Thursday, November 20, 2008

How many babies should you make at once?

There have been quite a few ETs this week and lots of personal rationalizations for the question "how many to transfer?" floating around. And it brought up my own thoughts about it and how crazy my own transfer was.

As any reader of mine knows, I'm ~very~ against transferring more embryos / IUI with more follicles than you are willing to carry. I am personally against using selective reduction to "reduce" babies that were deemed as "extra" when there was a chance all along at too many babies. On the opposite side, I'm not against selective reduction at all when it was more of an accidental situation like natural triplets/quads/etc. I also completely understand it's necessary to go through selective reduction when there are too many babies to safely carry (for mother or babies) but I will shake my head in disgust if the woman got herself there in the first place. I think these situations could be completely avoided if selfishness is simply put aside and if there are too many follicles to safely go forward with a cycle, take a break so you aren't forced to kill "reduce" any of the babies you may make. Personally, I would rather take more time to get pregnant and even chance getting pregnant at all, than to have to get rid of reduce "extras".

Around the blogosphere lately, I have been seeing the opposite trend with IVF - women going for single embryo transfers or maxing out at two. Unfortunately, I've also seen IUIs and timed intercourse going forward with 5, 6, 7 mature follicles which simply astounds me. My RE would cancel if more than 3 (2 in some cases) follicles were present. But I am betting many REs are cancelling and the woman just plows ahead on her own. Ugh.

Anywho, back to my point. I see these women transferring just one or two and having to really convince themselves and their readers of their choices. How crazy! They are doing such a good thing for themselves and for the health of their maybe-babies! Has the world really gone so multiple crazy that women and their family/friends are actually disappointed if they don't get multiples? Hey, twins are great and if you are willing to carry and take care of twin newborns, all the power to you. But if you aren't excited over the aspect of twins, it's ~okay~ to try for a singleton.

Now, here is where I will admit my complete and total hypocrisy. I went into ET with the "no more than two" frame of mind. And I later walked out with ~four~ embryos. Yes, FOUR. That is more than I could have carried. That is more than I could have taken care of. Yet, I approved the transfer.

Remember when I said no one should have to rationalize their personal decision? My hypocrisy pretty much forces me to it.

I had 2 Grade As (8 & 7 celled) and 2 Grade Bs (6 and 5 celled).

My RE pretty much poo-pooed my idea of putting back two. My lining was ~not~ good, remember? It was only 7mm and they wanted to just cancel me, but I pushed ahead. Plus my age (36) decreased my chances. So now it was between 3 and 4 embryos.

With three embryos, he gave me a 35% chance at a pregnancy. With all four, a 40% chance for a pregnancy. Of that 40%, we had a 79% chance at a singleton, 15% of twins, under 5% for triplets and less than 1% chance for quads. So doing the math, with transferring all four, I had a 40% of a singleton, 6% chance of twins, 2% chance for triplets and .4% chance at quads.

I'm a science believer. I'm a numbers believer. I'm not into fate or some bigger plan. I believe in MATH. So I took in those stats and that's how I made my decision. I didn't see a big difference between the 3 and 4 embryos in the multiples option and didn't want to let that little 5 celled one to die alone in a petri dish, so we included him too. (Funny that we all think he's the one who's sitting very uncomfortably in my giant belly right now, eh?)

The statistics remained though. I had a 60% chance of a BFN. A 31.6% chance of a singleton. A 6% chance for twins. 2% chance for triplets. A 0.4% chance at quads. Could I carry twins? Certainly. Could I carry triplets or quads? I don't know, probably not. And I can pretty much tell you I couldn't care for that many financially.

What would I have done if I fell into that 2.4% chance? Good lord, I have no idea. I felt like I would have to cross that bridge if I got there. But I was the first to admit my hypocrisy to my very strong feelings about not using selective reduction as a tool for better odds at pregnancy. I can tell you I would never transfer 8 embryos or some high number like that, but still, four was such a risk and I don't know how I would have lived with myself if I created 4 lives. I can say I am happy I did it ~now~, only because I know I got one out of the deal. But I still will admit how wrong I could have been.


Nikki said...

I think my decision would also factor in how many total embryos there are, and how many would be left over / frozen.

If I had 3, I would probably transfer all three (although knowing what we know about my uterus now - triplets would be impossible to carry). I would do that because if I transferred 2, that would leave 1 to freeze. Who knows if it would survive thaw later?

If I had more, I would probably transfer 2 and freeze the rest.

(Realistically though - after PGD, I am on my knees thanking God if we have even 1 normal embryo on ET day!!)

However - I agree with you on the IUI point. My RE would cancel an IUI if there were more than 2-3 follicles. But there seem to be some pretty aggressive REs out there that are hyperstimulating women almost to IVF levels! All about success rates huh?

chicklet said...

I was reading and reading and like, "Uh dood, you transferred 4?", but then you owned up to it, explained it, and well the math makes sense. I still find the concept of 4 terrifying and don't know if I could've done what you did (even WITH the math), but for you thankfully it worked out and there were no horrible choices to make.

Kymberli said...

Same thoughts, same thoughts, same thoughts.

The issue of S/R is a huge one in surrogacy. It is one of the main points, one of the FIRST points on which IPs and surrogates should agree. I've seen a few surrogacy situations get really nasty in which S/R became an issue during the pregnancy and the IPs and surrogate had differing opinions. It's a potential train wreck waiting to happen when a surrogate doesn't agree to S/R under any circumstance and matches with IPs who would reduce in the event of HOM (medically necessary or not). They go forward with the surrogacy thinking that likelihood of them ever being in that situation is slim, then end up getting pregnant with triplets. Bad, bad situation when the parties have differing opinions on S/R.

All of that said, I feel the same way you do about S/R. Exactly the same way. The adage in the surro-community is also "never transfer more than you want to carry". I always told myself no more than 2 fresh or 3 frozen, depending on embryo quality. For my very first transfer back in 2004, four ended up being transferred. There were four mediocre 3-dayers (7-celled, 6-celled, and two 4-celled) and the RE suggested transferring all 4 and gave us 35% chance of just one taking. We ended up with a chemical at the end of a brutal 2ww in which I had three rounds of positives that went negative.

So yeah - I've done the hypocrite thing and often wonder "what if?" I mean, with that transfer I got the first positive at 3dp3dt (which later the RE said was impossible but I know what the hell I saw on FIVE tests of different brands). I was scared shitless that all of them stuck.

nancy said...

Kym - Yup, obviously same thing here - FOUR 3-dayers transferred. It just goes to show how crazy emotions can overtake you at ET time. From my own experience, I can take my evil looks down a notch to all those women who put back too much because I ~know~ how strong the feeling of moving foward is. Although, had 4 stuck, shit. I may of had to punch myself in the face. I guarantee I'd of hated myself for the rest of my life.

Chicklet. dood. Yup, math made sense but it was still such a STUPID decision I made. So stupid.

jenn said...

I was triggered with one super good follie & one that could have possibly caught up. I was scared of twins, but we would have dealt with it. Now- had that other follie been super mature also- we may have done things differently. And that's with 2. We can't really afford 2 at once- not now. It would have changed our lives so much more drastically than having a singleton will. And since my numbers were on the higher side of normal before the first u/s- the thought did cross my mind.
I am happy we did what we did & that we have one little girl in there, but I know a little taste of that risk of going forward despite the fear. I can't judge anyone else's decisions in deciding on transferring 3-4.
But what I can say is that the arguement I hear for mandatory IF coverage is that paying for women to be able to transfer 1-2 embryos at a time would save the entire system a lot of money in the long run. We wouldn't feel as pressured to 'go for broke' and HOM would not be as prevalent as they are today. Giving everyone a better chance at happy healthy pregnancies & babies. (I know- politics, but thought I'd get it off my chest anyway!)

and yes- first time. very embarrassing, I can only imagine it will happen again. Damn- I felt broken, lol!

Mermaid said...

You hit the nail on the head - transfer time makes you crazy! Before transfer time, I would have scoffed at putting more than two back. At transfer time, I was bummed because we "only" put two back.

I could never selectively reduce. I also know that the doctors are the experts. They have the same goal as I do, so I have to trust them. They said two was best. Two it was. I was fully prepared to carry (and birth) three, if I got that lucky. But, it sickens me to hear of IUI patients who are cancelled b/c of too many follicles but proceed to give it a whirl on their own. That is reckless.

I do think the country has gone multiples-crazy. I blame Discovery Health Channel and TLC for showing endless multiples shows.

Great discussion!

margelina said...

While I really don't know anything about all of this, there is one story I do know.
Check out and read their story. This is a girl I worked with...she transfered 2 embies, and came out with 4 babies. Quads wasn't even an option on their statistics sheet, and yet it happened. Youjujst never, ever know.

The Captain's Wife said...

So this is a response to your response and has NOTHING to do with this post- so feel free to delete after reading...

I LOVE Gary Louris. We have met him on several occasions, even hung out with him one evening at one of the bars after the show.

I don't know what about him gets me going...the big hair? The geeky glasses? The fucking kick ass voice? I just love him so much! Husband knows that if I ever had my "chance" I would SO take it!

Have you listened to any Golden Smog? It is a band that has him, Jeff Tweety (Wilco), Marc Perlman and Craig Johnson (The Jayhawks) and Dan Murphy (Sonic Youth). Different sound than the Jayhawks.

Anonymous said...

I just wanted to say that I was a person who transfered 2 embies & one split so I was pg with triplets. The RE told me there was a 3% chance of that happening & when you have been TTC for 3 years your only goal is a BFP, you don't worry about that 3% chance at all.I was pg with identical twins & a "extra", they could not find a separting membrane between the two indenticals & told me it was very high risk to carry, I am only 5'1 100lbs too, I was frighted by the thought of carring 3 babies at once & as soon as the RE counted 3 babies the next word you hear is SR. I wonderful U/S to see your baby for the first time turns from a exciting event to a scary medical condition. At 12 weeks me & DH decided to reduce the identicals, it was like a bad dream but we did havea beautiful daughter who was born last Christmas Eve. I remeber reading about SR before we did IVF & I thought "that must be a horribe situation to be in, I would NEVER do that" but sometime when you are the one who has to make that choice you see both sides cleary, I is kinda crazt that after TTC for so long RE advise you to "reduce" something that you wanted for so long, a sick twist, but when you use medical to concieve this is what comes with that package. I probably could have carried the triplets to 30 weeks but I also had a 3 year old at the time & I thought about how having tripets who effect her life. I would never tell anyone to transfer more than 2 if they don't want more than 2 babies, I was ready for 2 but 3 was too much. I think people relate SR with someone being too greedy but it can happen even with someone who knows the dangers & only transfers 2 embies. I think about my other 2 everday of my live & I have to live with the "what if's" but I do not regret my decision I made, I just wish I never had to make it at all.

emilythehopeless said...

couldn't agree more.. we only had two left so that's what we transferred. my RE wouldn't let me transfer more than 2 if we had them though.

Io said...

Nancy, does this mean you won't support my decision to try for sextuplets?

Peeveme said...

Hey Nancy,

I am one of those who wrote a post justifying transferring one. Your words sum it up..."Has the world really gone so multiple crazy that women and their family/friends are actually disappointed if they don't get multiples?"....Um....Yes it has.

As usual I am in full agreement with you. Be responsible and do the math.

I see your situation as completely different than mine. You used your own eggs right? You own "old" eggs (just kidding). I used donor eggs which were much higher quality than someone my age (I think we are about the same age). So in this case one makes sense. With my own eggs I put back every single egg that survived to day 3. With the donor I had 8 blasts at day 5. Totally different. My chance of twins was like 40% if I put back two.

Like you, I'd rather have to try longer than risk multiples. The world think multiples are just a little more work and a lot more wonderful than a singleton. They are completely unaware (ignorant) of the risks.

Now if one of mine split then I would deal....but I see that as a totally different situation than someone putting in 2-3 high quality embryos. I guess the key here is: High quality.

And to Anon: I am so sorry. What a horrible situation for you and your DH. I think you made the only "right" decision you could have. I would hate to every be in that position and I realize you did not make decisions that were likely to put you in that situation. I think that's a huge difference. People who take the 3% "risk" (which is not a risk in my opinion...and I have a PH.D in statistics) and people who take the 30% risk...or even 15%.

Cece said...

I had 7 embroyos, and I transfered 2, I'm pregnant with one. I was only 32, and this was our 2nd round of IVF. I don't know what I would have done with a few more years of age and IVF cycles under my belt - I'm guessing I would have played the % game just like you did.

Lisa said...


Posts like this is why I love your blog. You are quick to give your opinion on a subject matter and call people out when they are being stupid/selfish. The great thing is that you are just as quick to call yourself all of those things when you feel you fit the bill.

I completely understand why you made the choice you did during your tranfer. The stats generally don't lie, so you were playing the odds. That is not necessarily a stupid thing to do.

I do agree with you that women undergoing treatment should only be willing to do whatthey are willing to live with. Implanting 6 embryos when you are not willing to have 6 babies is dumb! I look at Jon and Kate + 8. What they did was dumb. If not for the horrible tv show, they would never be able to provide for all those children. I also don't think the kids are better off. Children need to feel special and get some "alone time" with each parent. They cannot provide that for any of their kids.

I have no issue with fertility treatments as long as they are not abused. I conceived my twins naturally mainly because I was meant to have twins (a wonderful gift from my grandmother; she had 2 sets). I would not be able to handle another baby (some days I can't handle the two I have!) I am very happy that I was not blessed with triplets.

Women need to put their emotions aside when it comes to this kind of decision. What seems like the right thing to do at the time, can end up being the worse mistake. Take your situation for example. It all worked out for the best and yet you still admit that you thought what you did was stupid. But, in the heat of the moment, you listened to your heart and not your head.

MrsSpock said...

I agree with you 100%. Yes, I am pro-choice. However, it seems so hypocritical to hope and pray for the flicker of a heartbeat at one time, and then want to take one away at another. That's why I would never transfer more than I could carry. If what happened to Anon happened to me- I don't know what I would do. I do know my fibro becomes so bad with just one baby, that I couldn't dress myself or get into the bath tub on most days of the week, by the time I hit the 3rd tri.

In a few months time, I hope my fibro will be back at baseline and we can start the merry-go-round again. We've already been discussing that multiples, with my body, would be a very bad thing. I may conceive spontaneously, or I may need IVF. If the RE suggests an injectible/IUI, I don't know if I can be comfortable with that. I think I'd rather just do an IVF if I had 6-7 follicles. I make 2-3 follicles on 100 mg Clomid. I think putting back 2 would be our max, with 1 as the preference.

Motel Manager said...

I think this is a tough call. Often, I think that in the US the clinics are really to blame for the higher-order multiples. Sure, after you've been through years of IF and many failures, you are more willing to go with many embryos, and you may even be the one asking/demanding that your RE transfer more. (I'm using "you" in the general sense here, obv.) But the thing is, often more than one variable is being altered each cycle, so you never know when you're upping the number of embryos just when your meds are suddenly exactly right and your lining is at last perfect and all four are going to implant (or whatever).

I would also say that clinics want to keep their success rates up, and it seems to me that they often downplay the fact that ICSIed or AHed embryos have a MUCH higher chance of splitting than other embryos. In the IF blogosphere, we've seen people have an embryo split into three or even four. THAT would be a shocker!

Also, of course, in the US, you add on the financial considerations, and people want the biggest chance of success possible, hence the temptation to transfer more.

I say all of this as someone who was VERY adamant about transferring a limited number of embryos (like one at a time, MAYBE two if I were pressured), so I've spent time thinking about why others might choose to do more when it seems so perilous to my risk-averse eyes. But I was in a very good position -- I had GREAT insurance coverage (so could afford to do more cycles with one or two embryos each); I produced many embryos (making the cheaper FET cycles possible); and my clinic (a) had great success rates and (b) was a leader in elective single embryo transfer research and policies.

Wow, what a novel. I guess what I'm trying to say is that I think it's very complicated, and while selective reduction would be an awfully heartwrenching decision to have to make, I can see how someone would end up there without necessarily having been naive or irresponsible (not that that's what you were calling them).

Elana Kahn said...

I also agree that it's very much a numbers game. I was always going to put back two, which was confirmed by the fact that I was only left with two growing embryos (one of which was a 5 cell grade C the other a 10 cell grade B). I didn't want to freeze "5 cell" for many reasons (might not survive freeze, if it did it was still kinda small for a 1 embryo transfer, etc.) So I went ahead with my original "transfer two and pray" and what do you know, "5 cell" is a perfectly healthy growing fetus. lol So, I get to have twins and I feel good knowing I didn't put my second embryo at risk by freezing. I personally think that's what G-d wanted me to do in the first place. :-)

Christina said...

Although I will probably never be in this situation I would transfer 2. I couldn't deal with the thought of "reducing".

JamieD said...

I have noticed a big push from the CDC and SART for reducing the occurance of multiples in fertility treatments. Now, my RE will only transfer two embryos at a time in IVF. He might could be convinced to transfer more in special situations, but I don't know. We are not to the place of pursuring IVF, but I do remember him telling us this in our consultation.

I understand the risks and consenquences but when you are an infertile and desperate for a child I can see how you would be willing to throw caution to the wind and transfer eight if they would let you. Infertile logic tells me, if I can't get pregnant with one, what are ~really~ the chances I would get pregnant with eight?

This is the first time I have noticed your "I am a hypocrit" tag - I love it!

Anonymous said...

Here eSET is very very common. My clinic won't transfer 2 unless the woman is over 35 or has had prior failed cycles. Clinics pride themselves on low twin rates and you very very rarely hear of HOM here.

Because of my UU my RE mandated SET (we were planning, and went to, blasts). Fresh failed, FET worked. I definitely wanted to avoid twins anyway, so even with a normal uterus I'd have only transfered singles.

Clinics definitely seem to be more commercial in the US.