Bigger Sword

So it appears that Handsome and I will need a stronger weapon to defeat our dragon, our nemesis, infertility.  We were very disappointed that our last UPT came back negative and have decided to move forward with IVF.  We made an appointment with ARMS and both went in to see Dr. Moffitt yesterday.  While there we had a blood drawn for our infectious disease screening and genetic testing, I had to give 3 vials and Handsome 2.  The genetic testing is to see if we are carriers of any genetic diseases that we could pass on if we both are carriers.  I also have a phone appointment to speak to the financial lady again. 

Here is the road map that Dr. Moffitt gave us:  Get the genetic tests and infectious disease screenings, then on CD1 start on birth control, once the bleeding has stopped I will have a sonohysterogram (SHG) and Mock embryo transfer - the SHG shows a clearer look at the uterus to see if there are any polyps or fibroids that need to be removed while the mock transfer allows them to map the cervix to better prepare for implantation.  We have a tentative start date of May 12th to start the gonadotropins (stimulation shots) and then 5/21 would be the beginning of the week that egg retrieval is anticipated.  Three to 5 days after egg retrieval will be the embryo transfer (5 days we are hoping for blastocysts) and then UPT 14 days after egg retrieval. 

Dr. Moffitt expects me to be a high responder so I will be put on an injectable progesterone afterwards to help reduce my chances of ovarian hyperstimulation syndrome.  He says that in someone who responds like me he would expect around 20 eggs to be retrieved.  The stimulation shots will be for 10 days and I will have to go in every day of those 10 days for blood tests and ultrasounds.  According to the numbers Dr. Moffit gave us couples like us have a 56.5% chance of getting pregnant and he expects that I will probably be on the higher end of that average.  That being said he strongly recommends that we transplant one blastocyst although it is up to us whether we transplant 1 or 2. 

Lets lay out some of the numbers.  I'll start with the financials.  For the Attain IVF program we had originally considered it costs 18K, not including medication, for two fresh cycles and two frozen (and you have to alternate them, I asked).  If we decide to pay as we go it would be $10K, not including medication, for the fresh cycle and $2.1K, not including medication, for the frozen.  Which would mean we would have to do two fresh cycles or one fresh cycle coupled with 4 frozen cycles to make it cost effective to use the attain program instead of paying as we go.  Now because I am a high responder and we have a high likely hood of getting pregnant 1st or 2nd time it makes more sense to pay as we go.  The second part of this is how many blastocysts to transfer.  Dr. Moffitt is hoping/expecting for 20 follicles by the time these get down to blastocysts there will be anywhere from 3 - 6 (on average).  Blastocysts are 5-6 day old embryos and typically have higher rates of pregnancy rates that 2-3 day old embryos so less are recommended for transplant. Below I talk about the numbers behind the transfer.

Originally I thought that if we had a 50% chance with one blastocyst that it would mean with two blastocysts we would have a 75% chance of getting pregnant with at least one baby and a 25% chance of twins.  However much of what I have read says this may not be so.  A 2009 study showed that for fresh cycles the pregnancy rate (PR) was similar but that the live birth rate (LBR) was higher at 42.5 vs 28.4; however this study is about day 2-3 embryos and not blastocysts.  Another website for a different ART facility says that for women under age 35 (still me for a short while) with good quality blastocysts (hopefully) that an implantation rate(IR or PR) is 90%.  However they say that for this patient population (hopefully me) they will get pregnant with however many blastocysts are transferred.  They see that one blastocyst transfer reduced IR by 6% (so 84%) but two blastocysts have a multiple gestation rate of 40%, while one has only a 3-4% of twins or higher.  An article for TIME says that transferring a single fresh embryo followed by subsequent thawed embryos may be as effective as implanting multiple embryos at once.  This looks at a time period from 1995 - 1999.  They say that for each egg retrieval the overall pregnancy rate was 38% for single embryo transfer and 33% for multiple egg transfer.  At a Stanford fertility clinic using blastocyst transfer they saw that success rates were on par if not higher for single transfers.  Another study from 2010 showed that for single blastocyst transfer the IR was 60.9 - 70.5%, pregnancy rate was 60.9-76% and multiple pregnancy rates (MPR) was 0-3.2%.  They also note that couples who elected single blastocysts transfer were typically younger, has had a prior birth, had not had unsuccessful IVF treatment, and had multiple blastocyst able to be cryopreserved - we fit 3 of those criteria.  This article mainly focused on the fact that single blastocysts transfers were similar in IR and PR rates at double blastocysts transfer but much lower in MPR.  The last article I have shows that a double blastocyst transfer has similar viable pregnancy rate (PR) as triple blastocyst transfer - 62% vs 58%.  It also says that the chance of MPR was 39% for double blastocyst transfer vs 79% for triple.

A quick summary is that however it might feel, more is NOT better.  IR and PR seem to be similar between SBT (single blastocyst transfer) and DBT(double blastocyst transfer) and the DBT has an average of 40% ending up in multiple gestation (ie twins).  According to some studies and sites the delivery costs for twins is four times higher than singletons (although our insurance pays for all of that).  There are also health risks associated with twins - I will only lay out risks for fraternal twins since identical could happen either way and most twins from DBT are fraternal.  60% of the time twins are premature and end up in the NICU.  Twins are 5 - 7 times more likely to die during infancy, one twin in 27 will die in infancy compared to one in 135 in singletons.  They are more likely to suffer from cerebral palsy (7.4% vs 2%).  As the mother I am more at risk for gestational diabetes (twice as likely), placenta problems, heart problems (13X) and preeclampsia ( 1 in 3 chance) with twins than with singleton.

So we haven't decide yet whether to for single (SBT) or double (DBT) blastocyst transfer.  This is of course assuming we have multiple goo quality blastocysts.  So anyone out there have an opinion, feedback or advice?  Should we do one or two?


The Two Brothers
"Whosoever empties the cups will become the strongest man on earth, and will be able to wield the sword which is buried before the threshold of the door." The huntsman did not drink, but went out and sought for the sword in the ground, but was unable to move it from its place. Then he went in and emptied the cups, and now he was strong enough to take up the sword, and his hand could quite easily wield it.
Grimm, Jacob; Grimm, Wilhelm; Charles River Editors; Taylor, Edgar (2011-11-29). The Complete Brothers Grimm's Fairy Tales (Illustrated) (Kindle Locations 4278-4281). Unknown. Kindle Edition.