The next time around

So, lots of chatter today about limiting embryo transfers to reduce multiple births. Given that I'm a post-infertility mother of multiples, you might imagine that I'd have a thing or two to say about it, and you'd be right.

Quick recap for those of you who tuned in late: I got pregnant on my first injectibles/IUI cycle, which had been planned as a test run for IVF. I had six mature follicles at trigger, and I'm damn lucky that there were only two (plus something at 5 weeks that could have been a third sac). I got pretty sick from OHSS, and wound up in the hospital -- I didn't have a lot of free fluid, but my ovaries were the size of oranges, and I was in so much pain that they put me in for pain management. While I had lots of scares during my pregnancy, nothing actually went wrong until preterm labor at 32 weeks, which was easily stopped, and I ultimately had a smooth delivery and healthy babies. Overall, we were unbelievably fortunate, again and again and again.

We took a HUGE risk in going through with the cycle, one that I didn't really appreciate until well into the pregnancy. I was as informed as anyone could be -- my mother is the head nurse at my clinic, has 20 years of experience, has seen all the bad things that can happen, and told me all about them even when I didn't need to hear them. Still, I didn't really understand that a twin pregnancy was a big scary deal until, well, it got scary. In Julie's comments, I see a lot of sentiment that IVF patients should be better informed of the risks of multiple pregnancy, but honestly, my own opinion is that you could inform them until the cows come home and it wouldn't matter. Some things, you just can't learn by observation, only by experience; you think you understand what others are feeling, but then it actually happens to you, and you look back and laugh at your presumptuous self.

I don't think you could have told me anything that would have made me handle our cycle differently, short of looking at a crystal ball. But now that I've been through a multiple pregnancy, you better believe I'm giving a lot of thought to how we'll do things the next time around.

When you have twins, you learn pretty quickly that you could save yourself a lot of time and effort by just distributing a FAQ. You get asked the same questions over and over again, some disturbingly personal -- do they run in your family? (and its cousin, did you do infertility?) are they identical? can you tell them apart? do you nurse them, and at the same time? did you have a c-section?. Another popular one is "will you be having any more?", especially because ours are the same sex, and people tend to assume you want one of each. When I was pregnant, I would say I didn't know, but now that the babies are here, the clear answer is that we'd like to have more.

What's not clear, and won't be for some time yet, is just how possible that's going to be, and how much technology is going to be involved. Perhaps my unbelievable streak of reproductive good luck will extend to eventually start cycling on my own, and all these worries will be for naught. If it doesn't, though, we'll have a major dilemna on our hands about what to do about it. We know a couple of things from the last experience -- I don't respond to Clomid/Femara, I start slow and then go off like gangbusters with injectibles, G has great sperm, I'm prone to hyperstimulation, I can get pregnant if my ovaries can just be coaxed into spitting out the eggs. In a rather literal sense, all of our reproductive issues are in my head, tucked away in a questionably functional hypothalamic-pituitary axis.

If it weren't for the multiple thing, I think it would be a no-brainer to start off with injectibles/IUI, stimming a little more patiently to avoid the OHSS. And honestly, I'd be all right with risking twins again. I've had one successful twin pregnancy, making it somewhat more likely the second one would go OK. I'm doing reasonably well with twin motherhood, and while I suspect it would be a good deal harder if I had a pair of three-year-olds running around, I would also have the advantage of experience. I wouldn't consider it a desirable outcome, the way I did the first time, and I think I'd have a lot more oh-crap moments. But I wouldn't have a total meltdown about seeing two heartbeats, either.

What does make me want to go and hide under the bed is the thought of seeing *three* heartbeats, or more. We would not, we think, discuss selective reduction of triplets, but the idea of a triplet pregnancy fills me with fear. I don't think anyone has triplets without some pretty serious pregnancy and birth complications, and I'm not so desperate for more children that I'm really willing to put them, or myself, through that ordeal. Three or nothing is an entirely different proposition than five or two, and while I think I'd always be sad that we didn't have more babies, it's not the same as if we had none at all, or an only child.

So, if we're really serious about avoiding triplets, injectibles/IUI is off the menu -- even with a single follicle, I could still be in Jody's shoes. I think we'd go straight to IVF, transfer two, and hope that we wound up in the singleton 75% (contrary to the opinion expressed by a friend last night, who thought that almost all post-infertility births are multiples). I'm under 35, and have most of the factors that the studies say make single-embryo transfers successful, but my clinic's FET stats aren't that great. Fresh cycles are a big risk for me, with the OHSS, so regardless of cost, we'd have to lean toward FET to use up all our embryos if the single-embryo transfer didn't take. If the success rates were anywhere in the same ballpark, I'd consider it, but they're not and that's that. It's also an emotional thing -- I don't have the wherewithal to handle failed FET after failed FET.

So yeah, next time around, I think we'd just start with IVF and risk OHSS and twins again. Doesn't sound like much fun, though. I'd rather hope to just ovulate like a normal female.

And while we're at it, can I have a pony too?

(NB: Mind you, I'm not about to start back into treatment just yet -- I want the girls to be at least two before we start trying. But never say I don't consider my options well in advance!)