« Taking it to the streets | Main | Puppies, rainbows, chipmunks, and Julia »
10/26/2006
The first person to complain about "implant" gets it
Two news items of interest, ruthlessly excerpted:
IVF experts advise limits on embryo transfers
Medical groups representing U.S. fertility experts, alarmed by rising numbers of multiple births, on Tuesday advised limiting the number of embryos implanted in women undergoing in-vitro fertilization.
The new recommendations (PDF, 56KB) to fertility specialists, which are not enforceable, call for transfer of no more than two embryos for women under age 35, and say the transfer of a single embryo should be considered. For women aged 35 to 37, no more than two later-stage or three earlier-stage embryos should be transferred, according to the new guidelines. The recommendation rises to as many as four embryos for patients aged 38 to 40 and to five embryos for women over the ago of 40.
(Yes. Yes. I know Reuters used "implanted" where they should have used "transferred." I don't much care, and that's not the point. Keep reading.)
March of Dimes Applauds Effort to Reduce Multiple Births
The March of Dimes applauds new fertility treatment guidelines from the American Society of Reproductive Medicine (ASRM) calling for a limited number of embryos — in some cases only one — to be transferred during in-vitro fertilization procedures.More than one-third of pregnancies conceived using assisted reproductive therapies (transferring a fertilized egg into a uterus) result in a multiple birth.
The March of Dimes also suggested additional steps, beyond the ASRM guidelines, to help women make informed decisions about fertility treatments:
Require informed consent documents include explicit information about the risk of multiples and premature birth.
Requires annual review of clinics’ performance and publish a list of those with highest and lowest rates of higher-order multiple births.
Now, a very quick sketch of my initial reactions:
- I don't see anything immediately unreasonable about the guidelines. I
once read an article that stated that the goal of IVF should be "a
healthy singleton pregnancy," and I am largely in agreement with that statement.
- I'm all in favor of single-embryo transfers. If I ever had more than one good-looking embryo to transfer, I would strongly consider it. However, and this is a big however, I have a history of getting pregnant, even when I had only one to transfer, and I am not interested in carrying twins. But my position is almost entirely theoretical; I have never faced the situation of having three pretty embryos — or even three ugly ones — at a clinic whose frozen success rates are low.
- Although I've been willing to risk getting pregnant with twins, I never actively desired them, and hoped it wouldn't happen. But my understanding is that many, many infertile women — most? — do hope to complete their families with a single pregnancy, risks be damned. If a list were published advising infertile couples on which clinics had the highest rate of ongoing twin pregnancies, I wouldn't be surprised to see those clinics' patient load increase dramatically.
- Before we began IVF we were given clear and detailed information on the risks of multiple pregnancy and birth, including prematurity. I would have thought that was common practice, but the March of Dimes seems to suggest that it's not.
What do you think? Are these guidelines — which are, as Reuters takes pains to emphasize, unenforceable — reasonable or overly restrictive? Under what conditions would you consider a single-embryo transfer? Did your clinic make you aware of the risks of multiple pregnancy? And when pregnancy itself seemed so remote a chance to begin with, did you care?
Addendum: The ASRM recommendation, linked above and available for a limited time, contains this passage:
Strict limitations on the number of embryos transferred, as required by law in some countries, do not allow treatment plans to be individualized after careful consideration of each patient’s own unique circumstances. Accordingly, these guidelines may be modified, according to individual clinical conditions, including patient age, embryo quality, the opportunity for cryopreservation, and as clinical experience with newer techniques accumulates.
...which makes it that much more reasonable, huh?
Posted by Julie at 09:23 AM in Jane, you ignorant slut | Permalink
TrackBack
TrackBack URL for this entry:
http://www.typepad.com/services/trackback/6a00d834518e0569e200d83467048069e2
Listed below are links to weblogs that reference The first person to complain about "implant" gets it:
» The IVF ethics post I really didn't want to write from Better Make It A Double
I have IVF twins. We transferred more than one good-looking embryo. When I read Julie's post today, my heart sank, because I knew it was time to write about something I've been avoiding. It is hard to let two truths [Read More]
Tracked on Oct 27, 2006 1:30:22 PM
» Need NICU Notes! from Raising WEG
A friend asked me to write about our NICU experience with the support staff in the NICU -- speech and occupational therapists, other allied health providers. (I don't know whether she wants me to reveal her identity and blog or [Read More]
Tracked on Nov 14, 2006 11:36:55 AM
Comments (142)
I agree with you that most infertile women deeply desire twins. It's like hitting the fertility jackpot, and all they can imagine are two healthy, adorable babies ... because that's often what they see on the street, magazines or in playgroup. What they don't see are the multiples that didn't make it, and the health crises the mothers went through.
I also agree with the March of Dimes, that not enough information is given to women about the risks of multiple pregnancies, or it's not given in a way that sinks in. My clinic gave some info; but I have to say, most of my knowledge of the risks of twin pregnancies came from the chilling real-life accounts given by people on the internet like Tertia and Cecily. As much as I desired twins myself, reading what had actually happened to these two women made the risks seem very real. Maybe REs should make their archives required reading!
Posted by: lynn at Oct 26, 2006 9:34:45 AM
My RE was very clear on success = healthy singleton pregnancy. His practice ha da heavy slant towards women with craptacular FSH levels; I would think that that means a greater likelihood of unsuccessful embryos, and hence a tendency to need to transfer more of 'em to get an ongoing pregnancy.
I think, all things being equal, that transferring fewer is probably better. But all things are never equal. A woman on her first IVF with beautiful embryos has more reason to go with a lower number of embryos transferred than a women who's been through multiple BFNs or miscarriages, or so it seems to me.
I think what I'm in favor of is a better informed patient and a doctor who works with the patient to make decisions.
Hey, you know what would help? If IVF were covered by insurance, so the financial aspect of repeat tries could be removed from the picture. I'm off to tell insurance companies that; I'm sure it'll bring them right around.
Posted by: Slim at Oct 26, 2006 9:48:33 AM
The problem with the articles is that the criteria is inaccurate. Good-looking embryos aren't any more likely to produce healthy babies than good-looking men are to produce better sperm. The ASRM has also presented studies showing that PGD to exclude trisomies can actually improve pregnancy rates dramatically, lowering the need to transfer multiple embryos. But PGD isn't as profitable to clinics as donor egg cycles, or making women go through multiple IVFs. There is no ART and no science to stuffing as many embryos as you can into a uterus. But after everything IF couples go through, well, of course, we agree to anything that might work after awhile...
And I'm cynical about some RE's motives here because I've seen some clinic accounting records. (I'm friends with a bookkeeper.) Some are ethical and some fly first class if you know what I mean.
Posted by: Aurelia at Oct 26, 2006 9:53:32 AM
I am probably in the minority, twins always scared me so I never wanted them if avoidable. But as my time in treatment increased and we had been doing IUI's over 8 months with no luck, I started taking more risks. I would be so excited with the thought that it would actually work that time, and then scared that we might have mroe than one. I actually got up to 5 eggs.
I believe that we have to have good doctors who we put our trust in, my doctor said she would not normally allow that many eggs for an IUI but with my history and PCOS, I would be lucky to get pregnant with one. The cycle I got pregnant with had 4, and today is my ultrasound but all numbers indicate just one took, so she knew the odds and knew they were not likely for having too many. Its hard to put a limit when each circumstance is so different, and I don't think age is the factor since I just turned 36. I say they should just make sure all doctors are trained well and then let them decide on an individual basis.
Posted by: Deana at Oct 26, 2006 9:58:06 AM
After my first IVF failed with 2 embryos transferred I insisted on having 3 transferred for the next one and it resulted in a successful singleton pregnancy. I think these "guidelines" should be exactly that...a general guide to assist doctors and patients but I also think that there are many individual factors that are much more important and that should be the primary factor in deciding how many embryos to transfer. I don't know what I would have done if I had ended up with triplets but I knew that the chances of that were really low and I would have been delighted to have twins.
Posted by: Stacy at Oct 26, 2006 9:59:17 AM
I think these guidelines are very close to what they are doing in Europe and South Africa. I know my SA South Africa (one of the docs at Tertia's clinic), likes to be very conservative.
I do think that mandated insurance should be part of the guidelines as well. It would be much easier to follow these guidelines if you didn't also have to make difficult financial decisions at the same time.
My goal has always been a healthy singleton birth, but the longer I'm in the game and the older I get, I must admit I'm finding the thought of twins to be better and better. I just don't know if I can go through any more.
Do these guidelines mention anything at all about donor gametes? I really think that should be addressed as well. I know many of us who go down the donor path are tempted to 'put more in' just because we haven't had success.
Posted by: millie at Oct 26, 2006 10:01:30 AM
I am about to go for my first ultrasound (in a couple minutes) and I can say that while I hope it is a singleton, I will be happy with twins (if not a bit scared). I'm just so happy to be pregnant after 2 IVF cycles, an FET and then a final IVF. My doctor had only wanted to put one embryo back in but after so many failures I was insistent on two. I can speak for the two fertility clinics I've been too and I can say that they were very clear about the risks of a multiple birth. It was a risk I was definitely willing to take.
Posted by: Rebecca at Oct 26, 2006 10:11:47 AM
You know, Julie, I think the implanted v. transferred thing IS a big deal. It has a pretty big impact on how the workings of IVF are perceived. "Implanted" makes it sound like the little suckers have a much better chance of making it than they actually do. "Transferred," aside from being the correct term, gives a much better sense of the fragility and godawful uncertainty of the process. So while "implanting" two embryos might seem like a hell of a lot (and it would have been for me - implantation of two would have brought me closer to having twins, something that would have been expedient but rough), "transferring" two sounds like you are betting your hopes on hell getting chilly, which is much more apt.
We transferred three, three, and four, and got one kid out of the last try. If I'd only been given the option to transfer two, there's a big chance Polly wouldn't exist today. And I can't imagine a world like that.
Posted by: Menita at Oct 26, 2006 10:21:35 AM
This reminds me of a mom who gave birth at our hospital ... probably actually right around the time Charlie was born. She had quads. The nurses were all scandalized, because the IF clinic at the hospital didn't allow patients to carry more than three, but this woman had had her treatment elsewhere but gave birth at Baystate.
I do think that the guidelines are a good idea. Yeah, ultimately, it's the choice of the patient, but more information is better than less. Especially about the risks of prematurity (says the woman who failed to recognize PTL for what it was until it was waaaay too late).
Posted by: Sarah at Oct 26, 2006 10:22:49 AM
I don't think the limits are restrictive, but I think they're unlikely to be followed by very many REs outside the states that provide pretty generous coverage for IVF. (Wait: do any states mandate more than minimal coverage for IVF?)
I've read surveys suggesting that about 38% of couples beginning ART indicate an active interest in a twin birth. If the studies said whether that was before or after patients were informed of the risks attendant on multiple birth, I don't remember it. Anecdotally, most folks I encounter think twin pregnancy isn't that risky, and no amount of statistical conversation sways them. Triplets and more, they get. Twins? Come on, people have them without problems all the time. [Snort.]
I have a gut-level stress reaction whenever one of these recommendations comes out. Especially from the March of Dimes. At an intellectual level, I applaud their involvement in the debate: they want to reduce prematurity levels. At an emotional level, it's hard not to hear these things without also hearing "it's your fault your children were born prematurely."
Also: these sorts of guidelines tend to support REs in their single-minded advocacy of multifetal reduction.
Oooo, oooo: now I insert my PSA! Never, ever take SR advice from your RE. Always, always discuss that option with the best perinatalogist in your area. Peris are still pently pro-SR, but they have the added bonus of actually knowing what they're talking about, when it comes to the risks of multiple-birth pregnancy!
Posted by: Jody at Oct 26, 2006 10:23:44 AM
Oh, and Sarah, how did the IF clinic mandate that no one carry more than three? You can transfer two embryos and end up with quads, thanks to the increased rates of MZ twinning in IVF.
Do the REs mandate SR for patients who transfer two or three but end up with quads thanks to twinning? Because that seems pretty hard to imagine.
Oh, and, er, Peris are still PLENTLY pro-SR. I have no idea what pently is. A cut-rate Bentley?
Posted by: Jody at Oct 26, 2006 10:28:30 AM
My doctors were insistent on only one for me, even during IUI. Because of my special issues, they were concerned that I would have problems carrying even a singleton to term. Before starting any treatments, I was referred to a high-risk ob-gyn to discuss all the risks. After meeting with him, we were so frightened, we almost gave up trying altogether. After 3 failed IVFs, when they suggested transferring *gasp* TWO, I was concerned. hahahahaha. Anyway, we are still trying....
Posted by: SusanG at Oct 26, 2006 10:44:55 AM
From the rest of the world (and particularly here in Australia) the perception of IVF in the US is that due to your unfortunate insurance coverage and government funding (or lack there of), many couples go for broke and transfer up to 4 embryos to supposedly increase the chance of pregnancy for the lowest cost possible. Add in the higher risk of ID twins to that and disastrous multiple pregnancies abound!
Is Australia for example, universal medical coverage is funded by the government and most IVF drugs are included on our pharmacuetical benefits scheme. This ensures that Fertility specialists and patients have the luxury of playing it safe and only transfer 1 embryo for the MAJORITY of patients. We still have an Australia wide sucess rate of 35-40%.
In a previous entry you mentioned that IVF using your own eggs costs you over $8,500 EXCLUDING drugs. Here is Australia I am eternally greatful to our federal government because after Medicare rebates a fully stimulated IVF cycle including drugs, monitoring, collection, growth to blast, transfer, luteal support and freezing of excess only has me out of pocket $1,900 USD! This allows us the choice to transfer 1 and freeze the rest.
Maybe with enough lobbying your conservative government will one day ensure healthcare of all types should be universally available and therefore the risks to women aiming for multples will be reduced - but I don't hold my breath.
Posted by: Jodes at Oct 26, 2006 10:57:54 AM
I had a ringer of a 5-day blast transferred in mid-September. It was my first IVF. Being Canadian, we're a rather cautious bunch. My Dr's warned me stridently against anything more than a single transfer, due to my age, and the quality of the embryo. It was implied that ultimately it was my decision. But when I showed up on transfer day, there was just the one lonely blast - the rest were frozen.
It didn't work. Beta of 18. I was pretty bereft and decided next time: two. Next time is staring me down and I'm still pretty confident with my decision to transfer two, but ultimately, I would choose to have a single baby and a healthy pregnancy. Come to think of it, if I had my choice, I wouldn't be in the IVF shitstorm would I?
Posted by: olivegirl at Oct 26, 2006 10:59:20 AM
In the UK, the fertility regulatory body (HFEA) states that women under the age of 40 can have a maximum of two embryos transferred in a standard IVF cycle, and a woman over the age of 40 can have a maximum of three transferred. In a donor egg cycle, only two embryos can be transferred, regardless of the patient's age.
I wouldn't have wanted more than two embryos transferred, because I was terrified at the thought of anything more than a singleton pregnancy. Never did I think that having two or more babies in a single cycle would be desirable.
If we decide on trying for a second child in a few years' time and must do IVF again, I would consider selective reduction if I found out it was a pregnancy with multiples. I know that would increase the risk of miscarriage of all of the embryos, but I'd be willing to take that chance, so desperate am I not to be a mother to multiples.
I think the transfer of many embryos (is there even a limit in the US?) is the reason IVF is viewed with such suspicion by much of society. I must admit, I get very upset with women on TV programmes giving birth to quads and quints as a result of fertility treatment. The chances of those children being born even close to term and without difficulties is minute, and I think it's selfish to put your own needs in front of those of your children in this way. I also find it reprehensible that there are doctors out there willing to transfer that many embryos in the first place.
Phew...rant over.
Posted by: MsPrufrock at Oct 26, 2006 11:13:05 AM
I have IVF twins. I started to respond, but so much came pouring out, I posted about it instead. Thank you for your reasonable words about a subject that is difficult to talk about.
Posted by: Emmie (Better Make It Double) at Oct 26, 2006 11:15:05 AM
I am not there yet, having miscarried the baby I made on Clomid after 7 IUI's. I'll try a few more rounds of what worked. But after that, I want to do IVF ONLY if I can find someone who does Single Embryo Transfer. I am terrified of twins. After the miscarriage, I think I can say that I would rather have twins than none. But it is only after trauma that I find that to be true. I really want just one. Period.
That said, the guidelines should be guidelines. Patients and doctors should decide how many to transfer according to each individual situation and patient history. I hope that is allowed to continue to happen. But I am in agreement that some of those cases of a gajillion babies because of IVF anger and sadden me.
Posted by: bri at Oct 26, 2006 11:21:50 AM
I, too, used to desire twins and even hit that "jackpot" on our first successful cycle (but went on to lose a twin at 10 weeks). That desire disappeared after my first IVF baby graced us with colic from hell. That pretty much made the decision to transfer only one embryo on future attempts for a sibling obvious. As it turns out, IVF baby #2 is about 1,000 times worse with the colic, reflux, milk protein allergy, etc etc etc. I cannot imagine having this cranky baby x2 (well, I can imagine it, and it goes something like this: severe PPD, alcoholism, divorce, and maybe worse), let alone having to endure a twin pregnancy, possibly deliver extremely early and face health issues of the babies/long-term NICU residence and lifelong difficulties.
We are now convinced that we only breed really high-strung, high-needs babies. Either that, or it really IS a sin and this is our penance! (Sorry... lapsed Catholic humor there.) So even if we somehow develop amnesia and go for it again, only one embryo will EVER be transferred into my uterus.
Posted by: Jennifer at Oct 26, 2006 11:28:21 AM
Ah now, my opinion on this has changed with 2 children. Here in the UK guidelines similar to those have been in operation for some time and there are moves in the direction of single ETs in some circumstances. When I was in the midst of multiple cycles for #2 I would have given anything for them to transfer a whole clutch of embryos and was heartily jealous of the Americans on IVFC who could do just that. However, since it transpired that I only managed to carry my singleton to 34 weeks I dread to think what the outcome could have been with twins. So, on balance, I'm in favour of these guidelines.
Fiona
Posted by: Fiona at Oct 26, 2006 11:29:57 AM
I think the objective of the guidelines is admirable - a reduction in premature births would certainly be a good thing - but I also think that the number of embryos transferred is a personal decision that should be made based on the individual patient's situation and medical history. Our clinic did make us aware of the risks associated with multiple births but ultimately left the decision up to us. My RE said, "We really don't like triplets," and urged us to consider selective reduction if it came to that. We ended up transferring three embryos, two 4-cell ones and one 7 cell. We decided that we'd be okay with twins, though nervous. But we weren't sure we'd be able to afford a second IVF, so if we managed to get our reproducing done in one shot, that would be advantageous. I was willing to take the risks if we'd turned out to have twins - I'm very healthy and I just had an intuitive sense that everything would be OK. (Let's not get into "what-ifs", shall we?) I don't know what we would have done if all three embryos implanted. We were not keen on the idea of SR, but on the other hand, also not keen on the greatly increased risk of medical problems for all babies.
Our IVF resulted in one healthy singleton pregnancy and we were OK with that too. Now that we have Tommy, I'm glad we didn't have twins! I know we'd have managed, but one healthy baby is enough work as it is.
We have two frozen embryos that we are planning to thaw and transfer sometime next fall. I guess we'll have to consider the possibility of twins then as well. But we'll cross that bridge when we come to it - given that one or both embryos may not survive the thaw. Not really thinking about that right now - we're just enjoying our son and being very grateful to have him.
Posted by: Jessica at Oct 26, 2006 11:30:38 AM
After my long journey with IVF the only that I have clear is that outcome is imposible to predict. We had three failed cycles transfering two and on our last one the doctor told us he was going for three, mostly because two of them didn´t look like they were going to make it to freeze so we might as well throw them in there too, he reassured me that the odds of a triplet pregnancy were very very low. He was kinda right. I am now 20 weeks pregnant with quads. I knew I had big chanes for twins, very little for triplets and none for quads and that´s what I´ve got, guidelines or no guidelines there´s no way anyone could´ve planned for this outcome.
Posted by: Gigi at Oct 26, 2006 11:31:15 AM
Massachusetts mandates fertility coverage. I believe that there is at least one other state that covers fertility as well, but I don't know which one it is.
Mandating fertillity coverage and taking the finances out of the picture when factoring how many embryos to transfer seems so, so important. Living in MA, my husband and I were able to make our decision about how many embryos to transfer without checking our bank account first. If we'd been shelling out our own cash rather than our HMO's, I don't know what we would have done. I know that mandated coverage is a pipedream, but boy, it just seems like a no-brainer that it should exist. Everyone deserves access to fertility service. But that's another rant.
That said, we have twins. We transferred two, both took. I will say that we were given LOTS of counseling/information about the dangers of multiple pregnancy. Lots. Our clinic does not push "selective reduction" (hate that term) in the case of twins, but makes it very clear that they offer the service and certainly don't think it's a bad idea. I spent most of my (blessedly uneventful) pregnancy just waiting for the s*&$ to hit the fan because of all of the "Danger! Danger! Twins!" stories I got from my RE and then my OB.
We were lucky that I had no problems and our twins were born healthy and huge. But to bring this back to the guidelines, I think the guidelines make sense in when a) taken as guidelines--every case is so individual and b) when finances are not a part of the equation.
What a great, thought-provoking post.
Posted by: snickollet at Oct 26, 2006 11:32:01 AM
I really don't think that the guidelines are unreasonable; in fact, under these guidelines, we would have done exactly what we did do, put back three earlier-stage embryos and got what we did get - twins.
If my clinic did provide any solid data on the dangers of a twin pregnancy, I ignored it. I was 37 at the time and thought that completing our family in one stroke would be brilliant. And then I did get pre-ecclampsia; I did get hospitalized bed-rest for five months; I did deliver early (34 weeks) by general anethesia c-section; and I did deal with partial paralysis as a result of the above.
I don't think that my story would make anyone not want a twin pregnancy and I probably would have done things exactly the same. However, I had healthy babies at the end and some women who go through the same thing do not. It's a fine line to draw - between scaring people and informing them of twin pregnancy risks - but, yes, I think that more could be done.
Posted by: Suz at Oct 26, 2006 11:35:42 AM
I always thought I wanted twins. I got pregnant with twins on IVF#3 and was ecstatic. We lost one of the twins around 9 weeks and I will never forget my RE practically breathing a sigh of relief that we did. He was sensitive to my sadness but kept emphasizing how much less risky my pregnancy now was. A good friend who is an OBGYN was also very alarmed when he learned we were pregnant with twins. I had no idea that twins could produce such alarm, triplets, sure, but twins?
I went on to have a healthy singleton pregnancy and we are planning on doing another IVF cycle next year to try for a sibling. I really only want to do a single embryo transfer. I always have a multitude of great looking embryos on day 3 but never have anything good to freeze. But I cannot imagine having twins...a singleton is hard enough!
I think the guidelines make perfect sense.
Posted by: at Oct 26, 2006 11:38:12 AM
I like the concept of this guideline, but I still think that mandating insurance coverage for IVF would go further towards reducing the incentive to take those risks - it's much easier to decide to transfer one or maybe two if you know you'll be able to try again.
... I just wish the March of Dimes would throw its weight behind that proposition.
Posted by: Rachel at Oct 26, 2006 11:44:50 AM
Those guidelines sound similar to my clinic's guidelines. In our case, I was 39 and 40 at the time of my ivfs. I would not have wanted to transfer 3 in the first ivf (having read a lot of Jody's posts), but after the first failure I was quite ready to transfer 3 the next two times. However, because I knew about their guidelines, I interpreted the decision to transfer three as meaning that the three were not very good specimens, especially when I found out what "morula" meant.
I never had a conversation about the risk of multiples with anyone official. I did discuss the number to transfer with my RE to clarify a discrepancy between what he said at our initial consult and what was on the printed guidelines I was given the day before retrieval. The answer was: transfer x, unless the patient really doesn't want twins. Message: twins are ok, more isn't, from the clinic's point of view. (Also, for my age, there aren't many twin preganancies at all coming out of my clinic, at least according to the cdc stats.)
As Lynn said, I learned a lot more about the risks of twins from reading blogs than from anything official I ever read. I didn't want twins, but like a lot of people I didn't really think of it as risky in the same way that higher order multiples are.
Posted by: luolin at Oct 26, 2006 11:53:53 AM
My clinic is extremely conservative, at least with women under 35. They are constantly reminding patients that a successful treatment cycle will result in a healthy singleton pregnancy. My RE would not allow me to trigger ovulation in an IUI cycle with more than 2 mature follicles, and in an IVF cycle she said she would transfer one embryo unless there was an exceptionally good reason to transfer two (we haven't made it to an IVF cycle).
I had four IUI cycles, the last of which resulted in a singleton pregnancy (which I miscarried at 12+ weeks). Three of the four cycles were carefully controlled and had only one mature follicle at trigger time. The remaining cycle was almost cancelled because it almost looked like I would end up with three mature follicles, but one disappeared at the last minute. The successful cycle had only one mature follicle.
I think the guidelines, so long as they are not mandatory and enforceable, are completely within reasonable limits. While I love the idea of raising twins, I hate the idea of carrying and delivering twins, so I'm all for conservative, but I definitely understand why others are all for twins. A good friend of mine got pregnant with triplets and just lost two of them at 13 weeks... the losses may very well have resulted from the inherent risk with trying to grow three babies where there is only space for one. I still think that doctor and patient need to carefully weigh the risks based on each patient's specific circumstances.
Posted by: Karen C. at Oct 26, 2006 12:02:43 PM
Great post, great discussion.
If I got warned about risks of multiples, I don't remember it. I did nonetheless "get it" and stubbornly insisted against ever transferring more than two, against my REs' advice. Their take (two different clinics, 4 cycles) was that, starting at age 34 with high FSH, I had about an 0.5% of ever having any embryo stick, at all.
I'll admit it, though, twins seemed plausible to me, if not desirable. I was deeply ambivalent about which outcome (one or two sticking) I'd actually have preferred though ultimately, I think, relieved that I've ended up pregnant with a singleton. I want two, but prefer one at a time, even independent of the healthy baby issues (I mean, I'd rather deal with one baby at a time, even if I could have borne healthy twins). I was always clear that for me, SR was not an option and not a situation I wanted to put myself in, though as Gigi's story shows, anything can happen.
This toughest decision in this last cycle was what to do with embryo #3 -- 5 cells on day 3 (the other two were 7 & 8). Throw it back in because what the hell? Or stick to my principles? In the end I did the latter. It would have helped had my clinic thought to mention that the insurance coverage I finally had would include the cost of freezing as part of what I paid for the cycle -- so no financial cost to my decision. Given that I do want two, knowing that this clinic has a zero percent success rate with FETs in women my age (now 37) sure made it harder, especially since my impression is that most of the "problems" with FETs arise from the freezing process rather than what happens in the FET cycle itself -- I can move to other clinic for the transfer cycle, but cannot undo whatever damage has been done through an inferior cryopreservation technique or medium. Oh well.
I do think that many couples would choose twins, and that the financial cost is a huge part of this preference. I suspect that US insurance companies may actually spend more dealing with the problems that non-coverage creates (as some couples make decisions based on financial resources, not medical risks) than they would providing coverage, especially since as groups, they could negotiate better cycle costs than we can, as individuals.
Posted by: Alex at Oct 26, 2006 12:03:27 PM
I think the guidelines are more than reasonable. I do wish that IVF here in the US was more affordable because the decision of how many to transfer is largely based on wanting some type of success to avoid paying another 10K.
I am one of those that never wanted twins. Too much risk and a lot of work after they are born. We've transferred 2 embryos 3 times in the last couple of years. We chose two embryos after hearing that in each transfer one of the embryos was at so low quality the doc didn't recommend transferring. So essentially it was one healthy embryo each time. We were lucky all the way around...one son and another on the way.
Great post.
Posted by: Andreaa at Oct 26, 2006 12:23:05 PM
Well, since you asked. . . I don't think that the recommendations seem unreasonable, but think that Snickollet said that best in terms of finances and restrictions. My clinic DID "warn" about multiples and DID advise on transferring no more than 2 when I told them selection reduction wouldn't be in the cards for me. Did I go into it wanting twins? No. I wanted to have a healthy baby. But after so much loss and a track record less than successful, I didn't twins happening. I was rooting for the embryos to take hold, which, of course, would have resulted in twins. And I would have been as happy/nervous with two as I would have been with one. But the embryos didn't manage to implant for any of my three IVFs or three IUIs and then I became that annoying anecdote that my fellow infertile sisters will have to survive with a grimace forever (went to an adoption fair, found out a few days later that I was pregnant, etc.) Now I am rooting for this fetus's survival, just as I had been for every.other.single.embryo we created regardless of the setting.
Posted by: Charlotte at Oct 26, 2006 12:25:27 PM
If there is a large contingent of infertile women who want twins, I am not among them. Infertility has made me more accepting of a twin outcome, but I still wouldn't call myself pro-twin. I can see being relieved at the active infertile phase of my life being over, but I want more than two kids, and I'd still like them one at a time, even with the struggle.
My clinic not only warns of the risks of HOM, but also recently sent out a thick pamphlet on its lower than average multiple birth rates, achieved through its emphasis on single-embryo transfer. Surely its not the only clinic doing this?
Posted by: at Oct 26, 2006 12:41:02 PM
I am opposed to such limitations, but that's just because of my personal story.I agree with many who said that if we had insurance coverage, many of us (including myself) would not feel so much pressure to up the odds each cycle by transfering more. But finances definately play a role in all of this. I did all three of my IVFs when I was 29. IVF #1, we transfered two blastocysts and got a BFN. IVF #2, we transered three embryos on day three and got a chemical pregnancy. IVF #3, I insisted that they put back four embryos. I was tired. I was so sad. I was desperate. These embryos didn't look as good as the other cycles, but after my DH and I pushed for it, they agreed to put back four. We got pregnant with one - our DD is 8 months old. I'm convinced she was embryo #4.
Posted by: Holly at Oct 26, 2006 12:41:56 PM
I also read that article with interest (and a little cringe at "implanted.") Our clinic gave us information on the risks of multiple births and suggested that, given that I'm in my twenties, we transfer no more than two embryos during our IVF cycle. Although we had multiple nice looking embryos that had to be left for possible freezing, we followed through with transferring only two, neither of which took. So...would I do it again? Yes. While two for the price of one sounds fabulous, I'm too aware of the risks of multiple pregnancy and, for that matter, too aware of the huge job that is parenting. We'd have been happy with twins, but also worried about all the extra demands on us. I'm a pretty risk averse person and, even if we had cycled again, I think that I'd have stuck with 2. (...I think. Even as I write that I remember the desperation and wonder if I'm telling myself the truth.) Now that I'm pregnant after an FET in which only 1 of the 3 embryos survived the thaw and was transferred, I find that I am not a bit sad that I spent all this money and all I got was a singleton (a la the "went to disney world and just got this lousy shirt" t-shirts.) I've had a few friends sort of gently hint around about whether or not we were disappointed to "only" have one and the answer, quite honestly, is no. We really are thrilled. I really didn't have a huge desire for two (or more) at once.
I should add one more thing. Although I've written about the decision from the "do we want multiple?" point of view, I think that a lot of it was also tied up in money. This was all out-of-pocket and our try cost us what was, at the time, my annual salary. I wonder how many of us want this to just be about the moral and practical dimensions of transferring multiple embryos, but find that it's also very much about money. (Didn't I read somewhere that Britain and Australia, who have greater IVF coverage, have lower multiple rates?)
Posted by: Meredith at Oct 26, 2006 12:52:14 PM
Have you read "Making Parents" by Charis Thompson? She addresses this sort of thing:
* Requires annual review of clinics’ performance and publish a list of those with highest and lowest rates of higher-order multiple births.
And shows how hopelessly impossible it is to keep track of clinic success/failure/single, multiple (whatever) rates based on the many ways clinics manipulate their numbers. So I am wondering if, however laudable it would be--this is even possible.
Also, did you see that "American Exerience" dcocumentary on IVF the oterh day on PBS? I would love to hear someone smart (um, you?) who knows a lot more about this stuff address it. It was sort of a politically, ethically empty celebration of IVF that did not once address things like access (cost) or drug/hormone side effects on mothers or mutiple birth risks or anything of real interest.
Isn't there a new European trend towards "natural" cycles and single egg retrieval when possible? Or is it a media invented "trend?"
Posted by: shannon at Oct 26, 2006 1:12:06 PM
I got pregnant with twins during my first IVF cycle. I was 40 years old at the time, had 5 embryos that made it, and my RE recommended transferring ALL FIVE!!! And so he did. He said something like, "you'll be lucky to get pregnant, nevermind keeping the pregnancy."
Well, here I am now with 11 month b/g twins. I love them dearly and I was one of the very lucky ones. My pregnancy was uneventful and I delivered vaginally at 38 weeks. Go figure.
BUT, my RE did not clearly present me with risks and information. For instance, I had no idea that a twin pregnancy could be so much riskier! I was shocked when I began reading. More to the the point, he made me feel it was SUCH a remote possibility as to be like 1 ft. of snow in South Georgia that we didn't think twice about transferring all five.
That is my story, such as it is. I don't know that we would have changed our minds, but more information would have been useful.
Posted by: Deborah VA at Oct 26, 2006 1:15:39 PM
I did not make it as far as IVF, however, with IUI + injections in the wazoo, I was well informed of the risk of multiples. I was also wishing for twins.
I wanted twins so badly that I even named my pregnancy "Mr. Peabody and his pet boy Sherman".
The u/s gave us Peabody...
I suspect that most people who are going to IVF are paying out of pocket and the idea of multiples is not bad considering the cost of each IVF run. If IVF was covered by insurence, I think more people would transfer 1 to 2 instead of 2 or more.
I also think the March of Dimes is out of line here...But that is just me...
Posted by: Spacemom at Oct 26, 2006 1:22:22 PM
This is a great conversation and topic and I'm happy to hear so many other perspectives. We have not done IVF yet, but it's in the cards for February. We started IF treatment last year and when all our tests came back with positive news, our RE had fits trying to convince us to go slow so that we could avoid multiples. He was absolutely freaked out about the idea of my having more than one baby. Freaked the fuck out. He was convinced that given my history (32, ovulate regularly, DH has good swimmers, etc) that we would get pg. We hate him.
We did 5 medicated IUIs and only twice had more than one follicle (once had 4 and once had 2 both of those failed). Of the 5, we had only one chemical pregnancy.
We were led to believe that most of the higher order multiples were the result of IUI and not IVF. Were we misled?
As we prepare for IVF, all of the docs we've consulted advised that we transfer no more than two, but all are assuming we will make great looking embryos. Given some of the overly opimistic crap we've been told already, I'm assuming we'll make less than stellar embryos but will still probably only transfer two. I have a chronic disease that may make being pregnant difficult and adding twins to that sounds scary but a risk I'm willing to take. The only reason we plan to transfer two is that we are paying out of pocket and would like to increase our odds of getting pg and having a baby before we go bankrupt. Otherwise I'd be happy to just keep transfering one until it worked.
Posted by: Sarah at Oct 26, 2006 1:23:31 PM
I didn't have time to read all the comments, so sorry if I'm repeating someone.
Here (Ottawa, Canada) they absolutely will not consider transferring more than two if you are relatively healthy and under 35. For my IVF, we only had three 3-day embryos and had to freeze one. Despite my begging, they simply wouldn't consider it, and the risks of multiples was explained to me on more than one occasion.
In retrospect, while I'm not thrilled about the four years of freezer fees, I think this is a reasonable policy.
Posted by: DaniGirl at Oct 26, 2006 1:28:13 PM
Guidelines, fine. Laws, no. I don't need Bill Frist looking over my doctors' shoulders, thankyouverymuch.
After four cycles out of pocket, I finally have mandated coverage (I work in NJ). It covers donor egg, up to four times, which is what I'm doing next. I pay non-medical costs (donor fee, psych eval, etc.), deductible and co-pays. I should be able to do this for ~7k as opposed to ~27k.
In all honesty, if I didn't have coverage, I would probably transfer two. Since I do have coverage, I'm leaning toward a single embryo transfer. I'm playing it all by ear because who knows what will be by day 3 or 5.
When you're in the thick of this, twins can seem appealing and I don't think that there's anything the REs or peris of this world can do about that. When I read some of the IVF boards, I see a lot of women who just find out that they are pregnant with twins or trips get angry when their doctor discusses the risks. And a lot of twin/trip moms encouraging them...even the ones who had difficult pregnacies/deliveries.
The other thing about extreme HOM -- I believe that most are from either IUIs gone bad or, more likely, a woman stimmed for an IUI, responded better than anticipated, the RE cancelled the cycle and the couple went home and had sex, hoping for a freebie.
The media and the general public don't differentiate between IUIs and IVF. It's all the same as far as they're concerned. All that's ever said is "fertility treatments" without specifics as to what procedure it was.
Which is why, when I told a friend I was doing IVF, she panicked at thought I was going to have quintuplets the first go. Nevermind that I was 41 at the time.
(sorry this is so long)
Posted by: ...Lisa at Oct 26, 2006 1:41:30 PM
My clinic never discussed the risks of multiple births with us, but since I had a close friend with twins who were born prematurely and several cousins who are twins, I had an idea of the risks. Even so, I thought twins would be a good outcome because I would not have to go through IVF again. Money was certainly an issue. I borrowed money for our first IVF and two FETs and did not want to borrow more. If insurance would cover IVF (and all other infertility treatments), I would be in favor of the restrictions. However, if we are paying out of pocket, we make different decisions. Instead of a choice between a single baby later or multiples immediately (with the risks), we have a choice of multiples now or no baby at all if you can't afford more cycles. Despite the money issues, when it came time for our transfer with our FET, my RE recommended that we transfer 3 embryos, but I told her I only wanted 2 because I was terrified of the idea of triplets. When we showed up for the transfer, they had 3 embryos ready. One of the embryos only had 1 cell left (the other two were 8 cells) so I justified that it would be okay to transfer it. We got a BFN on that cycle. After that BFN, I wanted to transfer 3. We transferred three good embryos. When my beta numbers were high, I was so afraid that it would be triplets, but I ended up with twins. I had a healthy pregnancy and full term healthy babies. While going through the infertility treatment process, most women become more willing to take chances that will led to multiples. I think limits on transfers would be a good thing, but only if it is coupled with insurance coverage. Otherwise, the patient should be able to make the decision and the insurance company will have to pay the costs associated with multiple births.
Posted by: Sandy at Oct 26, 2006 2:08:20 PM
Because I live in and did IVF in a country with guidelines - that *are* enforced, a few of which piss me off - I guess I've drunk of the guidelines Kool-Aid. I see nothing wrong with them. (Good lord, I'm becoming Swiss?)
In Switzerland transfering more than two embryos is not allowed. (No insurance coverage either)When I asked why, since at the time all the info I had was US-based and many - most? - of the comments I was reading seemed to indicate transferring three was the norm, my doctor very clearly said because we don't want triplets (though of course with two embryos it can still happen) and proceeded to tell me the risks to myself and any potential triplets, no sugar-coating. (My RE, by the way, is great with the science but bedside manner? Well, he's Swiss so, um, none; at our first appointment he made me cry in the first five minutes.) He's also pretty upfront about the fact that he doesn't think twins are an optimal outcome either, though he will transfer two if that's what his patients want. But he'll tell you all the ways twins can do worse than singletons, too (he's got your back on that one, Jody!) (we transferred two and I had a singleton pregnancy).
Personally, since we have a pure male factor issue I would never transfer more than two (in the hypothetical that I lived someplace that allowed that), especially now that I know how well the first IVF went. Sure, any subsequent cycle could blow but I have to work under the assumption that if a fertilized egg actually makes it to my uterus, it'll stick.
What was most interesting to me was when I had to decided how many to transfer for my upcoming FET. I asked my RE how the risks to me of a twin pregnancy might have increased given I'm almost three years older. He said in that regard not much had changed - a twin pregnancy is riskier than a singleton at any age and I'm not so old that it has become disproportionately risky - but he made a big point about urging us to think about our son - that if we were to have twins now, he'd get the short end of the stick for the first year of their lives just because of the demands of twins. He actually said "You have to think about Son now. Your existing child is more important than any potential future child." Which, personally, I respect and, personally, I find myself going into the FET more conservatively - single embryo - than the initial IVF.
Of course, had all this failed I would always wonder if we'd been allowed to transfer three if that would have made the difference. So do I approve of the guidelines because they don't affect my situation and that allows me to disregard them? That's an awful thought to have about myself...
Posted by: swissmiss at Oct 26, 2006 2:23:32 PM
the way the law works here - there are never more than 2 embryos. but - it's as one commenter said: insurance pays for any tries necessary, up to two live children. this is because cost studies showed that the cost of severe prematurity/disability services end up more expensive than paying for more ivf - the ethics aside. it's an argument that you can make to insurance companies who don't care about health or anything, but do care about money.
Posted by: sara at Oct 26, 2006 2:48:23 PM
I'm with the "if they are so concerned, then push for insurance to cover it" camp.
I was quite suprised when the "implant vs. transfer" debate came up in my Catholic Theology class. Father insisting that part of the reason that doctors are "playing God" is because they implant the "baby." He said "implant" the way most people who say "pile of turds." I tried, and a nurse in the class, tried to set him straight, but he seemed confused.
And he wonders why I don't listen to him and his peeps on these issues?
Posted by: Kathleen at Oct 26, 2006 3:07:56 PM
What Sandy said.
Also - my story - we had two failed IVF cycles (canceled because of my poor response to meds... I *only* made 5-6 mature eggs, and my RE would only do retrieval for 7 or more!). ~6 months after those back-to-back IVF attempts, we decided to try the "unthinkable," and did IUI with injectibles. Our plan was to do no more than 3 cycles that way, as the risk of HOM really worried us.
I insisted on trying a new drug protocol, because of my poor response on the RE-recommended meds. First IUI/injectible cycle... several mature follicles, but a BFN. Had to suppress for a month. Second try (same drug protocol) yielded 21 follicles, at least 7 of which looked mature. I was TRIGGERED, and ended up pregnant. Initial beta result was reported as 643. My RE said we were pregnant with *at least* triplets... possibly sextuplets.
I was angry and scared. We had already adopted twice (first daughter was 2 at the time, and second daughter was being born concurrent with finding out this IUI had worked), and I couldn't imagine potentially having EIGHT children under 3 years old! That is, "best case" scenario, with all 3-6 babies born healthy (yeah, as if THAT would have happened). And I couldn't even bear to consider SR, given that we had spent 5 years and a small fortune trying to CREATE life.
Anyhow, all this to say... guidelines schmidelines. We would have LOVED to have twins (and kind of do now, with our two youngest daughters being only 7 months apart in age), but it was incredibly irresponsible of my RE to trigger me with 7 mature follicles. At the same time, if they had canceled my cycle (or tried turning it into an IVF instead), we probably wouldn't have Samantha.
Everything needs to be addressed on a case-by-case basis, after taking all the medical/risk information and personal history into consideration.
And yes... having insurance cover the COST would make things SO much easier!
Posted by: Woody's Girl at Oct 26, 2006 3:16:03 PM
I think each person's RE should do what's best for them. I had 6 eggs retrieved, 4 were mature and 2 fertilized and were put back resulting in a singlton pregnancy. I think they might be more concerned with RE's doing IUI's with women who have more than 5 or so mature follicle's. I wonder how much of the increase of multiple pregnancies have to do with that?
Posted by: Wendy at Oct 26, 2006 3:35:00 PM
I think the guidelines are reasonable, and I also think it's good that they are unenforceable. Every woman's case is unique, every woman knows how much she can handle, and I think it is up to the woman and her doctor to decide how many embryos should be transferred.
I never had to face such a decision, as my IVF resulted in just two embryos, both of which were transferred, resulting in one twin lost at 7 weeks gestation and one healthy baby boy. Because I'm 38, transferring 4 embryos (as the guidelines recommend) sounds good to me. I would hope that when we try IVF again, we'll actually have the option to transfer more than one.
Interestingly, while my RE did warn about the risk of multiple pregnancy, he was later extremely resmorseful when we lost our twin, and even said how nice it would have been for us to have been able to have two kids with one pregnancy. So I guess he thinks it's worth the risk, as did I.
Back then I would have been thrilled to have twins, but I was so happy to have just one baby on the way, the loss of the twin was not as painful as one might expect. Now that we're heading for IVF#2, though, the prospect of twins would mean finding and moving into a new (bigger, less expensive) house, and me pretty much quitting my wonderful work-at-home freelance job. I'm sure we could make it work, but it would be much more of a burden financially. That said, however, I'd still go for the 4 embryos, if we had them to transfer.
On a totally different, but related subject, Julie, have you or anyone else here doing IVF tried DHEA? I've been reading that in combo with fertility drugs, it can increase egg output in older women. I bought some but am hesitant to take it, as there seems to be little research on potential negative side effects.
Posted by: kristylynne at Oct 26, 2006 3:41:20 PM
I don't have a huge problem with the 'guidelines' but I really believe they should be VERY flexible. I have had 5 IVFs, the first with 2 and all the rest with 3. I am 34 now, and when I went for the latest transfer the dr said he would put in 2. I pushed for 3. I would have been thrilled with twins. I do understand the risks and issues, and I am ok with them. I think with my health and H's health, and the hospitals here, that much of the fear would have been mitigated.
The dr finally agreed and made both myself and H sign something that said we were warned about the risk of triplets and we accept it. We both signed gladly.
Today is 6w0d and we apparently have 1 healthy embryo???/fetus???. I don't even know what I am supposed to call it now, we have never successfully gotten this far.
Posted by: Nicole at Oct 26, 2006 3:55:51 PM
I do believe that most HOMs result from IUI not IVF. Though I don't know that, and the CDC stats that clinics are supposed to report apply only to IVFs.
Posted by: Alex at Oct 26, 2006 4:14:09 PM
I'm interested in discussing the insurance coverage aspect of the situation. I've always been against IF coverage, because it's not medically necessary. I don't know about you, but our health insurance costs are out of control. I've always put IVF coverage in the same category as a variety of medically unnecessary procedures -- everything from nose jobs to sex-change operations -- which do cause varying levels of trauma and mental anguish to the patient, but should taxpayers and/or health insurance group members have to help me pay for it?
I struggle with this question. As a Libertarian I am against covering optional procedures. As a woman battling infertility, it would be great for me if it were free. Tough place to find yourself.
Posted by: marie at Oct 26, 2006 4:35:34 PM
This one gets me started. In the UK where we have "free" healthcare (hahahaha!) someone who has stuffed themselves full of lard and inhaled the smoke of 40 cigs a day will get the heart bypass op for free because it's "medically necessary"...however, infertiles are allowed only 2 rounds of IVF and only if they have no other children, stepchildren included.
Posted by: Fiona at Oct 26, 2006 4:43:23 PM
