This post was prompted by two things: Another blogger's accounting of her painful response to lupron during a FET, and yet another multiples (triplet that transformed to twin) pregnancy that may just end in the unthinkable
All in all, I am struck by how often doctors just follow a set protocol without being thoughtful about the situation, the patients problem, the patient's comfort, and the long term safety, of both the mother and the child. If the doctors can't think about all these things, then the patient should think about them, because ultimately, they are the ones facing it all.
There are many roads to infertility. All we can do is identify the problem and treat it intelligently. When I say treat it intelligently, I mean choose a path that minimizes the number of injections you have to take, the hormonal overload you face, the number of FETs you have to do and importantly, choose a path that allows single embryo transfers so you do not have to face the higher risks associated with a twin/triplet/quad pregnancy.
Here are some practical examples:
The third thing is a comfortable place to be in: If you have twelve day 3 embryos, you can easily make the decision to grow them further, and most people do. The testing is up to your doctor anyway. On the day of transfer, you have to make the harder decision of transferring one or two. Remember, a day 5 blast has about a 50% chance of implanting.
The fourth choice is the hardest. What if you get only 3 fertilized eggs? Making the decision to wait and grow those in the lab for 5 days, knowing that all of them may arrest at day 3 or 4, and facing the reality of going home empty handed from your IVF is the hardest decision to make. But therein is the gamble. You could transfer all three embryos on day 3, be ecstatic when you have a positive pregnancy test, and 20 odd weeks later, lose two or three babies. It has happened SO many times, and I'm writing this post because I am very, very tired of seeing it happen. Everybody thinks that this could not possibly happen to them, or they choose not to think of it at all when going for embryo transfer, but really, they should. Not all doctors have a single embryo transfer policy, and they should. Because gambling like this is not acceptable.
Despite my preaching, and my knowing all this, I gambled too. I wanted to transfer only one blastocyst at a time, but my doctor froze my embryos in pairs even after I specified that I wanted an elective single embryo transfer. I could have then done two things to address the situation: gotten two surrogates, or refrozen one of the embryos. I did neither...I okayed the transfer of two embryos to one surrogate, and prayed only one would implant, and I got lucky. My OB-GYN, who regularly sees surrogates, told me that she considered all surrogates high-risk. My mouth fell open then, and I asked...even the ones carrying singletons? She said yes, She said they were high risk for many reasons, not all of which that I bought completely. As we move into the second half of pregnancy, I am terrified of pre-term birth. And that is with a singleton. If there were twins now, my stress levels would be much higher, and my fears would be perfectly valid. Tomorrow is an ultrasound, and we will be at 16w5d. Praying her cervix is holding nice and tight and long, and all is well. And I'm also giving fervent thanks that there is only one in there.
All in all, I am struck by how often doctors just follow a set protocol without being thoughtful about the situation, the patients problem, the patient's comfort, and the long term safety, of both the mother and the child. If the doctors can't think about all these things, then the patient should think about them, because ultimately, they are the ones facing it all.
There are many roads to infertility. All we can do is identify the problem and treat it intelligently. When I say treat it intelligently, I mean choose a path that minimizes the number of injections you have to take, the hormonal overload you face, the number of FETs you have to do and importantly, choose a path that allows single embryo transfers so you do not have to face the higher risks associated with a twin/triplet/quad pregnancy.
Here are some practical examples:
- If you have a high-ish antral follicle count and a normal-ish cycle, choose the antagonist protocol over the long agonist protocol: The antagonist protocol is infinitely more "natural" than the agonist. Overall, most studies fail to show any benefit of one over the other. The antagonist protocol is infinitely kinder to patients: you have to take a far fewer number of injections (Doctors, yes, this DOES matter). You can skip lupron. You have a reduced risk of OHSS. Knowing all this though, many doctors prefer the long protocol to the short protocol simply because it has been around longer.
- If you can identify a relative date of ovulation, even with +/-3 days of variation, choose to do a natural FET over a medicated FET. That way, you don''t have to start your pregnancy already having been on lupron followed by estrogen followed by progesterone injections, you simply start with Beta-HCG (RMA-NJ has a trial on this) followed by progesterone, and transfer 3 days or 5 days after ovulation. Many doctors are now going with a natural FET now. Incidentally, this study found better results with a natural cycle as opposed to a medicated cycle. This does not surprise me, because mother nature is the best architect, and giving somebody 3 hormones to mimic the complex natural process should be the inferior approach. I don't know why REs prefer a medicated FET. One fertility center basically said that some doctors like the medicated cycle better because it is less of a hassle with respect to scheduling. Needless to say, I don't respect doctors who would pick medicated FETs for solely this reason.
- If you end up with a large number of embryos, then do your best to pick the best one in the bunch from the getgo, so you do not have to do 5-10 transfers to find your two good ones. There are two things you can do for this: let your embryos grow till day 5 (most of which arrest are shown to be chromosomally abnormal) and test the rest. This part is up to your doctor. The embryoscope has some utility in this weeding out process to allow you to transfer your best embryo first. But it is not a conclusive/fool proof test by any means. To really know which of your embryos is okay, you need to find a doctor who has the technology to offer a trophectoderm biopsy with CGH microarray testing. Note that a day 3 biopsy and FISH testing are useless. Day 3 biopsies are bad for two reasons: Most embryos are actually chromosomally abnormal at day 3, and if you test at this point, you may throw out a good embryo (the doctor at RMA-NJ told me that a lot of the embryos that they had discarded as "abnormal" through day 3 testing/FISH turned out to be normal when tested at day 5 with CGH microarray...they had been "rescued"). The second reason is that the biopsy itself can damage the embryo, given that you are pulling out 1 cell out of 8.
- Avoid transferring multiple embryos: To do this, you have to let the embryo grow in the lab till day 5. This is where the patients may balk:If a low number of eggs are obtained, then most patients are reluctant to even grow their embryos to blasts. They don't want to see their embryos arrest in the lab, and somehow feel that if it goes into them, it may have a better chance. Here is the problem with that idea: right now there is little to no evidence to show that the womb poses any advantage over the petri dish. And if you transfer all 3 of your day 3 embryos or two blasts at one go, you may win the battle but lose the war. I've lost count of the number of people on the blogsphere I've seen this happen to. I've seen some people pull through through the skin of their teeth, after being on bedrest for months, and enduring unbelievable stress. Compared to that, a failed IVF cycle is a walk in the park. If you can...grow your embryos to blasts, biopsy them on day 5, find out which one is chromosmally normal, and transfer that (pregnancy rate: rate 66.4%) Failing that, transfer one blast at a time without biopsying (pregnancy rate: 47.9%).
The third thing is a comfortable place to be in: If you have twelve day 3 embryos, you can easily make the decision to grow them further, and most people do. The testing is up to your doctor anyway. On the day of transfer, you have to make the harder decision of transferring one or two. Remember, a day 5 blast has about a 50% chance of implanting.
The fourth choice is the hardest. What if you get only 3 fertilized eggs? Making the decision to wait and grow those in the lab for 5 days, knowing that all of them may arrest at day 3 or 4, and facing the reality of going home empty handed from your IVF is the hardest decision to make. But therein is the gamble. You could transfer all three embryos on day 3, be ecstatic when you have a positive pregnancy test, and 20 odd weeks later, lose two or three babies. It has happened SO many times, and I'm writing this post because I am very, very tired of seeing it happen. Everybody thinks that this could not possibly happen to them, or they choose not to think of it at all when going for embryo transfer, but really, they should. Not all doctors have a single embryo transfer policy, and they should. Because gambling like this is not acceptable.
Despite my preaching, and my knowing all this, I gambled too. I wanted to transfer only one blastocyst at a time, but my doctor froze my embryos in pairs even after I specified that I wanted an elective single embryo transfer. I could have then done two things to address the situation: gotten two surrogates, or refrozen one of the embryos. I did neither...I okayed the transfer of two embryos to one surrogate, and prayed only one would implant, and I got lucky. My OB-GYN, who regularly sees surrogates, told me that she considered all surrogates high-risk. My mouth fell open then, and I asked...even the ones carrying singletons? She said yes, She said they were high risk for many reasons, not all of which that I bought completely. As we move into the second half of pregnancy, I am terrified of pre-term birth. And that is with a singleton. If there were twins now, my stress levels would be much higher, and my fears would be perfectly valid. Tomorrow is an ultrasound, and we will be at 16w5d. Praying her cervix is holding nice and tight and long, and all is well. And I'm also giving fervent thanks that there is only one in there.
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