Friday, July 27, 2007
posted by Tinker at 12:06

Sarah asked a few good questions yesterday about "giving the tinkering a second go". To start, a bit of history might give some clarity.

I grew up as the eldest of three children and the only girl; we are each two years apart in age give or take a couple of months. From the time I was quite young I knew that when I got around to having kids myself that I wanted them to be relatively close in age as I found relating to my brothers difficult at times. It may have been that I was particularly mature for my age or that I was dealing with younger boys, but I found two years to be the maximum time that I would want between children.

I also knew that I didn't want to have three kids, probably because of the dynamic that most often left me feeling like the odd one out, though I was also aware when one of my brothers was the one left out. Having an only child was never really a consideration because I didn't much like the only children that I did know, and I didn't want a child of mine to miss out on a sibling relationship (particularly after I and my future husband had passed away).

When I finally met my husband, I was a month shy of my 30th birthday. He was 34. We didn't waste time in starting talk about a family and what our ideals were, as both of us were focused on finding a life mate and didn't want to waste too much time. My husband is a real planner and admitted to having 5-year and 10-year plans and that he had already overshot his deadline of getting married by a few years. I confessed to premonitions from age 17 that I wouldn't be ready to marry until I was at least 23, and certainly not ready for children until 28. Interestingly, the baby cravings hit hard when I was 28.

Fast forward to 2004 when, after three years of trying on our own, we finally had our first real appointment with the RE. He seemed nice enough, but a bit detached -- like it was far too routine and verging on uninteresting. In hindsight, I can understand his point of view. The thing was, that with the testing behind us, he simply handed me a prescription for Clomid and told me how to go about testing for a surge (not that I hadn't been doing that already) and calling in to book an IUI. We were very lucky that summer, conceiving our son on our very first ART cycle.

While pregnant with Little R, I renewed our early conversations about how large a family we would like. He remained constant at 'two'. I suggested that I would like either two or four. We agreed that neither of us wanted just one, and he could see my point about three, he being the youngest of three (though with his sister eight years his senior and his two-year-older brother having Down Syndrome, the dynamic was significantly different). We left it at that.

Once Little R was born my mind was made up. I swiftly fell so deeply and certainly in love with this little man that I clearly knew I had to have four, and convincing my husband wasn't so difficult either. After the haze of the first postpartum months lifted, I decided that a year-and-a-half between children would be best. That way, the kids would be close enough in age to relate well to one another and I should be done childbearing by about my 39th birthday.

When Little R was eight months, we had another visit with the RE to talk about cycling again right away. He didn't want me to continue breastfeeding, as the little guy didn't need the hormones that could come through my breastmilk, so to ensure we were able to start immediately, Little R was weaned very abruptly (something I don't recommend, in part because it was exceedingly painful!). I wasn't ready to stop breastfeeding and I'm not sure Little R was completely prepared, but it had to be done. I assumed that within another few months I would be pregnant again and we would have our roughly 18-month spacing. No such luck.

It took a year of pushing my RE as hard as he would let me go and undergoing increasingly invasive treatments and tests (including a laparoscopy and a miscarriage with resultant D&C) to get to IVF. I tried to be optimistic each time that the next step would work, and was increasingly frustrated that my ideal family was quickly being pushed out of possibility's realm. I was ever antsy to start the next cycle to again hope for success.

As with our first Clomid-IUI, our first IVF went very well. You can read in the archives of how ecstatic I was to discover we could be having two babies, as this put me back on track for actually having four children before I reach 40 in spite of the two-and-a-half years that would now space Little R from his siblings.

As an aside, I chose 40 as a deadline because I don't want to be too old to enjoy my children as they grow and start families of their own. Theoretically, my fertility (or that which can be classed as fertility in an infertile) should be okay until then as my mother was born to my grandmother at 37 and her sister followed when my grandmother was 40. That same aunt had her own second child at 40. On the other side, my paternal grandmother had her fourth child at 37. My husband was born to his mother at 40 as well. Our diagnosis is 'unexplained'.

The curious thing too is that we've effectively pre-empted the first of the acceptable family configurations -- two children. We're going from the not-so-desirable only child to the similarly-not-so-desirable three-child family. I feel that it's fate telling me that four is the right decision.

I've already been thinking about the FET that will follow the birth of the twins. Depending upon how things go, I'd like to start trying again before they're a year old. I've imagined the insanity of having a 4-year-old, two 1.5-year-olds and a newborn in the house, but while it might be crazy for a while, it is temporary, and hopefully will keep my kids connected with each other.

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Friday, July 13, 2007
posted by Tinker at 08:44

My appointment with my obstetrician yesterday was entirely uneventful. He gave me a requisition for the gestational diabetes screen (which I don't anticipate being an issue), offered to answer questions or address concerns (of which I have none), and listened in on the kids (heart rates of 147bpm and 154bpm). I'm measuring 34 weeks, but that's not entirely out-of-line with twins. The only thing that did surprise me a little was that he mentioned that one baby is now breech whereas both have been transverse practically since we could see the fetal poles.

I think I know when the kid made the jump, as I was feeling a particularly large amount of movement from one baby a few days ago. My guess is that it's Baby B (the girl) getting into a better position to kick her brother (poor guy -- defenselessly squished up on the bottom). We'll see for sure on August 1st at the next ultrasound unless she decides to jump back and pretend like nothing is going on (cheeky monkey!).

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Saturday, July 7, 2007
posted by Tinker at 15:39

Well, weeks ago I had thought that the 24-week milestone would be a very exciting one, but it's just another day in the life of a pregnant lady. I suppose it's mostly because I know that viability doesn't have a discrete beginning but is dependent upon a number of factors, all strongly correlated with birthweight.

The World Health Organisation actually places 22 weeks of gestational age or 500 grams birthweight at the lower limit of viability, though this seems to be only for the purpose of 'perinatal' statistics. Some babies born at 22 weeks survive, but almost all have some neurological issues. So viability sits on a kind of continuum and seems fraught with the issue of quality of life for survivors. Yes, very premature babies can be made to survive, but with what kind of long-term effects resulting from that prematurity?

The reason for viability hanging around 24 weeks is because the development of the alveoli in the lungs (essential for survival) happens at this point in fetal development. Still, about half of surviving infants born at 24 weeks have moderate to severe disability.

So I suppose this leaves me with a feeling of "Yes, babies born now would have a decent chance of survival.", with the flipside being "Is survival worth a degraded quality of life?". Perhaps that's why I'm not jumping around having reached the viability marker, but rather, am going about my day hoping to keep the kids "indoors" for another 13 weeks or so.

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Friday, July 6, 2007
posted by Tinker at 17:47

A quick update on today's ultrasound:

Some surprisingly excellent news was that my cervix is still long and closed at 5cm! I guess knowing a number of twin moms-to-be from a bulletin board who are having cervix issues had me rather concerned.

Baby A (boy) measures 1lb 11oz (90th percentile ~25w).
Baby B (girl) measures 1lb 6oz (30th percentile ~23w4d).
It looks like a large discrepancy when you look at percentiles and weeks, but it's not a big deal and both kids are considered right on track. Both are still lying transverse (bunk-bed-style) and were thoroughly uncooperative, refusing to have their (3D) pictures taken. Baby A across the bottom was facing my feet, often hiding what we could see of his face with both his hands and his feet. Baby B across the top was looking toward my spine and refused to turn making a photo completely impossible.

The next ultrasound is in four weeks, but will be back at the MFM clinic, so no 3D. Oh well.

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Thursday, July 5, 2007
posted by Tinker at 15:51

It's 33 Celsius here today (91F). The sun is shining and it's gorgeous outside, but all I want to do is stay inside while my evaporating sweat takes some of the heat out. No, that's not quite true -- I'd love to be lounging by a nicely shaded cool pool, but in this city there are few and those are grilling in the sun and crammed to overflowing (well, maybe not on a Thursday, but you get the picture).

The last few days have been a smidge cooler and Little R and I have sought refuge in the airconditioning of the shopping centres, but there's only so long you can wander a mall without completely numbing your brain.

Tomorrow is at least expected to be a few degrees cooler with a small chance of an afternoon thunderstorm to sizzle on the sidewalk, but this time next week will see more of the same. A twin pregnancy through the summer is a bad idea.

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Wednesday, July 4, 2007
posted by Tinker at 23:05

I thought I'd follow up my December post on PGD pros and cons after watching tonight's National newscast.

The news reported a 36% (if I recall correctly) success rate for IVF in general with only a 24% or 26% success rate for IVF with PGD (they referred to it as PGS: Preimplantation Genetic Screening). Their numbers come from a report in the most recent New England Journal of Medicine. The online news story follows:

Screening embryos reduces pregnancy in older women: study
Last Updated Wed, 04 Jul 2007 11:13:43 EDT
CBC News


An older woman using in vitro fertilization may reduce her chances of giving birth if she opts to have her embryos screened for defects before they are implanted in her womb, say doctors.

Pregnancy and live birth rates were substantially lower among women whose embryos were screened compared with those whose were not, according to a study presented Wednesday at a Lyon meeting of the European Society of Human Reproduction and Embryology.

The surprise finding, which was questioned by some experts, suggests genetic screening should not be a routine part of fertility treatment for women over 35.

"Based on our research, I would say skip the pre-genetic screening and stick with regular in vitro fertilization," Dr. Sebastiaan Mastenbroek, from the Centre for Reproductive Medicine at the University of Amsterdam, told the Associated Press.

In the study, published Wednesday in the New England Journal of Medicine, the authors point out that pregnancy rates in older women undergoing IVF are "disappointingly low."

That's why many IVF clinics screen embryos before implantation. It's thought that by ruling out chromosomal abnormalities, which are more common among babies born to women over the age of 35, women will have a better chance of carrying a healthy baby to term.

Mastenbroek and colleagues were trying to determine the value of pre-genetic screening, a process that involves taking a single cell from a developing embryo to look for chromosomal defects that could lead to problems such as Down's syndrome.

In a study of roughly 400 women between the ages of 35 and 41, researchers found that at 12 weeks, the pregnancy rate in the women assigned to pre-implantation genetic screening was 25 per cent. That compares to a pregnancy rate of 37 per cent for participants whose embryos were not screened.

While there is no definitive explanation, Mastenbroek suggested the test itself might be to blame.

"It is possible that the biopsy of a cell from an early embryo on Day 3 after conception hampers the potential of an embryo to successfully implant, though the effect of biopsy alone on pregnancy rates has not been studied," he said in a statement.

The researchers also suggest limitations in the number of chromosomes that can be analyzed could lead to the transfer of embryos mistakenly labelled as normal.

Meanwhile, some experts have expressed concern that fertility centres promote the genetic tests because they generate profit — with a single test costing up to $5,000.

Peter Braude, professor of obstetrics and gynecology at Kings College London, told Reuters the work showed screening did not work in older mothers-to-be and similar studies were needed on whether it helped younger women with repeated IVF failure.

"Vulnerable patients should no longer be exploited financially under the impression that it works," he said.

Other experts had reservations about the researchers' methodology.

"The way they performed this process tells us that they did not have a lot of expertise in this," Dr. Anna Ferraretti, scientific director of the Italian Society for the Study of Reproductive Medicine, told the Associated Press.

Ferraretti and others said that sometimes the researchers took one cell to biopsy from a four-cell embryo, earlier than is standard for pre-genetic testing.

With files from the Associated Press

So the 2004 summary of PGD issues by Health Canada basically discouraging PGD/PGS now has some more scientific backing. Is it enough to discourage people from using the technology? Probably not. Even the news story indicates that poorly trained embryologists doing biopsies impacts the overall success rate -- that's easily overcome by finding the right clinic.

And I know I'd like to see the original article to determine how patients were selected to be in each of the groups, as well as the miscarriage rate and rate of live births with chromosomal abnormalities in both groups, among other things.

UPDATE:
Thanks to Adrienne for sharing the full text with me. I have issues particularly with the way the data from this study were analysed and summarized but am simply too lazy to outline them all right now. Suffice it to say, I wouldn't put as much weight on these conclusions as the abstract suggests we should.

There are some additional opinions here from Aurelia and Sharah (a statistician).

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