Single Embryo Transfer

I am in that limbo right now, that squishy space between making a new plan and actually having that plan in my hands, ready to go. I had my consult with my doctor and was very, very pleased with how we left things. There are changes, changes that are a direct result of my advocating for myself and having a wonderful husband who is a strong advocate and can put on his "business voice" to get down to the meat of why certain things are the way they are. I researched like a fiend prior to this appointment. I gathered information from other people, people who were successful where I was not. And here are the results:

- a hysteroscopy/gentle D&C to rejuvenate my endometrium prior to the next cycle
- Medrol, a steroid that allegedly can address the uterus's possible rejection of embryos as foreign objects, for four days before transfer
- more progesterone support
- the decision to move forward with Single Embryo Transfer (SET) for our two remaining frozen blastocysts

The hysteroscopy was not my idea, but I had asked about the endometrial scratch biopsy, which they weren't down with but this basically has the same purpose and puts eyeballs on my naughty uterus, which for nothing else than peace of mind has its benefits. This is happening this Friday, and unfortunately for me is happening in the afternoon. No food after midnight makes Jess a cranky, cranky girl more prone to migraine, and waiting until afternoon for the procedure is not going to be fun. My plan: eat a big meal at 11, stay up until 2 am (easier said than done), and try to sleep in most of the morning, waking up to hydrate up until 4 hours before the time for surgery so that they can slip that IV right in. IV insertion gives me nightmares as I've had times when it took 4 tries, which is unpleasant to say the least.

Medrol was totally my idea and supported by other ladies' protocols from different highly respected clinics. I am afraid that my uterus is going OUT OUT DAMN EMBRYO and washing it all away. Maybe this will keep that from happening. The weird thing is that my clinic does use Medrol, but only for Day 3 transfers involving assisted hatching. (I looked this up, and apparently on Day 3 an embryo would actually be in your tubes if things were "normal," and so it is not a normal time in your cycle for the uterus to expect company.) However, they don't do it with regular 3 day embryos and they don't do it for Day 5 transfers, either. Why if there's a chance that the uterus could nix something, and we know there is a medication that can address that, wouldn't you use it all the time? This I do not get. I understand there are protocols for a reason, but in my mind "That's how we do it" is not a reason. Luckily this fell into the "can't hurt and may help, so why not?" camp. So onto my protocol it goes.

Progesterone increase was another thought I brought to the table, and it again fell into the "can't hurt and may help" camp. Nothing too earth-shattering here. More shots for me, but if more needles equals actual baby, BRING ON THE NEEDLES.

Single Embryo Transfer turned out to be the most controversial of the items on our "to discuss" list. Which was a little surprising. Or maybe not. SET is when you transfer just one embryo. Even the language I subconsciously use, "just one" denotes the controversy over this, both personal and socially and even medically. Most clinics that I know of will transfer two, even two blasts. The thinking behind this is that two gives you more of a chance at pregnancy success than one, because two embryos could mean that if one doesn't attach, the other will. Or both will, resulting in twins. And aren't twins a good thing, the proverbial "two for one sale" in the infertility world? I actually wrote about my lust for twins in this post. I wrote this post while in my two week wait for my third IVF, the one where my protocol was new and exciting (and, ahem, egg-quality based). The IVF that resulted in a low positive that improbably kept doubling and tripling, but then went wonky and was still low and caused concern that was totally warranted because it was ectopic and it and my tube needed to go lest they, you know, cause me to bleed to death or something. I had at the time gone through completely and totally unsuccessful IUIs, and two IVFs that resulted in surprisingly poor end results (even before the negative) and so the thought of being done with all this infertility AND completing my family of four ALL IN ONE SWOOP was very, very appealing.

That appeal is pretty much gone now, which was initially puzzling to my doctor. Why wouldn't I want the possibility of twins? Most people in waiting rooms when asked would WELCOME twins. Well, our answer was this: we want to be pregnant, we want a healthy pregnancy, we want the best chance for the best possible outcome, which is ONE healthy baby born without complication. Singletons are not immune from complications such as preeclampsia, low birth weight, and early term labor. In fact (and please don't freak out, pregnant people reading this), for some reason women who do IVF are at a higher risk for all three of those complications, whether you're carrying singletons or more. I don't know if that's because we're already an at-risk population, or on average women doing IVF are older and at risk anyway--it is a mystery and not one I'm willing to research right now. (I want to research how I can GET pregnant and STAY that way, researching birth complications is just not an added stress I need right now.) But in any case, add a second baby in your womb and you increase your risks significantly. Do I know (or know of) women who did IVF, got pregnant with twins, and gave birth at full-term without complications of any kind? Yes, but not a whole heck of a lot. I know more women who spent significant time in the NICU, who feared for their children's survival, who suffered preterm labor too early for survival or complications that ended in tragic infant death. Now, most twin people that I know ended up with babies who are perfectly healthy, after the terrifying and taxing time in the NICU. I just don't know if, at this point in my pathway through this loss, where NOTHING seems to go the way it is "supposed to," if I am willing to take any more risks. Even though twins do have a sense of appeal (I still wonder about how it would feel to be done all in one shot), at this point it is not outweighed by nervousness over the risks.

I'm not alone in this--I actually found a ton of research and articles and interviews and journals that support that the ultimate successful outcome for an IVF cycle is ONE baby per birth. That twins aren't actually considered an optimal outcome. Here is a link to an article by the ASRM (American Society of Reproductive Medicine) that I found really interesting. It isn't a Today show clip (although if you google "single embryo transfer" you will find a fair number of those as well as some Time magazine articles on the subject), but it is awfully interesting how compelling the data is. I have heard the adage, "Two embryos only significantly increases your chances of having twins, it does not actually increase your chances of getting pregnant in any significant way." When digging deeper, I found that transferring two increases your chances by 10% for pregnancy, but 50% for twinning. Hmmm, from a cost-to-risk benefit standpoint, not looking so good. Because, for instance, this last transfer that we had was a double transfer. Two blasts were put into my uterus. Neither of them stuck. Now, if we had only transferred one, it's possible that that wouldn't have stuck, but then we would be playing with THREE blasts for frozen transfers with our new and improved protocol, instead of TWO. We actually would have MORE chances. And that's what a lot of the paper I've linked to states--that you have a higher level of success PER RETRIEVAL with single embryo transfer. Doing a fresh cycle is expensive. Doing a frozen cycle is cheaper, minus the fact that you have to pay for cryopreservation and storage, but that's a one time fee for a set period of time, so if you do your FETs within that period of time you actually have MORE CHANCES for LESS MONEY. Hmmmm. Sounded pretty good to me. Plus, apparently some clinics are offering free cryopreservation and storage to patients who elect for SET as an incentive, because while it may lower success rates per transfer, it increases success rates per retrieval and the possibility of a healthy pregnancy and live birth are higher. The decrease in costs to insurance companies is a benefit as well--the NICU is EXPENSIVE. Oh, and here is another interesting tidbit--in areas (whether countries or states) where there is INSURANCE COVERAGE FOR IVF, the rate of Single Embryo Transfer is considerably HIGHER. Which begs the question, do you want to make a decision on how to have the healthiest pregnancy possible based on the possibility of how much it could cost you in the long run? I know that I have thought this way, because I do not have insurance coverage for IVF, that twins would be "cheaper." But are they, really? Between the higher likelihood of NICU stays and the fears of early labor with not-quite-fully-baked organs like lungs in the mix, and more complications to the mother at birth, I'm not sure that's cheaper. It's covered by insurance, thank goodness, but there is still a cost. 

This is an interesting choice. I struggled with it, because I wanted to hang on to the "one and done" possibility, and I fear that doing a transfer with just one embryo lowers our chances. But, let's be honest. I have put 18 embryos into my uterus. Sometimes three at a time. Never less than two. And I have NEVER EVER gotten pregnant with twins. I have gotten pregnant, but both the freak ectopic and the devastating miscarriage were singletons. I'm pretty sure I can give up on my misguided desire for twins. If I was going to have twins, maybe it would have happened by now. Maybe if my uterus has been doing a rejection service, it has had more notice because there are two or three little HCG emitting babylings in at a time. Maybe one embryo could do a stealth act and sneak on through to the burrowing stage undetected. (Maybe this is crazy conjecture, but it makes sense to me). Is getting two babies for the price of one worth all the risks when I'm already at risk for so much and have experienced so much loss? I really want a healthy baby and a healthy pregnancy. My best chance at that is to give myself the best possibility for only one fetus. Transferring just one doesn't mean that twins are impossible--identicals happen when the embryo splits. I know people this has happened to. If twins are going to happen (and they do, "in the wild," no medication necessary), they will happen. But do I need to induce the conditions to make that risk more likely? In my opinion, for myself, nope. I have had enough. I have put my body through an awful lot. It's not like pregnancy in itself isn't traumatic on the body (your internal organs SHIFT AROUND, for pete's sake!), do I want to TRY to magnify that with a twin pregnancy?

So we convinced our doctor that we are not completely crazy in wanting a single embryo transfer. We opt for more chances to get pregnant over time, rather than putting all our eggs in one basket. We don't have a lot of blasts in the freezer. We have two more chances at a five day transfer, and we don't want to throw them both in at the same time. If (and dear lord I hope we don't have to) we go through both blasts with nothing, we still have six Day One embryos in the freezer as well. These won't get to Day Five and they won't all make it to Day Three. We will HAVE to transfer more than one, because we will have to thaw them in groups since they won't all make it due to attrition. So there's still a chance we could end up with more than one baby in my basket. But hopefully those little frozen embryolets will be reserved for sibling tries. Because that's another benefit of SET--frozen transfers are less traumatic on the body. Shots, yes, but no surgery/recovery/swollen ovaries to contend with when you have a toddler bopping around. It makes thinking about doing this process with a child already if not attractive, then palatable. Doable.

I am not one hundred percent thrilled about this new plan, despite all the logic behind it. What if I need that 10%? Change is scary. But, when looking at the big picture, having more tries with our embryos gives us a better chance of success overall. As Bryce said, when our doctor said, "I'm thinking of your timeline, because we want to get you pregnant as soon as we can" and Bryce retorted, "Nothing messes with your timeline like NOT GETTING PREGNANT." Putting all our embryos in at once puts a lot of pressure on that one transfer. Bryce, ever the scientist, is all about SET, especially given the data. I am going to try to swallow my butterflies and fully commit, mentally, to this decision. After all, both ladies who cycled around the same time as me who are now successfully pregnant transferred a single embryo. One embryo, one baby, more chances hanging out in the freezer for future family building. Sounds like a good plan to me.