Thursday, 31 October 2013

The Twins Dilemma

*Disclaimer: this post discusses my brutally honest feelings about having twins. Those with twins may wish to skip this post*

A few hours after I told an old friend about our infertility issues and plans for IVF, she hugged me at the train station and whispered in my ear, "I hope IVF brings you a two-for-one!" On the morning after Marshall and Lilly's wedding, I had the same conversation about IVF with Robin and she responded, "well, you'll have twins, but they'll be best friends for life..." Both comments pissed me off, but I didn't say anything to follow up as in the first situation, as I needed to catch a train, and in the second incidence, I was tired and a bit hung over.

I was annoyed that the first friend presumed that I would want to have twins, and irritated as the second assumed that IVF equals a twin pregnancy, although to her credit, she does have two friends who did IVF and both have twins. It is a little more straight forward in our case, as Husband and I decided long ago that we only want to have one child. As we're both only children ourselves, we've lived through the advantages and feel we're reaping the benefits as adults. Echoing some of the words my dad used when I was growing up 'we're going for quality, not quantity' or 'we're choosing to specalise!" There are a few other practical reasons, as we don't have family nearby to help us, we know it would be quite a struggle to manage twins in our life. Husband frets about the financial implications, and while I'm living in the delusion that I can bounce my body back from a singleton pregnancy, I know twins would wreck me.

In the world of obstetrics, things always seem to come in groups of three. I'll encounter an uncommon condition and within the next week or so, I'll see two more cases. There's often trends with occupations, I'll often note that within a day I'll have three nurses, or three teachers, three hair dressers... Keeping with that theme, earlier this year was Twins Day. It was back in April and Co-worker was really starting to show with her twin pregnancy. There were three new OB patients on the schedule; all IVF pregnancies, all twin gestations. The first had a single embryo transfer which resulted in a chemical pregnancy, and thus they decided to transfer two embryos with her first FET. The second patient had a BFN from a single embryo transfer, but she transferred two on her first FET attempt and had a singleton pregnancy. Naturally, they decided to use 2 embryos for the second FET, which produced twins. The third patient failed three previous IVF cycles and had her fourth cycle cancelled. They decided to proceed with a pair of donor embryos and voila!

Interestingly, I also had two patients who had naturally conceived twins coming in for a follow up that day (truly designating it as Twins Day). Both of these patients had identical twins who were sharing the same gestational sac, but had a separate amniotic sac. About a week later (to complete the theme of three) I had yet another patient with naturally conceived twins, but this time both twins were in the same amniotic sac -the most riskiest type of twin pregnancy. Despite all the controversy regarding assisted reproduction and twin pregnancies, they do tend to yield dizygotic twins, which is the safer form of a twin gestation.

Naturally, all patients were excited to be receiving their education from a nurse who was expecting twins herself. I was in my two week wait from my first IUI and I was surrounded by non-stop twin chatter. When we had a moment alone, Co-worker commented, "maybe it's a sign!" as she glanced at my uterus. Yeah... I barely had a single mature follicle and we only used 5 sperm for the insemination, so I was pretty confident that twins were not in my immediate future. I didn't want to acknowledge to her that often my silver lining for a BFN was the thought 'well, at least I'm not facing twins!' I started to worry a little during IUI # 4 and 5 when I started producing co-dominant follicles, but I knew it was such a long shot at that point in time, that I would look silly expressing such a concern.

As we started to discuss moving forward with IVF, I thought the ability to do a single embryo transfer could reduce my concerns about the potential for twins. Yet what happens if the first one or two single transfers fail? How can you not consider transferring two? Why does it feel that we have to make the choice between twins or no baby? On the advice of Non Sequitur Chica, I wanted to have this conversation with my RE at an early point in time, before I was too loopy from all the hormones injected into my body. He described that for the first cycle, he typically recommends transferring (2) 3-day embryos or (1) 5-day embryo. We both acknowledged why patients desire twins. It's more efficient for those who desire more than one child. It avoids all the uncertainty (not to mention expense) of going through another FET or fresh IVF cycle. Yet he commented, "some just see the novelty of the double pram...they don't ever see the 27 week premies in the NICU."

He then started to share a case from his fellowship of a young woman whose partner had male factor infertility. She tried to conceive on her own for two years before finally seeking evaluation, and their diagnosis prompted an immediate REI referral. She failed two IUIs before starting the IVF process and she responded beautifully. She pleaded with him to transfer two embryos as she had "been through so much..." While acknowledging that her infertility experience was rather short compared to other patients, he agree to transfer two embryos for her. He started scanning my ovaries and didn't finish his story. I didn't ask what happened, but I figured it was a very bad outcome if it stayed in his memory this long.

He summarised by noting that it depends on how much the patient is willing to accept the risk of twins. I reminded him that I have seen the 27 week premies, but the risk hits a little closer to home for me. A few weeks ago, I asked my colleague how one of the patients with naturally conceived twins faired. "Oh, she made it to thirty six weeks" he replied. Wow, good for twins, I thought. "She had severe pre-eclampsia." he continued, "She was in the ICU for over a week." Alas, that is why I can't risk twins. I'm already concerned that my blood pressure issues could pre-dispose me to pre-eclampsia with any pregnancy, but it seems like it would be a sure thing if I were to be pregnant with twins. I just can't take that risk. There is a bona fide concern that outweighs all my superficial ones. This also helps solidify our decision to do PGD and proceed with single embryo transfers. There can only be one bun in my oven.


  1. Lol, even w/ twins on the way, I can sti appreciate this post and your feelings! I always thought twins would be "cool" and wanted more than one child. However, when it came down to the end, I was concerned about the risk factors involved and would have been very happy with one. Well, we ended up with the two anyway which we are very excited about, but hope on a daily basis ends with a happy ending. Your reasoning behind only wanting one makes perfect sense. It is a personal decision, and in your case, I think it's super smart to want to only transfer one. I wish you the very best of luck. When is the estimated retrieval date?

  2. Yes yes yes. I was in the same boat with the same thought process and the same concern over the same risks. I hope all is going well with your cycle.

  3. I have to agree with Amber. I love my babies oh-so-much but honestly it has been a challenge. My pregnancy went as well as a twinkie pregnancy could but I was miserable so much towards the end. Then I hemorrhaged after delivery because my over-streched uterus wouldn't contact down. It wasn't scary at the time because I was out of it but scary for my husband. I think it is great that you know what you want and are considering all those risks. That is so important. People think twins is all glitz and glamour and it has been such a blessing but they don't think about all the challenges that come with pregnancy and taking care of them afterwards.

  4. People are unbelievable! It's frustrating how they automatically assume if you are going through IVF that you will end up with twins!! Ay ay ay :)

  5. If you know that you only want one child then there is no reason to transfer two embryos. It increases your chances of getting pregnant by less than 10%.

    So glad that I was of help! :-)

  6. This post hit home for me as someone who has 4 month old twins after a very scary high-risk pregnancy. As much as I love my babies more than life itself, i am now a huge advocate for SET. Having twins (pregnancy and afterwards) is very very hard. Good for you for thinking long and hard about this! We ended up with only 2 embryos after they retrieved 19 eggs and ended up doing a Day 2 transfer...our plan was always a SET but then we got scared and transferred 2! Surprise!

  7. In Canada, there's only one province that funds IVF treatment. In Quebec, they will do up to three cycles of IVF if (and only if) you do single embryo transfer. The whole point of it is that the province actually SAVES money this way, since it cuts down on the hospital costs incurred by twin IVF pregnancies (which often require at least a few days in NICU, if not more). I've read that they've only been funding it for a couple of years, but they're already seeing savings. Makes sense...pretty much everyone I know with twins (even those that had very few complications) ended up in NICU for a short period of time. People just don't often talk about it unless you ask.

  8. I'm up in the air on how many to transfer, but in my experience transferring two doesn't equal twins. My first IVF cycle, we transferred two A qualities and neither took. My second, I only had two embryos. On transfer day, one was a compacting 8-cell, A quality embryo and the other was a two-cell D quality that hadn't progressed in 24 hours. We put them both in, one took (presumably the better of the two). I used to hope and pray for twins...we have four losses and countless treatments under our belts. But after hearing of so many twin horror stories, I'm a bit relieved that I have a healthy singleton in there. Good luck!

  9. Your reasoning makes perfect sense, especially if you know you only want one child. Our clinic has a similar policy to yours - and for some reason, the assumption was that I'd have "many" eggs and that we'd be able to go to day 5, and transfer one. Well, and then we got the call on day 3 to come in for transfer, and had to make the one-or-two decision within minutes. And we wanted at least two kids...
    My poor husband has serious regrets about making this decision. I try to tell him that it could have worked, or that only one might have stuck, and that we ended up having really bad luck... I do hope the couple in your RE's story fared a bit better than this.

  10. Having twins was not my first choice, but I did want 2 kids. By the time I got to IVF it seemed like twins was my only shot at that happening so I accepted the possibility/risk by transferring more than one. After 2 failed IVFs, I didn't really think we could get 2 to actually stick. Now here I am, a shining example of things going wrong - preeclampsia, emergency csection, and babies in the NICU- despite an uncomplicated pregnancy. Thankfully, all is ok, but having twins is not something to be taken lightly. I think some people just see cute matching outfits and don't think about all the other stuff.
    There is no reason to transfer more than one if you truly only want one child. I don't think it increases your odds by any significant amount. Good luck!