Wednesday, November 19, 2008

Elective Single Embryo Transfer: An Agonizing Decision

First I'll cut to the chase. Second I will take you through my agonizing decision-making process in which I weigh my options, try to rise above, yet acknowledge, the emotionality of the circumstances and use logic and statistics to arrive at my ultimate course of action (as usual). Also, I express my frustration with people and do a little rant (as usual).

8 out of 12 made it to blast.
I have one in me and the rest were frozen.
Half of all retrieved eggs (16) turned into blasts.
The Donor has really good quality eggs. Since she was not a "proven" donor I was a bit worried. For not!

So why only 1? To tell the truth it's really hard to transfer one given how much I want this NOW and the fact that single transfers are not done that often (yet).

I really, really agonized about this and was not sure what I would do until I was in that transfer chair. But in the end I felt it was the responsible thing to do.

Lets review the stats of donor egg outcomes from my clinic:

Transferring 2 -blasts:
75-80% chance of pregnancy
50% of these will be twins

Transferring 1:
40-50% chance of pregnancy
0 % chance of twins

I think most people focus on the BFP rate. I mean, transferring two does have the greatest chance of a BFP. By transferring one I have a good chance of not getting pregnant this cycle and if you haven't noticed this year has sucked reproductively speaking and I really, really want and need a BFP. (Did that run-on sentence better convey my desperation than one with proper punctuation?) I wont die if I don't get a BFP in a week. I wont die physically but would be a tough blow. So I "get it"that transferring two is the thing most people want to do. Me too. I want to optimize my chances of a BFP now. But then I get to that second statistic: Chance of twins. And this is where I have to stop being emotional and try to be logical.

The risks associated with carrying multiples are real. I think most people are blissfully unaware of this. I, like them, used to be like that. I used to think that the only thing about twins is that it's much more work than a singleont but it's twice as exciting. After being baby-starved, two all at once sounde pretty good to me. But over the years I have read many blogs where a multiple pregnancy did not go well. The outcomes range from really scary to down right tragic. Of course, most of the time it turns out just fine but the times it does not are crushing.

From what I have seen other people experience I believe a best-case scenario for me carrying twins would go like this:

Increased fatigue and morning sickness
When I was pregnant with Picolinna I found fatigue and morning sickness to be debilitating. Lifting my head off my pillow was darned near impossible. Twins usually increases fatigue and morning sickness.

Increased risk of Pre-mature Labor and Delivery:
On average twins are born 5 weeks earlier than singletons bringing with it all the risks of pre-mature birth.

Other increased complications:
Other conditions such as preeclampsia, placental dysfunction, and TTTS are more prevalent in twin pregnancy and increase the risk of an early delivery.

Increased risk of bed-rest
Since right now my income is our only reliable income my career is super important for our family. Going on unpaid leave is just not an option.

I have no reason to believe that I would have a harder time with twins than anyone else other than I'm short. I have seen many people, short and tall, carry twins successfully. Usually, twins are just fine. But after how hard I have worked to get here do I want to risk it? And what would I be risking it for? Because I can't wait? Because I need to be pregnant now? I want to be pregnant as much as anyone but I wont die if I have to do a FET. If I was pregnant with twins on the other or both of them might die and I can not live with that level of risk. My goal is a live birth, not just a pregnancy.

Now, with my eggs, which were not high quality, I did transfer two but with high quality embryos the risk of multiples is just too high for me. My RE just attended a conference in which "paper after paper" examined high quality-single embryo transfer vs. transferring two and each came to the conclusion that over time, success rate are the same but with single you avoid the risk. Single embryo transfer of high quality blasts seems to be the emerging trend (or so he thinks).

I know some readers are carrying twins or transferred two embryos. In no way is this a criticism of your decision. This is my thought process. Again, the vast majority of the time twins are perfectly healthy. I just know how much anxiety I have with a singleton pregnancy. No way could I handle the increased level of anxiety that would come along with twins. I am fully supportive of people making their own reproductive decisions provided they are informed.

So there you have it. Wanted to transfer two. Ended up transferring one. Hard, hard choice. In a week from now I may wish I had done it differently but I can live with that more than I could live with a multiple pregnancy gone south no matter how remote that possibility is. I am going to be a mother again. It just may take a month or two longer than I originally anticipated.

Which brings us to my rant. I seem to have to justify transferred 1 to people (husband, sisters). It makes me mad becasue I agonized over this and I think I did the responsible thing instead of the emotional thing. I think I showed remarkable restraint and to be getting second guessed instead of applauded makes me all crazy-mad. Instead of feeling like I have a slam-dunk going on here I know my chances are about 50/50. I am possibly looking at a FET (and an additional 3-4K) instead of a trip to the OB. And yet, I still chose a single becasue I felt it was the responsible thing to do even if I WANTED to transfer two. It's like criticizing someone on a diet for not eating the whole piece of pie when it took every ounce of will power to just have the one bite.

I'm not looking for you to tell me that I did it all right. I'm just sorting things out in my mind. Maybe after ranting I will be better able to calmly explain this to the next poor sap who asks why I only transferred one.

I was really counting on this cycle being the BFP. Now I have to start preparing myself that it might not work out this time. Eventually it will. It's not a race I'm trying to win. In fact, this is not about me at all. In some ways I feel like I have made the first decision for the welfare of these children.


BTW: I'm not sure about what I will do with the FET. Those success rates are 30% for single. That would be a 60% chance of pregnancy transferring two. If 50% of those are twins (not sure if that is how it works) the chance of twins is less than with fresh so maybe my thought process would change given those stats. Also, if this cycle does not work there may be something about me and my uterus that makes implantation harder so transferring more than one might make more sense.


Crap, I have to add something else (this is really taking the wind out of my "How deep and wonderful am I"? statement at the end).

If I only had 3 or so blasts I probably would have transferred two. I hope to have two children from this cycle. I have 7 more on ice to FET with. Many chances. If I had only a few chances I would have wanted to maximize the fresh cycle. The lower success rates of the FET seem to be ameliorated by the large number of frozen embryos.


soapchick said...

You transferred one beautiful blast! Awesome!!!

Hope C said...

Thanks so much for this post. DH and I are seriously considering a SET but the possibility it won't work out terrifies me.

This post made some great points.
Good Luck!

PJ said...

I think it's becoming more acceptable to transfer one. I know at least one of the bloggers I read transferred one, and she is about 18 weeks now! I've also read research backing this.

Good luck with you! I'll be reading.

Summer said...

I completely understand transferring one. I went through the same line of thinking but ultimately in the end, even though I wanted to transfer one, I ended up transferring two. I think the decision of how many to transfer is a very difficult one to make if your goal is a singleton. In my case, transferring two got me the singleton, but it definitely was a gamble.

Ophelia said...

I've been waiting for this update!

I fully support your decision and respect you for it.


bleu said...

I totally get your decision and see how it was so much the best choice for you. I wanted twins much more after losing them and I am also tall and have lots of room, but it still would have been so hard and ultimately I know being pregnant with a singleton was best for me. I have a friend who trasnferred two and only one made it but it was twins from that one so no one ever knows.I applaud you soooo much for being so very thoughtful with this decision.
I am so sorry others have not applauded you as they should have.

Much love and I am so thrilled for you!!!

nancy said...

You certainly don't have to rationalize your own decisions with us. We'll all support you no matter what.

Did your clinic happen to quote the twin rate with one embryo? Since ICSI increases the chance of identical twins? Just wondering if they even said anything about that.

I wanted ~one~ baby. I knew I could handle two if that's what happened, but I wanted ONE. I went into our FET with wanting one perfect or two not so perfect transferred. I walked out with FOUR embryos. FOUR. Holy shit - peer pressure! peer pressure!

I had 2 grade As (7 & 8 celled) and 2 grade Bs (6 and 5 celled). We left 3 more out to see if they'd make it to refreeze (we froze on day1) and they didn't make it.

I was given these stats for my FOUR embryos due to my lining issues:
~ 40% chance for a singleton.
~ Of that 40%, we've got a 15% of twins and under 5% for triplets with barely any chance at quads.

We fell into the 40%. :)

Anywho, I don't know why I'm compelled to tell my own story. It's not to show you that more is better - not at all. But how for each person, there is a definite personal decision to be made. And it's all YOUR decision to make.

Pepper said...

At the end of the day only you can decide what's best for you. It sounds like your decision is well-thought out and heartfelt. Honestly, if you'd said, "I transferred one because I wanted to" that would've been fine with me too. :o)

Best of luck! It sounds like this was a great cycle. Eight blasts is fantastic!

Sparkle said...

Excellent - what day did you transfer again?
Completely different approach here, single embryo transfer is the norm. But then again, we are subsidised far better with our national health care - so far cheaper.

Mermaid said...

You had amazing numebers! Congratulations! I think your decision was difficult but you made an informed, intelligent, respectable decision that was best for you and your family. I applaud you and you don't need to justify it! Best of luck!

Shelli said...

Such an individual decision. I don't know what my thinking will be when I get there, but kudos to you for thinking really hard and making an informed decision!

Thinking good thoughts for you as always!

luna said...

wow, 8 blasts, that's amazing. of course it doesn't matter what I think, but I think you did the right thing. obviously you thought long and hard about it. wishing you good distractions in the 2ww.

jodie38 said...

Makes perfect sense to me. You made an informed, rational, difficult decision, and it's nobody's to make but yours. Good for you, and wishing you all the best for the dreaded 2WW.

I'm not sure what we'll do when transfer time comes. Last time we transferred 2 high-grade embryos and ended up with a singleton. Beggars can't really be choosers, but I'd be lying if I said I'm not worried about a twin pregnancy, for all the reasons you listed and then some. I can't say for sure, but I'm leaning toward making the same decision you did.

Hang in there!

Brenda said...

Hi, I'm late in jumping in, but you probably know I agonized about the same thing. I am glad you are comfortable with you decision. Really, in the end, that's all we can hope for :)

sprogblogger said...

I can't blame you at all. I know I'm not equipped - physically, mentally, or emotionally - for multiples. This is the MOST personal of personal decisions & kudos to you for being honest with yourself, and for being true to what you KNOW is right for you.

Shall be watching and waiting. Hang in there!

Sky said...

I posted about this EXACT subject/scenario.

Honestly, it's just impossible to know how you'll decide until the day of transfer.

It's one thing if you're told you have 8 kick-ass blasts and are asked if you want a single-embryo transfer vs. being told you have 3 good blasts and then deciding on a single-embryo transfer.

We all know there is a difference in success rates between fresh and frozen. Now, I know frozens are PLENTY successful and people get pregnant on frozen embryo transfers ALL THE TIME - YES, ALL THE TIME!!! Yet the number still isn't as high as fresh.

Therefore, it's tough to transfer 1 blast if all you'll be left with is 2 good blasts in the freezer with a reduced success stat.

So I get it, the entire agonizing decision. You're amazing that you made it with such confidence and conviction. I fear saying, "Put in all 7!" :)

Anonymous said...

Hello...I think that you did (are)making the right decision. I have been doing the reproductive medicine for about four years now. AFter 1 failed fresh/1 failed frozen IVF cycle, we finally conceived twins in 2006.....there were many complications throughout the pregnancy...unexplained bleeding...and worse, we lost one twins at 16 weeks. I was heartbroken. My daughter was born 8 weeks early following that. She is the light of our life. Because we were so ready for more, we did another cycle...transferred two embryos again....and we were pregnant with twins again. On January 2, 2009 I went into preterm labor at 24 weeks and lost both my son and daughter. I truly agree with transferring one embryo. Many people make it to term with their multiples and everything is ok, but there is that we found out...that the multiples carry a high risk.

charmedgirl said...

i'm so glad i clicked on 2008...i am having my ET tomorrow morning, and i think i'll be transferring one as well. it IS SO terrifying!! doing all this crap, for it not to work?!? the thought of it drives me insane. and double good luck for me, we already know that your single embro transfer worked!! i am going to stop agonizing over blogs now, and take your success with me tomorrow. it only takes one, right? (i hate that saying...)