Tomorrow my wife will be undergoing a procedure that I had never thought would be something we would have to consider. No, it is NOT technically an "abortion" as her pregnancy will continue, though I doubt that would matter much to the anti-choice crowd. No, my wife will be having "selective reduction" to reduce the number of fetuses she is carrying from 3 to 1. My wife and I have discussed this at length, consulted with at least four different doctors as well as friends and family and made the determination that this was, in fact, the best chance of bringing home a healthy baby in 6 months. It is the hardest, most gut-wrenching decision that we've ever had to make, but at least it's our decision to make.
How did we get here?
It started a few years ago when my wife and I decided that it was time to start our family. My wife went off birth control and we started trying to get pregnant. After about 6-8 months of trying we began to wonder if something was wrong. I bought an over-the-counter sperm count test and 10 minutes later it showed what I feared: low sperm count.
A visit to the doctor and a full sperm analysis confirmed not only this, but also low motility and low percentage of normal morphology. He suggested essentially taking a specific set of vitamins and trying again for 6 more months. We tried for a bit longer than that, though off and on due to various other medical concerns, but in the end, with no pregnancy, he suggested that we jump to IVF based on my sperm analysis results.
With that suggestion, we headed to the fertility clinic near the beginning of this year, not really knowing what to expect. For those that don't know, let me give you a quick recap of IVF.
First, the clinic needs to "retrieve" eggs from the woman's ovaries. However, normally a woman will only mature and release a single egg from an ovary each month, so in order to be get more the doctor prescribes a barrage of hormones and drugs (most of which are very expensive and not covered by insurance and many of which are injections or vaginal suppositories) to hyper-stimulate the ovaries. During this closely-monitored process, the ovaries swell in size and it can be very uncomfortable for the patient. Eventually, when the doctor determines that they can retrieve the maximum number of viable eggs, a "trigger" shot is given exactly 48 hours prior to retrieval process and, under general anesthesia, the retrieval is done.
For my wife, they retrieved 16 eggs. After that, they try to fertilize the eggs to create viable blastocysts (embryos) for implantation. Depending on the situation, the blastocysts are allowed to mature for 3 or 5 days, and then are either frozen or implanted. Due to my wife's progesterone levels immediately after her retrieval, it was recommended that we freeze our embryos and do the transfer the following month. In the end, they were able to successfully freeze 6 embryos. During this time, my wife was still prescribed a barrage of hormones and drugs, including this time intramuscular shots that I had to administer. Yes, my beautiful wife was a complete champ throughout the whole process and I love her dearly.
On transfer day we had a bit of a curve ball, actually. At some point during the process we had to sign a form that said we were ok with having no more than 2 embryos implanted. However, in our pre-transfer meeting with our doctor it was recommended transferring just one to start because we had one very high quality embryo (the others were all still good, but just 1 had the highest rating). We agreed with this, but on transfer day the embryologist came out to talk to us and said they had successfully thawed two embryos. We asked to speak to the doctor, who assured us that we could re-freeze one of the embryos if we wanted to, but that transferring two typically boosted chance of success by about 10%. My wife and I had discussed the possibility of two before and, given everything that we'd gone through to get to that point, we just decided to go with the two they had already thawed (there is a very slight chance that the embryo doesn't survive the re-freezing and re-thawing process as well) to give us the very best chance of getting pregnant.
After the transfer then... we waited 2 weeks before getting a pregnancy test. During this time, some of the hormones and drugs continued. Two weeks later, we received the extremely happy news that my wife was pregnant. Still continuing with hormone injections, my wife was still being monitored closely to make sure everything was progressing normally. Based on how my wife's HCG levels were increasing we had basically figured that we were having two. We were prepared and excited for the next step.
A little over a week from finding out she was pregnant was our first ultrasound. We were ready for the ultrasound tech to confirm that we were pregnant with two babies. She found one, then continued searching around and found another. "We figured it was two", my wife said. Then the technician said, "What if I told you it was more than two?"
We sort of looked at her in shock. More than two? Yes... sure enough, one of our embryos had split into two. We now had identical twins and a singleton... triplets.
Now, this scenario had only ever been talked about very briefly, usually in jest. Our doctor did indicate that it was a possibility, but not normally a very high chance of it. Looking up some studies about it we found that ending up with triplets from having 2 embryos transferred occurs in less than 3% of cases. I think our mouths were pretty much agape for the rest of that day. We spoke to the doctor briefly about it and she basically outlined some next steps. The doctor also mentioned that in these situations that usually the twins are "reduced". This honestly surprised us. Why should we reduce 2 instead of 1?
We weren't really sure what to do. We actually were considering keeping all 3 for awhile, but we hadn't met with any of the recommended doctors yet. Our fertility doctor had recommended a couple different doctors, one that would potentially perform a reduction, and another who would be a good option if we decided to keep all 3. We also found out from some further follow-ups at the fertility clinic that our identical twins were "monochorionic-diamniotic", meaning they share a placenta but are in separate sacs. This is the "good" kind of identical twins as far as many of the complications go ("mono-mono" twins have all kinds of other risks that can make the pregnancy very very difficult). With this information we scheduled our next appointments. Our first visit was to the doctor who would potentially do a reduction, and it was extremely illuminating and in some parts devastating.
We were given a prepared packet of information with various statistics and studies. The toplines are this: Triplets average gestational age at delivery is 34-35 weeks, with a preterm delivery rate of 80-85%. Preterm delivery is any birth which occurs prior to 37 weeks of gestation. Additionally, the doctor said that the chance of delivering before 32 weeks of gestation with 3 was about 30%. Obviously, with today's medicine babies can survive and grow after being delivered early, but there are still obvious risks associated with it, the earlier they are delivered the higher the risks. The particular scenario of identical twins and a singleton for some reason exacerbates some of the risks as well.
Additionally, the doctor repeated that the "rule of thumb" is to reduce the twins in this scenario. Twins still have a preterm delivery rate of about 40-50%, and additionally there is an issue called Twin-to-Twin Transfusion Syndrome (TTTS) where one of the twins will steal resources from the other, potentially negatively affecting both of them. This apparently occurs in about 10-15% of cases for twins (though in about 50% of cases if we kept the triplets). It was recommended that we do a CVS test to make sure that the fetuses didn't have any major genetic abnormalities before making a final decision about reduction.
I want to stop here for a second and ask you to imagine what it would be like to get this information and NOT have any choice in the matter. Every week I feel like I read new headlines about abortion rights being rolled back in states, with even Michigan just recently trying to push a fetal heartbeat bill that would effectively ban abortion, and I'm sure fetal reduction. This whole process has really given us a lot more perspective on this and I just can't imagine being told that there were no options available. While it saddened us, keeping the triplets just wasn't a good option given all of the risks associated with it, given all of the trouble we went through to get pregnant, and given that this is our first pregnancy. But we were still leaning towards keeping the twins despite 2 doctor's recommendation that we should reduce to 1.
I wasn't able to go with my wife to her next appointment, but this was the doctor that was a potential option if we were to keep the triplets, or even the twins. Nevertheless, the doctor recommended the exact same thing. In fact, the doctor was even more adamant that the twins should be reduced, based additionally on their positioning within the uterus. This was 3 doctor's now recommending the same thing. We started looking up more and more studies and re-analyzing the data given to us. Were we being "selfish" in wanting to keep the twins?
Before the CVS we consulted with a Genetic Counselor and a doctor specializing in reproductive genetics, who also recommended the same thing that every other doctor recommended: reducing the twins. We discussed it at length, hemming and hawing, going back and forth sometimes from one day to the next. Would we want to do IVF again? Is it worth even a 15% chance of TTTS to keep the twins and a 50/50 chance of pre-term delivery? This was just such a horrible decision to have to make. How can we choose? Ultimately, we thought about the entire process we had just gone through and why we went through it in the first place. We went into IVF with the purpose of ultimately coming home with a healthy baby. There are no guarantees in life, obviously, but if that is our ultimate goal, we should make the choice that gives us the best chance of reaching it. We decided that, assuming nothing in the CVS results gave us reason to change our minds, we should keep the singleton.
We received CVS results for the twins last week and they came back normal, but for some reason the singleton results were taking longer. They did a "FISH" test that basically tests for just a few of the major genetic abnormalities and that came back normal. A bit of a complication, but the FISH is usually pretty accurate and usually issues with the other chromosomes that it doesn't test will cause a pregnancy to miscarry anyway. On the advice of our doctor, we are continuing with the reduction as planned.
It has been a really difficult process, but we're ready to get beyond this... ready to get into the next phase of the pregnancy and start telling the joyous news to the world beyond our close friends and family (my wife just entered her second trimester). We've had to make an impossible decision, but it's one that, for us, needed to be made.