Thursday, March 12, 2009

Decisions, decisions: tough choices on transfer day

Will and I are trying to wrap our minds around how many embryos to transfer, which has been a decidedly challenging task.

The facts of our situation are what they are:
1. I'm over 35.
2. I have a history of chemotherapy and radiation exposure.
3. I have had multiple failed IVFs.
4. I've had three prior miscarriages due to chromosomal abnormalities.

Over the course of our IVF cycles (not including the current one), we've made 31 embryos, which sounds really good, except that of all these embryos, only 2 have made it to the blastocyst stage (one of these took, but turned out to have multiple chromosomal abnormalities). And out of 31 embryos, we've never had a single embryo that was good enough quality to freeze.

After our last failed cycle, we consulted with Dr. Schoolcraft at CCRM, and he theorized that most, if not all, of our embryos may be chromosomally abnormal due to my medical history. We don't know if he is correct or not. But we do know that even should we be so lucky to get pregnant, there is (at least) a 20-25% chance of miscarriage in the first trimester, as is true in any pregnancy at my age.

We looked at the data this way and that way. We have talked and slept on it and talked some more. We have consulted with our RE. But ultimately we are left to decide how to proceed with our embryos now culturing in the Womb Away From Home.

The crux of the dilemma is this, as written by a poster on this topic to IVFConnections.com: "We've wrestled with the question of how many to transfer and here's how we solved it: Which do you want more? To have a baby, even if it means you have to deal with the issue of selective reduction, because you transferred so many OR to avoid selective reduction no matter what, even if it means you reduce your odds of conceiving?"

How we would answer this question has changed as we've progressed through the journey. IVF cycles 1, 2, and even 3, we could not imagine risking the possibility of higher order multiples (and the looming question of reduction if we conceived triplets and the certainty of reduction if we conceived more than that).

We put in two blasts, then one embryo, then three embryos. Almost two years later, we still have nothing to show for any of it. We're starting to feel fairly beaten down by the process of multiple IVFs and multiple miscarriages. We're starting to consider things we never considered before.

We want - and we know our RE wants - to be more aggressive, but how aggressive is too aggressive? We will speak to our doctor a little later today to hear more of his thoughts and also will get the embryology report on how the gang of 11 are fairing. Around 2pm, Will and I will meet back at the IVF OR suite for the transfer.

What is a reasonable number of embryos to transfer, given our situation? We honestly don't know.

One thing is for sure. There are no easy answers.

Mo

Add to Google Reader or Homepage Subscribe in NewsGator Online Subscribe in Bloglines Add to My AOL

23 comments:

  1. I think the biggest part of the question you pose is when would you do selective reduction...with twins? triplets? quads? or only more? Personally, given our poor embryo quality, we've put back 3 the last two times, knowing odds really aren't in our favor for all of them sticking. If I would have had four, I probably would have put four back. But we set our limit at four, mostly because we've never had more than that to consider. If we had, the question would be the selective reduction one--and I know we wouldn't even consider it until there were more than four actually babies in there. Maybe that's a place to start?

    Thinking about you guys all day...keep us posted!

    ReplyDelete
  2. There is no good answer. I told you in the past I transferred 6 on my 4th IVF. I was desperate and my embryos were low quality. I won't do it again. That being said only one of those six really took and it was normal (the other that took had turners). It is scary to consider either prospect... no baby or too many. Will they call you in advance and tell you how the embryos are doing? Dr. S did this which was nice to be prepared walking into the room especially since for my first ET I got the ice princess and she didn't want to talk to me at all (god forbid the patient have questions about the embryos they have been through hell to make and gone into debt for). I hope you have a healthy baby from this cycle no matter what is transferred. Take care.

    ReplyDelete
  3. I have never done IVF (but will be in the next month or so) but I just wanted to comment...Just remember your health as well - Im assuming the more you put back - IF all took it puts your life in jeapordy as well. I think without knowing anything about IVF but only knowing what friends have done - at your age why not put 3? I am not sure if that is too much or too little but it seems like a good number to me...
    I wish you the MOST luck today and look forward to hearing your decision!!!
    Hugs!

    ReplyDelete
  4. I have never done IVF (but will be in the next month or so) but I just wanted to comment...Just remember your health as well - Im assuming the more you put back - IF all took it puts your life in jeapordy as well. I think without knowing anything about IVF but only knowing what friends have done - at your age why not put 3? I am not sure if that is too much or too little but it seems like a good number to me...
    I wish you the MOST luck today and look forward to hearing your decision!!!
    Hugs!

    ReplyDelete
  5. Yes, most definitely a difficult decision. It sucks to have to decide this.

    Like you said, give the history... the chances of more than 2 or 3 even taking it low... I'd go as high as they'd allow. Although, like you earlier on, I know I couldn't reduce.

    I really hope the discussion w/ your doctor this morning helps & may you have peace w/ your decision at transfer time & beyond.

    Thinking about you today lots.

    ReplyDelete
  6. Mo, this is such a difficult decision, and the stupid octomom has made it just that much harder. For someone with your history and age it MIGHT be the best to put in 6, but for her it was ridiculous. And are you willing to do SR? I know my first IVF we only put in 1 (we actually only had one, and from DE!). I have uterine problems and and only carry a singleton. And, we were using those magical DEs, from a nubile (or not so) young thing. But this time I have doubts, should we try 2? I don't have to decide until next week, but I'm right with you as you agonize over this choice. Good luck.

    ReplyDelete
  7. Thinking of you and wishing your peace, wisdom & guidance in making your decision...

    ReplyDelete
  8. As with most life decisions that matter there rarely is ever an easy answer. Not having been through IVF (but being infertile)it is hard to feel "qualified" to offer an opinion. Having read so much of your story here and your history and knowing how much you truly want to be parents why not be a bit more aggressive than you might normally otherwise. Four? Five? Whatever you choose I am sure it will be the best choice for you. I will keep you in my prayers.

    ReplyDelete
  9. Mo - there are no easy answers and it is even harder getting to a decision. I feel your pain and had I had more than three to put back today (which is what we put back) I would have tried to put more back.

    XOXO thinking of you and looking forward to your update. I know we do not know each other but I will be around in this blogsphere to support your decisions - on transfer, on selective reduction, on whatever.

    Good luck.

    ReplyDelete
  10. Ain't that the truth! We've always transferred as many as made it to day 5 (only one blast usually), and got pregnant once, but not the other time. I remember inteh beginning when this all seemed so possible, my husband argued for 1--needless to say, we've always done 3.
    Best of luck with your tricky decision.

    ReplyDelete
  11. Can I ask why PGD wasn't an option? To me, it seems natural given your chemo/chromosomal history.

    But it sounds like that ship has sailed, and now you're on to the difficult decision.

    I'd say no less than two. When would do you consider or do SR? four? Maybe that means three's your max?

    An upper limit is so hard - I'm very curious what your doctor says. I can absolutely see why he's pushing you to be aggressive, but he's not the one who has to follow those consequences downstream.

    ReplyDelete
  12. EJW,

    We considered PGD after our first loss and have been told by multiple centers that PGD would not help in our case and has not been shown to improve pregnancy rates when the issue is aneuploidy. the biopsy procedure is so damaging to the embryos and has a high error rate, due to mosaicism in early embryos.

    Mo

    ReplyDelete
  13. I think there's another issue, though I'm not sure if it complicates or simplifies matters -- at what point does transfering "one more" embryo not improve your chances of getting a take-home baby? There are strong cohort effects in cycles (i.e. the probability of pregnancy is "low" but the probability of any pregnancy realized being a twin pregnancy is "high."), and of course SR (etc.) reduces the probability that any of the embryos that implant will survive to viability (relative to not needing SR in the first place, not necessarily relative to not using SR if it's indicated).

    For me, these two facts combined have led me to think that many of us transfer too many embryos much of the time -- taking on more risk for little benefit, on average. But of course you're not interested in average and your case is unique, so I'm not sure how helpful that is. I hope you can make a decision that you are both comfortable with and one that is the "right" decision in terms of its outcome.

    ReplyDelete
  14. I will be keeping you in my prayers and sending lots of Baby Dust your way. Think positive and follow what your heart tells you is the right thing to do at that very moment :)

    Good luck and keep us posted. get LOTS of rest when you get back home.

    Take care,
    Tracy

    ReplyDelete
  15. yikes, what a decision. Personally, I would wait to hear about embryo quality(and compare that to before). I wouldn't be able to handle transferring more than 4. But, it is a case by case thing. I know someone whose RE transferred 4 blasts(!) b/c of her history, and 1 took.

    Good luck.

    ReplyDelete
  16. I'm thinking of you both on this oh-so-important day.

    Also, I've given you (both!) an award on my blog. Maybe it will give you something to do during your two week wait!

    ReplyDelete
  17. I have read a lot of research on this and will be happy to send you the articles if you're interested.

    In general, the recommendation in women who are over 35, with previous unsuccessful cycles is to be less conservative than transferring just one or two embryos.

    Personally, I transferred four embryos four times - it was standard at the time (1993-95) and got pregnant twice, once with one and once with twins (all made it to term).

    ReplyDelete
  18. You are right...there are no easy answers. I wish there was a crystal ball, and you could see how everything is going to turn out....so you would just KNOW how many to put back.

    Thinking about you and hoping you are at peace with whatever decision you make.

    ReplyDelete
  19. Thinking of both of you today and wishing that you have a great transfer. We transferred 3, 3 days, 4 survived the thaw and the fourth looked a little odd.

    ReplyDelete
  20. I wish there was an easy answer for you, but there's not I guess. I think whatever you choose and feel in your heart is the right answer.

    ReplyDelete
  21. I went in to transfer thinking we'd put in two. My RE pushed for 4 and that's how many we agreed to, which resulted in a singleton. I was shocked he was really pushing for 4, but I'm glad we did. Our own reasons were:
    1) over 35
    2) thin lining, only reaching 7mm
    3) scar tissue in uterus from 4 uterine surgeries.

    Good luck in making your decision. It sucks that the chick in the news makes us question ourselves even more now.

    ReplyDelete
  22. By now you've decided and are well on your way into the 2WW, but I wanted to say that no, none of these questions are easy to wrangle with, and with your history and everything I don't think I would have any idea what the *right* thing to do is. But since I am older, have less time, I would gamble toward the many rather than the few should I get to choose, but with 4 follicles in the game this round, there will not be "many" anythings. Good luck with everything-- and I hope you are resting tonight with the feeling that good things are possible. Wishing you well. --Kate

    ReplyDelete
  23. You may know enough about my story... but in case you don't know the details, we had a total of 39 ferts. Seven made it to blast over our several cycles, four of those were considered "borderline" or not of good enough quality to transfer (we made them transfer anyway). I am also over 35. PGD showed that we had complex chromosomal abnormalities. After multiple failed cycles we transferred the four we had saved up over three cycles (2 of which were "unsuitable" for freezing)... and, well, you know what happened... quintuplets. I was not wiling to have SR but did eventually miscarry the identical twins.

    I agree with those who have said there is no easy answer. Looking back, I would have made the same decision again with the information that I had at the time. That is all you can do, make the most informed decision you can... and follow your gut.

    Wishing you wisdom and peace.
    Good luck!

    ReplyDelete

What do YOU think?

Related Posts with Thumbnails

Popular Posts