Decisions, decisions: a few thoughts about deciding how many embryos to transfer

One of the difficult parts of an IVF cycle comes near the end when the decision about how many embryos to transfer back must be made.  From a medical standpoint, this decision can be difficult because there are no hard and fast rules; every individual situation is different and involves multiple factors such as embryo quality, maternal age, prior treatment history, etc.

From a psychological standpoint, the decision about the number of embryos to transfer can be tricky as. Well.  Usually, these decisions need to be made quickly because the information about the embryos is only available right before the transfer. Further, by this point in the cycle, emotions and hormone levels as running high, making clear and rational thought a challenge.

Perhaps most importantly, however, is the fact that by the time a person is usually facing their IVF transfer, they have been dealing with infertility for a while.  Thus, they are naturally desperate for the whole thing to be over and done with as soon as possible.  The idea that putting another embryo or two back might increase their chances of success, meaning they could be on their way to parenthood very soon, is quite seductive.  If financial issues are a concern, an increased chance of success in fewer cycles is also a strong motivation.

I hear many clients tell me that their ideal outcome of an IVF cycle would be twins.  "Two for the price of one," and "buy one, get one free," are common refrains.  I totally understand that sentiment.  I think I may even have said those things regarding my own treatment at one point or another.  However, part my practice involves working with people who have experienced perinatal loss and/or who have given birth prematurely and whose children have spent an extended time in the neonatal intensive care unit.  Many of these people began their path to parenthood via IVF, and transferred multiple embryos.  There experiences in the NICU are often extemely difficult, traumatic, and of extended duration.  All of them have expressed a wish that someone had really helped them understand the risks associated with multiple pregnancies before their IVF transfer.

In addition, even if things work out medically, my work with the parents of multiples has taught me that having twins or triplets can sometimes be hard on a relationship as well, especially if there are other life stressors occurring simultaneously.

I don't mean to be full of doom and gloom here, as I know many healthy and happy families with twins and triplets.  But I do urge people to really educate themselves about the medical and psychological risks associated with multiple pregnancies before they get to transfer day, so they are prepared.  The good news is that with today's improvements in embryo freezing technology, single embryo transfer is a more viable option with a greater chance of success.

Sometimes the decision about how many embryos to transfer is made for you by the situation; you may only have one viable embryo, or the quality of the embryos may suggest transferring multiple embryos.  If you do end up with a choice, then you need to weigh the risks of multiple pregnancy against the emotional and physical wear and tear of doing another frozen embryo transfer.  After seeing the problems that can arise with multiple pregnancies, I find myself recommending single embryo transfer more often these days.

Of course, the decision about how many embryos to transfer back is a personal one, and can only be made by you and your partner.  Just be sure that you have all the facts, so you can make the choice that is best for your situation.

Infertility, pregnancy, and self-esteem

I was picking up my daughter at a class the other day, when I overheard one of the other mothers talking to the school director.  "Did my daughter tell you our news?" she asked excitedly.  It turned out that this woman was unexpectedly pregnant, after undergoing infertility treatment to conceive her children.  Her face was all aglow, and she went on and on about how she was finally normal, finally experiencing a miracle.  To her credit, the school director told her, "Well, I think all your children are miracles," but that really didn't even slow her down.

I left feeling uneasy, and frankly, a little irritated by what I had overheard.  I was also irritated at myself--shouldn't I be as happy for this woman as she was for herself?  After all, she was experiencing the holy grail of infertility treatment--the spontaneous pregnancy.  As I further considered my reaction, I realized that what was really bothering me was this woman's assertion that now, and only now that she had achieved a pregnancy without treatment, that she was normal.  That now, she could feel good about herself.

The more I work in the field of infertliity, the more I am able to see how much we, as a society, tie the concept of fertility in with our sense of self-esteem.  If a woman can be pregnant and successfully deliver a baby, she's normal and good; if she can't, she's something else--at best someone to feel sorry for, and at worst someone who God/the universe is trying to tell that she doesn't really deserve to be a mother anyway.

The pain that this societal assumption causes is immense.  Further galling, anyone who thinks rationally for any amount of time about this assumption will realize it is patently and ridiculously untrue.  Of course we all know supremely fertile women who are failing miserably at parenting; and we all know (and might well be) supremely infertile women who will make amazing parents once their infertility crisis is resolved.

I guess this is why I felt so annoyed with the woman at my daughter's class-a feeling of "et tu, Brute?"  After all, she is one of us--and yet she still bought into the fertility=normal/good equation hook, line, and sinker.

After a long and protracted battle with infertility and my body in my quest to have children, I have come to realize that I can't let my infertility define how I feel about myself.  It was all beyond my control anyhow, and even if it wasn't, I can't feel worse about myself because of it.  In the same light, I can't feel like I'm a better, normal/good person because today my lungs are functioning well.  That's out of my control too.  Instead, I must judge myself on how I respond to my circumstances, and how I treat others in my life. 

I hope if you are struggling with infertility, you try to do the same; remember that fertility, or infertility is not the measure of a person.  Our efforts, our choices, and our treatment of others are much more valid criteria for self-assessment.

The light at the end of the tunnel: aging out of expectations of fertility

When I was in the throes of infertility treatment, I remember often reading and hearing that infertility was just a life phase, and that over time, it would resolve itself one way or the other. Life would go back to normal. Of course, this was intended to give me hope, and strength, but instead of finding it comforting, it just made me want to throw up.  I could already see then, as I can confirm now, that there was no way I was ever going to be the same person after going through all of that pain and disappointment.

In that way, it seems that infertility never ends--even when the struggle is over, our perspectives and relationships have changed.  However, I can say that one of the silver linings of getting older is that now no one is expecting me to be able to have babies anymore!  As I approach my mid-forties, I no longer am asked whether or not I am going to have children, or have more children.  People just assume that it's all done with, and because of my age, I am not very likely to become pregnant--and here is the important part--JUST LIKE EVERY OTHER WOMAN MY AGE.  Yes, I've found myself back in the "normal" group again.  It took a decade or two for everyone else to catch up with me, but now we are all in the same boat.

I can't tell you what a sweet relief I have found this to be.  It almost takes the sting out of my encroaching wrinkles and grey hairs--almost.  Now that the book is closed and the dust is settled, it occurs to me that most women my age had their children quite some time ago, and that they haven't defined themselves by their ability, or inability, to get pregnant for quite some time.  They have left all that behind and have moved on to other aspects of their lives.  Perhaps that's one of the problems with infertility--it can imprison us in the "reproductive phase" of our lives for extended periods of time, but without the easy ability to complete the phase successfully.

Thus, although the emotional changes infertility causes never fully leave us (nor, in my opinion, should they) it does seem that society's expectation that we go forth and multiply does, thankfully, come to an end.  As for me, I notice the difference in myself when I am social situations with people I don't know very well.  For years, every time I met someone new, I had been unconsciously bracing myself for the questions about babies and pregnancy, whether they actually arose or not.  Now I can observe myself feeling much calmer and lighter in these situations, knowing that the questions just aren't going to come up.  Although that's not a complete end to the "infertility" phase of my life, it certainly feels much better, and it isn't as much of a constant presence in my mind.

The Infertility Therapist gets cranky, part III: a study of dubious usefulness

Perhaps I'm just in a cranky mood, but I was shocked to open my January 2013 issue of Fertility and Sterility and discover an article entitled, "Attractiveness of women with rectovaginal endometriosis: a case control study" (Vercellini, Buggio, Somigliana, Barbara, Vigano, and Fedele).  I first thought that surely the article couldn't be about what I thought was about, but a closer examination revealed that I was correct.  The authors spent considerable time and effort to compare women with different types of endometriosis--rectovaginal, ovarian and peritoneal, along with women with other gynecological conditions--on the variables of BMI, breast size, waist to hip ratio, and age of first coitius.   They were also evaluated for attractiveness by a panel of four judges.  According to the findings of the study, it turns out that women with rectovaginal endometriosis are considered to be significantly hotter than the women with the other conditions.  So ladies, if that's you, you have my congratulations.

Can someone out there in the blogosphere please enlighten me as to 1) why this study was conducted in the first place and 2) why it was accepted for publication in a major scientific journal?  The study authors argue that different types of gynecological disorders might be due to different genetic phenotypes, which would cause women to have different types of appearances.  But is that really going to be helpful to science?  Are doctors really going to start diagnosing the type of gynecological disorders a patient has based on how attractive they seem or when they lost their virginity?  Especially when we can already diagnose these disorders using things that seem a bit more reliable, like ultrasound images, DNA testing, or surgical reports.

Endometriosis is a complicated disorder that causes a great deal of pain and suffering.  Heck, I even have it myself (although not, as you may have guessed, the kind that makes a girl look appealing to a panel of four trained judges).  Isn't there a better way to work on finding a treatment and a cure?  In my opinion, infertility patients deserve better than an objectifying and demeaning study like this one, which seems to serve no one's interests.

Top tips for surviving infertility treatment, day ten--recognize your own strength!

In infertility treatment, it's all too easy to focus on what's gone wrong, and on what you can't seem to do.  It is harder to take a step back and see things from a broader perspective, in which it becomes clear all that you have done, and all that you have learned.  Almost all of us are changed by our experiences with infertility, and I feel mostly in a positive way.  We know that we can be strong, and tough, and brave, even when the stakes are high.  We learn that we can endure more than we thought we could.  We learn new and better ways of coping with stress and difficult feelings. We see how much empathy we can have for others experiencing similar difficulties.  We show ourselves that our capacity to love is strong, and profound.

When you are feeling down about how things are going, I would encourage you to take a step back, and look for your own private moments of heroism.  Think about all the things you have learned, and the distance that you have come.  I'm confident that you will find a great deal of good mixed in with all of the bad. 

Recognizing your own strength can restore some of the self-esteem that infertility can erode away.  And above all, remember:  infertility is a medical, biological problem over which you have little or no control.  It isn't a referendum on your character, and it isn't some sort of cosmic message that you wouldn't make a good parent.  You are more than the functioning of your organs or cells.  You are just as good as anybody else! 

I wish you all the best of luck in your infertility treatment, and would love to hear how things are going.  If  you have any questions, comments, or suggestions, please leave me a comment, or email me at lisarouff@gmail.com.

Top tips for surviving infertility treatment, day nine: take the long view

Many times, it seems that the pace of infertility treatment can be excruciatingly slow.  First, you have to wait  to get a period, then have tests done and then wait for results.  Even after treatment occurs, you often must wait nine or more days to find out if it worked, and even if it did, you must wait again to see if your hormone levels are rising properly, etc., etc.  The waiting is so terribly difficult, especially because by this stage of the game, you are already probably "behind" on your life plan of when you would start your family.

Thus, it makes sense that people generally are in a big rush when it comes to infertility treatment.  Being stuck in the process, not knowing how it is all going to turn out is very painful, so naturally we want to get through it as quickly as possible.  However, sometimes it is necessary or prudent to wait--either until medically the situation is optimal, or until we can get an appointment with the doctor we think might be most helpful.   Setbacks and delays are common.  I remember one RE telling me during my treatment, "In the scheme of your life, it won't matter if you get pregnant now or a few months from now."  I thought he was crazy (and I ended up getting pregnant five YEARS later) but now with the benefit of hindsight I see that what he said was true.

It's true that infertility treatment is painful and anxiety provoking. But it's also true that we have limited resources to devote to it and a limited biological window of opportunity to exploit--so sometimes it pays to take a couple of extra months to get everything lined up just right, to give ourselves the best chance we can have at treatment success.

If you find yourself rushing around, it might be wise to ask yourself if there is anything else you might be missing.  And if your doctor or nurse is telling you to wait or slow down, chances are they have a pretty good reason.

In the end, it all comes down to taking the long view. You need to do everything you can do to the best of your ability to prevent having regrets later on down the line, when you can't do anything to change the situation.  Try to think of how you might view your current decisions in ten or twenty years, and make sure they won't be likely to cause you future pain.

Thanks for reading, and I'll be back tomorrow with a final tip in this series.  Have a great day!

Top tips for surviving infertility treatment, day eight--remember that "different" isn't bad

One of the things I have learned throughout my life is that people tend to have very negative initial reactions to things or events that are outside the realm of "normal".  If you think about it, negative reactions to things or people that are different are probably the cause of most of the trouble in the world, including prejudice, wars, and everyday common social cruelties.

Infertility treatment provides plenty of opportunities for such negative reactions.  By the time infertility treatment gets into full swing, "normal" has usually been left far behind.  We are left trying to figure out how to deal with the fact that our families didn't come into being the "normal" way.  What will we tell our children, our families, our friends, and those nosy folks who make inappropriate comments at the supermarket?

I've been struggling with this in my personal life for over a decade now, and because my oldest daughter is adopted and looks quite different than me,  she and I have had our share of questions and comments about our deviations from "normal".  I have always tried to emphasize to her and to others that being different doesn't mean things are worse somehow.  Being different just makes us interesting.  And interesting is good--we have a unique and special story to tell about how we became a family.
For the most part, I have been remarkably fortunate that when I present things in this light, people respond positively.  It seems to help them challenge their own assumptions, and to feel a little better about themselves and world.

So remember, although you may be on a different path to parenthood that is outside of the norm, it doesn't necessarily mean it's bad.  It just means it's different, and different can have it's own charms and wonders.

Thanks for reading, and I hope you had a great day!