Wednesday, April 26, 2006

How many embryos should I transfer?

I got the following question in my mail today:

"Hi, I'm in the process of going through donor egg after many failed IVF cycles. My doctor has advised that we have 2 embryos transferred but I am concerned of the risks - mainly of health issues that can occur from delivering premature babies which is usually the case with twins."

Tough question. I looked up the research that's been done on the topic and found the following review of research from The Cochrane Library, Issue 1, 2006(

In simple terms, when transferring two embryos you raise both the likelihood of achieving pregnancy and the likelihood of twins. Following is a quote with the statistical data removed:

"The clinical pregnancy rate per woman/couple associated with two embryo transfer was significantly higher compared to single embryo transfer. The live birth rate per woman/couple associated with two embryo transfer was also significantly higher than that associated with single embryo transfer. The multiple pregnancy rate was significantly lower in women who had single embryo transfer. "

In the research led by Dr. Ann Thurin, from Sahlgrenska University Hospital ( the transfer of single embryos (SET) was compared to double embryo transfer (DET) and the rate of pregnancies after the transfer of two embryos was not very different (39.7% vs. 43%). However, many of those opting for SET had to go through an additional frozen transfer cycle to transfer the second embryo.

With regard to twin prematurity, in a French study (Rufat et al., 1994) of 1263 IVF pregnancies, the prematurity rate (less than 37 weeks of amenorrhoea) in twins was 43.8% compared with 12.2% in singletons, the corresponding figures were 13.9 and 2.9% for extreme prematurity (less than 33 weeks of amenorrhoea). Indeed, at least according to this study, having a twin pregnancy more than triples the risk of prematurity. In this article - (the abstract is in English, the article in French), there's some good news - early diagnosis of twin pregnancy by ultrasound and subsequent treatment (resting at home and regular clinical examination of the cervix) was successful in reducing the rate of prematurity.

When I was going through IVF (Rachel's story), it was common to transfer 4 embryos, which I did 4 times. Two of those cycles failed, one resulted in the birth of a singleton and one in the development of three sacs - 2 of which became embryos and resulted in the birth of twins. In my last IVF cycle, I transferred two embryos and became pregnant with a singleton (I later miscarried due to a large uterine hematoma).

My experience was that carrying twins was a bigger strain on the body. During my twin pregnancy I was much more susceptible to illness and even spent a few miserable days in the hospital hooked up to an IV after I came down with a mysterious (non-pregnancy related) virus in my mouth. I was lucky to have an uncomplicated pregnancy that continued through the 39th week, when my doctor decided to strip my membranes to induce labor.

Carrying twins, of course, is not the only issue. Once they're born, you have two babies to take care of... quite a challenge. I read this very insightful blog entry on Infertility Is Funny. I think she captured well what being a new mom is like. Multiply that (at least) times two if you're thinking of twins...

The decision of how many embryos to transfer is not an easy one. I think today I'm actually glad I didn't have all the information in front of me when I made my decision.

Sunday, April 02, 2006

Nomi's here...

We're still not sure how we're going to spell it, but our new daughter got her name yesterday - Naomi (Nomi) Hallel.

Two weeks ago, an ultrasound showed that the abdomen circumference (AC) was larger than the other dimensions. As I wrote in the previous post, there was also too much amniotic fluid & testing showed that I had gestational diabetes.

On Thursday morning, I went to the hospital to be induced. The delivery room was packed with people. So packed that they were delivering babies in the room generally used to assess the condition of women who reach the delivery room... We were told that we'd have to wait. At first it seemed I'd be able to go home, but then the doctor advised that I stay there - that my health insurance wouldn't cover me were anything to happen to me when I was outside of the hospital. I stayed, hoping they'd call me sometime during the night. They didn't. Friday morning, my husband came back & we waited all day. Finally, around 11pm, he went home, knowing he'd sleep best in his own bed (we live about 35 minutes from the hospital). The woman beside me was snoring loudly & I couldn't get to sleep. One of the nurses gave me a bed in another room and I finally was able to sleep. At 2am, they came to call me.

I was immediately wide awake. I collected all my stuff and went to the delivery room. I took a nice shower & started to get ready for the induction. My husband arrived at around 3. Finally, we were able to talk to a doctor - all along, we'd been trying to understand the risks of delivering a baby in our situation, but it was hard to get anyone to really listen. With the weight estimated at 8lbs6oz & being told that the error was up to 10%, we feared that the baby could be as big as 9lbs4oz - not too big under normal circumstances, but with gestational diabetes, the shoulders can be wider than normal & then have trouble getting through. If that happens, there's nothing that can be done... So we debated whether we should opt for an elective c-section. We collected all the information that we had from all the different sources (2 ultrasounds, 4 or 5 doctors and my personal experience with 2 previous births of babies over 8lbs) and decided to go for a regular delivery.

They started me on the pitocin drip at 5:30am. I was dilated 1.5cm & 50% effaced. It didn't take long for the contractions to start & they were manageable. I had decided early on that when it started to get really painful I'd ask for an epidural. I kept my husband busy putting ice in my mouth every few minutes & kept the midwife busy putting the monitor on & taking it off every time I decided to go to the restroom. I felt the contractions mostly in my back & had my husband put an ice pack on. It was amazing how much it helped. It seemed like the time was flying by. For a while I sat on a chair, with the monitor & the ice. My husband fell asleep on the bed :-) I dozed off a few times myself... At around 4cm, the contractions were getting harder to manage (though I was doing OK with the breathing) & I wanted to make sure they'd have someone to give me the epidural (usually it takes about an hour). The anesthesiologist just happened to be there at the time and decided to do it right away.

He was an annoying guy & I didn't enjoy having the epidural put in, but the pain went away & that was pretty nice. Every hour they gave me another dose. After the 2nd dose, the head had moved down low enough for the midwife to decide to break the waters. I was somewhere around 5cm. Two of the doses didn't spread evenly & there was one place where I had a lot of pain, but it was still tolerable. Amazingly, throughout the entire labor, the baby's heartbeat was good & the baby was active. I could feel kicking practically to the end.

The midwife asked me if I had the urge to push & I said I didn't. She checked me and said I was almost fully dilated. During the next contraction, she asked me to push lightly. 10cm! She told me we were ready to push & I was really excited. I pushed during the next contraction and the head was out! The midwife had me sit up and told me we were going to deliver the baby together. I thought she meant that I'd push and she would catch the baby... Actually, she meant that we would catch the baby. She put both my hands on the baby's head and I pushed and held the baby as she slipped into the world.

With the midwife's hands still on her, I placed the baby on my chest. We did it! It was 4:10pm Saturday afternoon. My husband and I were overjoyed!

It turned out that the baby was just 8lbs1oz. Her blood sugar level was tested every 3 hours for her first 24 hours. All of the tests were normal. My tests were normal too :-)

On Monday night, I got a few hours off from the hospital & I went to my little sister's wedding. I left after the 6 o'clock feeding and was back in time for the 9 o'clock feeding... Amazingly, my sister had chosen a wedding hall right next to the hospital. I left the hospital all dressed up... proud to have my hospital bracelet around my wrist.

My parents hosted a weekend in honor of my sister & her husband this past weekend. My 3 brothers came with their families, so all 21 cousins got to spend the weekend together :-) We piggy-backed on it & my husband's family joined us on Saturday morning, when we named our baby.

Nomi just seemed like the right name for the baby. Hallel means praise. Praise for G-d is exactly what I felt when our baby daughter was born safely and healthy.