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.