I don't think I could do this. Not from two to one. I don't know at what point I could do it. (I have thoughts swarming my head like "At four, would you?" "What about three?") No answer seems right, and no one should have to make these decisions in life. Not based on morality, or based on religion or based on anything else in life. I can only imagine the painful nature of this decision and pray I will not be a part of it's sticky web. I hope to avoid any and all need to have to face this option. But it's one that's always in the back of my mind.

eSET - Elective single embryo transfer
Something I found in my research is called ESET, elective single embryo transfer. This is where a couple by choice (and sometimes there is no choice because there could only be one good embryo for transfer) chooses to only transfer back one embryo. This is usually done by women under the age of 35 with at least two good embryos (blastocycts at that stage?) to put back, one they can do now "fresh", and one to freeze and thaw out if the first cycle doesn't work, or if they want to try again in the future. The frozen embryo transfers are called (FET).

Of course, by transferring over only one embryo instead of two or three, doesn't one's chance of getting pregnant decrease by a huge amount??? Nah, not by that much.

There are several studies out there on SET and it's success rates. Most studies find the pregnancy rates comparable, but without all the twins and triplets. And did you know that several other countries MANDATE only one blastocyst/embryo transfer for patients under 35 years of age? A lot of the logic I'm sure centers around public health care, and the burden of costs with multiple pregnancies/births - however if the SET policy is that pronounced in other countries, how come we're not hearing about that here in the ole United States of America?

SET seems not to be commonly practiced in the US for a couple reasons. The burden of costs is on the patient, so we Americans like to get our money's worth. Many couples only have one shot or two of getting pregnant else they move on to something else. With only one or two chances of getting this right, SET seems like a foolish gamble. Why screw with your odds? Twins seems like a much better gamble. The more embryos transferred, the higher your pregnancy rates.

A clinic with a 75% pregnancy rate looks GREAT on paper, but if you dig in a little deeper, and find that out of that 75% --- 60% are twins, and 15% are triplets - that's an amazing amount of multiple pregnancies!! Amazing!! And not so amazing if you don't want a multiple pregnancy.

SART gives great information on success rates by clinic in one's area.

The important fact about SET is one needs to consider a cycle being both embryos. The fresh first SET, and then the FET if the first cycle doesn't work. Both the fresh and frozen embryos need to be considered in these success rates. Frozen embryos have less of a chance of survival than fresh embryos but their success rate is still remarkable. If you're spending two embryos up front, is that not the same as spending two, just one at a time?

I've been warned by other IVF women who chose to go the SET route, that doctors in the US are often unsupportive of wanting an SET, are quick to offer deflated pregnancy rates in hopes of encouraging patients to transfer more back. This will be something M and I bring up at our next consultation with Dr. O. I'd like to know his feelings and opinion on the subject, and I'd like to better understand his own eSET experience. From the SART data, his clinic performed 0 in the year 2005. This scares me.

They say in the pregnancy and birthing process that it's good to put your fears out there, in hopes of dispelling them, not giving them power, making them something less than what they are. The IVF process brings a lot of decisions which in turn drive a lot of fear. Never before in such a quick time have I had to make decisions about my own morality, mortality, decisions that will affect myself and my family for the rest of our lives.

I feel like the wind has been taken out of my sails a bit, I'm forgetting what it's like to just simply want to be pregnant, and instead fighting this feeling like pregnancy is a hurdle to jump, an obstacle to conquer, I feel like I'm losing an innocence to myself, and it's hard to describe. Pregnancy, birth and parenthood seem so overwhelming and big right now.

I guess what I'm saying is sometimes it's easy to forget what you're fighting for.