Post from IF board: Mind if I ask you MOMs a question?

Manada · June 2013

I have already put in a call to a midwife friend seeking her professional opinion, but I am curious to know what you parents of multiples may in with as well - so hope you won't mind me asking this on your board.

My partner and I both have infertility issues. We are now planning an IVF cycle in the fall to retrieve her eggs and do a fresh transfer to her body (hopefully with some to freeze as well). Today we just had our pre-plan appointment with our RE to discuss the plan going forward, as well as the results of my partner's LAP surgery last week and her tube removal during that surgery.

In that meeting our RE strongly advocated for a Single Embryo Transfer only, and really discouraged any suggestion that we might consider transferring two blasts (if we are lucky enough to get them). My partner has a tendency to agree with the doc, because she is afraid of twin-pregnancies being high-risk.

Me, I am more aware that our IVF cycle will completely drain out finances & savings - so much so that a frozen embryo transfer will be out of reach for a long time if our fresh transfer fails. We have also been through so much heartache in the fertility process so far. I have worked with midwives in the past and have seen many healthy twin pregnancies & births come through the doors --- and I know that's really influencing where I'm coming from. For me, I am feeling more comfortable in potentially getting twins if we're also raising our chances to get a BFP on our IVF cycle.

So my question for you Parents of Multiples --- looking back, what would you do in our position? You have the knowledge and experience that we can't speak from here, and I am quite interested in anything you may advise that we haven't thought of.

Thanks.

(oh - and background - while Midwives won't normally do twin pregnancies in our area, because my partner and I are of a "marginalized population" (and we have midwife friends) we expect that if we were to get pregnant with twins our prenatal care and birth would be shared by a registered midwife and a high-risk OB at a hospital.

CaliCarly77 · June 2013

I am only 7 weeks in and I didn't do IVF, but here are my initial thoughts. The risks are multiplied by 3, instead of just by two, for so many things. You could also need to be put on bed rest way early on, and your babies are at risk of so many things, including low birth weights and NICU time, which would quickly out-cost the savings with the rounds of IVF. I am thankful for this gift from God but I am pretty scared to be going down this road, and am mourning the loss of having the opportunity to enjoy a singleton pregnancy. My excitement and enthusiasm for 1 baby on board was thrown out the window and replaced by fear, anxiety and apprehension with 2 on board. I am sure I will feel better after we pass into the safe zone (which I believe is 20 weeks for twins, not 12 like a singleton) but there are so many dangers along the way.

So if I had the choice and was doing IVF, I would transfer just 1. You never know, IVF embryos have a higher propensity of splitting, so you could end up with two after all.

Missa_g · June 2013

A lot of things would factor into my decision. For me personally, with my history, I would only transfer one.

Things to consider would be : Finances and insurance coverage if bed rest, long hospital stays, and NICU time are required, is there any history of procedures that might preclude mom to PTL or IC, and general health of mom. If there is anything at all that leads to high risk of PTL or IC I would definitely not transfer multiples.

Good luck!

CNYBride05 · June 2013

My husband and I did IVF. We transferred 1 embryo. I'm 31w pregnant with identical twins. It has been a complicated and scary pregnancy, currently 7w,4d into hospital bed rest. I do grieve the loss of a "normal" pregnancy, but am also so excited to meet my babies sometime in the next 6 weeks.

And the $$ is nothing to scoff at either! Why is your RE recommending transferring only 1? Many people transfer 2 or 3 and end up with a singleton or not pregnant... I wonder what their rationale is for their recommendation.

Twin pregnancies do not have to be high risk or overly complicated, but you do take that risk. However, you take that risk when you (or she) gets pregnant.

Good luck with your decision!

caden · June 2013

my background. 3 IVF cycles. 1) BFN (2 transferred), 2) c/p (2 transferred), 3) twins (3 transferred). Dx of MFI

Am I reading your siggie correctly that your partner has DOR/POF? Or is it you that has the dx? If it's your partner, I think it's very odd for your RE to lean towards a SET, especially now when you haven't started the cycle and have no idea how many embryos there will be, or what quality. I had 2 REs and both based the decision on how many I should transfer on my age, quality of embryos, & number of embryos on the day of transfer. We made no final decisions until I was literally laying on the transfer table with a full bladder. I transferred 3 on my last cycle b/c 2 were good quality and the 3rd wasn't, so I figured what the hell. (It actually implanted but was a vanishing triplet.) I don't think the final decision of how many to transfer needs to be made in advance at all. Just come up with various scenarios and discuss with your partner what you'd be comfortable with. If you have a bunch of high quality embryos at day 5, then you could do a SET and have some to freeze. That is the least risky scenario and it's a good one, but it's unlikely with DOR/POF. You might end up with 1 high quality embryo and a few others of lower quality, and then the twin risk won't be as high as if you transferred multiple high quality embryos. I totally understand the feeling of desperation that comes with IVF. The emotional side and the financial side. We had no money either by the end of it. I won't lie, I chose to transfer 3 b/c I thought it was now or never. But really, twins+ are far more expensive than a FET, (I spent 15w on bedrest) so it's still better to be a bit more objective about it and base it on your/her health and the embryos.

Also, have you looked up your RE's stats on sart.org? I looked up the national data on Sart and for DOR the % of couples doing SETs is 4.9%. So in your shoes I'd be asking why your RE feels you should not be doing what 95% of the other couples in your situation are doing, which is probably transferring 2 embryos.

PurpleIris30 · June 2013

I think it's good to thoroughly investigate the risks of twins before being in the transfer room and making an emotional decision to transfer more than one based on fear of it not working, but I also think it's impossible to make the final decision until you know the quality of your embryos.

Important factors are your partner's age, diagnosis, and number of previous IVF failures. Additionally, transferring 5 day blasts versus 3 day embryos also makes a big difference. If your partner has no previous IVF failures, is younger, and you have a good quality blast on Day 5, then I would absolutely, 100% only transfer one. If it's your partner that has DOR, then you'll have to evaluate the number of embryos and their quality -- she can certainly make good blasts, but perhaps just not as many.

A twin pregnancy (or more) is absolutely no joke. Sure, everything can go fine, but you are higher risk (both for the mother and all the babies). I've been on the IF boards for enough years to have seen all too many situations where things have not gone well. At my clinic (and this is true of the good clinics with high success rates and high implantation rates), transferring more than one doesn't increase your chance of success, it just increases your chance of multiples. The ideal situation is to have babies one at a time, and a FET down the road doesn't cost that much in the grand scheme of things.

As for my story, we had one good blast on Day 5, we transferred one (at our RE's recommendation, and due to the limited access to specialist health care for twin pregnancies in our area), and we were shocked to find out at our first ultrasound that it had split into identical twins. I am so thankful we didn't transfer more than one, have them both implant, and be facing a triplet pregnancy -- I'm stressed out enough about the risks of a twin pregnancy!

Manada · June 2013

caden:
Am I reading your siggie correctly that your partner has DOR/POF? Or is it you that has the dx?

Sorry - I know it can be unclear, we've had a lot in the past year! I am the one with the DOR/POR dx. I have recently met with another RE to get a second opinion on my own infertility, but so far the agreement between doctors is that my AFC & AMH are low enough, and I was a poor responder to injects, that IVF shouldn't be a priority with my eggs.

My partner was just dx'd with severe, stage 4 endometriosis via LAP surgery. The doctor went in last week to treat a hydrosalpinx and ended up removing both of her fallopian tubes because the adhesions were so bad. That said, my partner has a very high AMH and AFC, so there is a better chance that we will get more eggs from her, quality will depend on how the Endo affects it all....

We're also in Canada so we are 100% OOP for IVF treatment and FETs, but we have the advantage of health care coverage for pregnancy and any children that are born.

JodiAriel · June 2013

I didn't do IVF my girls are from IUI but I am the proof that twin pregnancies can be uneventful. I was never on bedrest, I only gained 17 lbs, I carried my girls to 40 weeks (actually had to be induced to get them out) and I worked in a medical office until 35 weeks (when I was just too big to walk around all day). Twin pregnancy does not automatically=high risk.

octbride1234 · June 2013

For me my biggest issue was the "quality" of my eggs due to stage four endometrosis so for us we transferred two at a time. Other things that we took into consideration was that we were determined to do what was necessary to try and have a family, my age at the time I was in my early 30s and the fact that if I had any chance of getting pregnant it would never be on my own, it would be through IVF. I had several failed attempts but after having my tubes removed that next fresh cycle worked for us. We were blessed with healthy twin girls. Fast forward to two years later, I was 35 when we decided we wanted to try again. We decided to transfer just one, each time failing so during our last attempt we transferred the two we had left that were frozen. To our surprise both took and we are now expecting a boy and girl in a month. I guess we were not meant to have "one baby" at a time. Yes there are risks involved with having multiples but I also learned that each pregnancy is so different. My first twin pregnancy I was on strict bed rest from 16 weeks until 34 weeks when they came into this world. This pregnancy I am almost 34 weeks and just told to take it easy and take time to rest. It is a personal decsion and you and your partner really need to talk and make sure you are both on the same page before getting started. The most important thing is to make sure you both know how far you are willing to go and what you are willing to do for a family. I wish you both the best of luck!

E&RMommy · June 2013

For most the delivery rate does not dramatically increase between single transfer vs. transferring two. Check out the SART rates - it's pretty astonishing. My RE fiend just gave a talk about it.

FET is much cheaper than a fresh cycle.

I had so many issues I would not want another twin pregnancy if I could avoid it.

ballygirl · June 2013

I went through 3 IVF cycles and transferred 2 eggs each time. None of them succeeded (we ended up conceiving ID twins naturally after going on Metformin). For us it was a matter of age and egg quality - I am 38, and my embryo quality was ok but not great. My RE generally will tranfer 2 embryos only if the maternal age is over 35.

As far as the pregnancy goes - I'm only halfway through, so I probably shouldn't speak too soon but so far at almost 21 weeks we have had no medical issues. I think its hard to predict how complicated any pregnancy will be - whether single or multiple. While its true that pregnancy with multiples is higher risk, I know 3 other mothers of twins who breezed through their pregnancies. One particular woman had a very difficult first pregnancy with a singleton and delivered at 28 weeks with pre-e, only to conceive twins later and have virtually no complications. So, I think every pregnancy is different, even in the same woman. I think being aware of the risks is important, but in the end, many many women give birth to very healthy twins every year. Good luck in your decision and your IVF!

SkyBee · June 2013

MrsLee04:
I understand where you are coming from as far as the money and the heartache goes with IF and IVF. You want the "most bang for your buck." But if the RE is pushing single embryo transfer, and your partner wants to go in that direction, I think you should respect that. I know I wouldn't have wanted my DH telling me how many babies I should carry, even if I wasn't comfortable with it.

this exactly

SV917 · June 2013

I'm 19 weeks pregnant with twins after transferring 2 embryos. I just spent the last day of our vacation at two different hospitals. It's my first pregnancy, so maybe I would be a nervous mess with one, but I would have seriously rethought a two embryo transfer if I knew it would be so stressful.

themarquis0 · June 2013

Warning - this is not a story of a happy, healthy twin pregnancy -- don't read on if it might be upsetting (esp. for those of you reading who are currently pregnant with twins)

I do not have multiples (though I do have some relevant experience as you'll see), but I recognize you from the LGBT board so I thought I might weigh in.

My partner and I currently have a healthy, perfect 3 month old baby girl. However, our first pregnancy ended tragically. We conceived twins (no meds or IVF, just 'good luck', I guess) and in the beginning everything seemed okay, though we were terrified. We ended up losing both babies in the second trimester. The first baby (not sure if he/she was a boy or girl) was a genetic fluke (a birth defect in which the bladder/urinary tract did not form correctly). The second baby -- long story -- ended up being born very prematurely four weeks later due to preterm labor. She was too small to survive. Autopsy revealed that she was perfectly healthy but died because her twin's placenta had developed a large blood clot (much more common in multiple placentation), causing issues in the uterus that resulted in infection and preterm labor. In other words, our baby Alice died BECAUSE she was a twin.

I hate being the scary anti-twin lady but it's important that you have all the facts to make your decision. Twin pregnancies *are* absolutely, inherantly high risk. Statistically, you are much more likely to lose one or both or for one or both to suffer severe disabilities due to premature birth. Many, many people have healthy twin pregnancies. But many, many people don't. Anecdotes of healthy wonderful full-term twin pregnancies are worthless -- you need to look at the numbers, at the facts.

On top of the numbers, the kinds of losses (late loss, stillbirth) that are common in multiples pregnancies can be particularly devastating to families. I simply cannot describe to you what it is like to lose a child close to or after viability, what it is like to labor and deliver and hold a baby that cannot survive -- it is not something anyone should have to endure.

All of this being said (I know, it's all horrible) you have a tough decision. If what you are saying is that you may lose your chance at starting a family if you don't implant more than one, then this is a really, really tough decision. I don't know in this case that there is a right or a wrong decision. If it is more of a matter of financial comfort or desired timing/impatience, then I would strongly advise you against tipping the odds in favor of multiples. Definitely do your research very carefully. I have seen some studies (you will need to confirm and do the research yourself/ask your RE) that indicate that SETs are as likely/more likely to result in a live baby as multiple transfers (while of course decreasing the risk of multiples). If this is the case (and I don't know if the study population was selected in some way or not representative of the general IVF population) then I don't see why there would be any reason not to do a SET.

Two*True · June 2013

I've had a singleton pregnancy and now the twin pregnancy. If I had things to do over again, I would not have taken clomid the second time. For me though the decision not to take clomid and increase the risk of multiples is more about money, lifestyle, and my relationship.

I've had a very easy twin pregnancy. I'm 36wks along and have had no issues so far. That said, this multiple pregnancy thing is a ***! It's so much different than my singleton pregnancy. If I had this knowledge going into things, and DW was the one pushing to transfer two (or take clomid in our case) I would stand my ground and not do it.

I understand where you are coming from in regards to money and wanting things to work (hell, that's why I DID take clomid) but if you both aren't 100% comfortable with transfering two, don't do it.

Good luck with a tough decision!

MyPlus5 · June 2013

We went through IVF and transferred 2. We frequently say that we would never have made that decision if we would have researched it more. Hands down, we would have only transferred one. Multiples are extremely common with IVF, why risk the babies health, the mothers health, finances, relationships, etc? This is the hardest thing we have done in our lives and they aren't even here yet. I know once they get here and are healthy (we are still praying for this), I'm certain we will enjoy them both to pieces... it's just a h&lluva path to take.

caden · June 2013

Manada:
caden:
Am I reading your siggie correctly that your partner has DOR/POF? Or is it you that has the dx?
 Sorry - I know it can be unclear, we've had a lot in the past year!   I am the one with the DOR/POR dx.   I have recently met with another RE to get a second opinion on my own infertility, but so far the agreement between doctors is that my AFC & AMH are low enough, and I was a poor responder to injects, that IVF shouldn't be a priority with my eggs.
My partner was just dx'd with severe, stage 4 endometriosis via LAP surgery.  The doctor went in last week to treat a hydrosalpinx and ended up removing both of her fallopian tubes because the adhesions were so bad.   That said, my partner has a very high AMH and AFC, so there is a better chance that we will get more eggs from her, quality will depend on how the Endo affects it all....
 
We're also in Canada so we are 100% OOP for IVF treatment and FETs, but we have the advantage of health care coverage for pregnancy and any children that are born.

Thanks for updating. I take back what I said then about finding it odd that your RE would recommend transferring 1. I still think it's best to wait until you know what your embryos are like before making a final decision, but it's a good idea to consider a SET, esp if you end up with multiple high quality embryos. like a pp said 2 embryos may not up your chances for a take home baby. GL to you. :

macchiatto · June 2013

That's a tough one. I had a fairly complication-free, full-term twin pregnancy, but I still would want my odds of multiples as low as possible. There are just too many risks, even for healthy women. One of my twins did turn out to have a bunch of developmental issues (not necessarily related to being a twin, but it does put kids at such higher risk of so many problems and conditions) and that makes me even less likely to want to risk anything. I can understand the financial aspect that does make it a tougher call but for me personally, I would go with single embryo transfer.

Also, just curious; why does being a marginalized population affect who you see for prenatal care?

NantucketSunset · June 2013

All of the pps have given you good advice. I'll just add regarding your financial concerns, keep in mind frozen transfers are *much* less expensive than fresh cycles. At our clinic it was something like $3k vs. $12k (incl meds). And frozen transfers are so much easier on the patient than fresh cycles. Multiples pregnancies can have many complications and involve months of bedrest. Even with disability insurance (I'm speaking from a US perspective) it can hit your finances.

Also, I know it's hard because you both want to think of everything as a joint and equal decision, and certainly ideally it would be as you were just as willing to be the one to do IVF, but in the end it is your partner who will go through the IVF procedures and face the potential physical and mental ordeal of bedrest etc. I have the most supportive husband in the world and we made all of our IVF decisions together, but he always recognized that in the end I was the one that had to go through the procedures and the pregnancy and I knew that if I ever disagreed he would defer to my wishes, no questions. I think it's in your best interest to find out what she wants to do and support it. Obviously get all of the information you can and consider it objectively, but you don't want to talk her into something she is not comfortable with. IVF is stressful enough.

jessican08 · June 2013

You've already gotten a lot of good advice. DH and I decided to let our RE make the recommendation as to whether we'd transfer 1 or 2 on the day of transfer depending on the quality of our blasts. While I had great #s at retrieval, by our 5dt we only had a few embies left and none were great quality embies. We decided to transfer two back and both stuck (none of the others made it to freeze). Our RE was surprised I was PG at all let alone with twins.

I'm not going to lie, I was scared s*&tless my whole PG of losing one or both of the babies because I've been around the boards long enough to know too many wonderful ladies who've lost their twins or triplets. I'm very thankful for my twins and wouldn't change things for the world but I would've liked to have enjoyed my PG a bit more.

I had constant contractions from 15w on that landed me in L&D several times. Luckily I never went into PTL and delivered two healthy babies at 38w2d.

I know one of the other posters said twins doesn't always equal high risk but that's not an entirely true statement. A PG involving multiples is a high risk PG (and should be treated as one) - the fact that you are PG with more than one baby means that you are at a higher risk of complications - that's a fact. It's not a guarantee that you'll have complications, you're just more likely to than someone who's PG with a singleton.

GL in your decision! I hope everything works out for you!

macchiatto · June 2013

jessican08:
I had constant contractions from 15w on that landed me in L&D several times. Luckily I never went into PTL and delivered two healthy babies at 38w2d.
I know one of the other posters said twins doesn't always equal high risk but that's not an entirely true statement. A PG involving multiples is a high risk PG (and should be treated as one) - the fact that you are PG with more than one baby means that you are at a higher risk of complications - that's a fact. It's not a guarantee that you'll have complications, you're just more likely to than someone who's PG with a singleton.
GL in your decision! I hope everything works out for you!

And I agree with this. Complications, preterm labor, etc., may or may not happen to an individual expectant MoM and her babies, but the risks of many things are higher for both mom and babies in multiples pregnancies.

KateC9999 · June 2013

I wouldn't do anything different, because it resulted in the birth of my healthy b/g twins. I had 3 embryos transferred and they all took. Then one of them split, so I was pregnant with quads. We chose selective reduction of two of the embryos. If you think IVF is emotionally painful, imagine willfully choosing to end the beginning of the life you've hoped for for so long. It was the right choice, my pregnancy was difficult and my daughter wouldn't have survived the triplet pregnancy, never mind a quad one. But my heart is broken over the other babies, and I have to live with that on my conscience.

Please discuss what you will do in the event of high multiples if you transfer more than one embryo. Good luck, and I'll be keeping you in my prayers.

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