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IVF Twins

Learning About The IVF Process And Twin Pregnancy From A Mother And M.D.

Foreward by ~ Kellie Asaro (site founder)

IVF twins are becoming commonplace among women undergoing infertility treatments these days. Mother's expecting twins (and even those who already have them) will often be asked by perfect strangers if their particular twin pregnancy was due to infertility treatments or IVF (In Vitro Fertilization)...as if it's anyone's business. And what does it really matter anyway? Needless to say, they will still be asked. How they answer however, will vary.

I think the unknown is always intriguing, hence the inevitable inquiries. What most people don't, and will likely never fully understand, is the amazing, stressful, chaotic, painful, surprising, depressing, confusing, inspirational, journey that women undergoing IVF treatments embark on....and I have only scratched the surface on the scope of emotions.

Luckily, there is a growing sisterhood of women willing to share their own stories of IVF and twin pregnancy. I was happy to be able to connect with one of them myself and get her take on the process. She's a mother of twins, as well as an M.D., so her story includes much of the "science" behind infertility treatments as well as her refreshing, frank, sometimes humorous account. Please read her story below...

IVF, or what it's REALLY like to not get pregnant in your twenties, have hot flushes at twenty-nine, lose your mind at thirty and have twins at thirty-one.
by geohde - 2009

I'm not sure what I've got planned for thirty-two as yet.

I'm writing a little on the IVF process and my experiences, from astride the stirrups (so to speak), instead of the clever version that comes with the brochure in the average clinic showing Happy Couple + Infant on the cover. I don't have any objection to the clever version, other than that it all sounds so very neat and tidy and life is rarely so. Presumably for some people it IS. But for many it's not simply a few injections along the way, a nice sleep in an operating theater and BAMMO, babies (sometimes several at once, even).

No, IVF is not quite like that.

It's also not ten inch needles and rivers of blood.

The truth is, as is often the case, somewhere in between. It's not That Scary but it's also Not Especially Fun. Additionally, the main thing the brochures completely neglect to mention is that very few couples wake up one day with a spare ten thousand dollars burning a hole in their pocket and think 'I know! Let's do IVF, just for kicks.'

It's totally normal to be fairly wrung out by a couple of years of fertility treatment and persistent not getting OR not staying pregnant before IVF looms on the horizon. It's normal to feel like you've hit the end of the line. It's normal to be a bit scared about the whole thing, and rather more anxious than a long-tailed cat in a rocking chair factory.

Me? I was an utter irritating mess during my cycles. I distinctly recall, with more than a little shame now that I have the clear vision of hindsight that the retrospectoscope provides, lying on my couch all weekend after my first transfer, obsessing that the ride home may have dislodged a precious embryo, and mortally convinced my feverish feeling meant I'd gone and caught raving endometritis from the transfer catheter and the whole thing wouldn't work. Although it is always irritating to hear ex-IVFers roll their eyes at this sort of worry when it's YOU in the firing line, I'm going to go out on a limb and say that it IS actually okay to carry on like normal after your transfer. Success rates are not influenced by how horizontal you are in the two week wait. Truly.

But I'm getting ahead of things. Who am I, anyway?

I'll share my experience, since like most people I find it very easy to talk about myself. My story is not that uncommon, but note that the reasons you may reach IVF personally may be quite different from my own. The details of my cycles may be slightly different to yours, but the general process is much the same and I suspect my emotions were fairly typical.

How to NOT Get Pregnant in Your Twenties:

I have a fairly common condition called polycystic ovarian syndrome which means that not only do I not ovulate on my own, but I get some pretty impressive acne. For most of my adult life, to be honest, the bad skin was my major focus and I spent a veritible fortune on potions and the contraceptive pill to banish them. But then my husband and I decided to have a baby.

We didn't suceed for the first year because it's hard to get pregnant when you don't ovulate. The first infertility treatment I took was Clomiphene. Clomiphene isn't so bad, since there's nothing sharp involved and there's not that many side effects for most women. I had a few hot flushes, but that's about it. I responded to the medication.

Caution! Science content:

I'll be very honest, all of this attention on reproduction didn't do much for our you-know-what life. 'Honey! I'm ovulating!' doesn't rank all that highly in the wink-wink stakes. It's not an uncommon problem in couples with infertility.

Although I was now ovulating, that was not enough on it's own. Further testing revealed that like about a third of couples with infertility, both of us had reasons to explain the lack of two pink lines. We had male factor infertility in the kind of range for which ICSI is utilised. ICSI requires IVF.

Caution! Science content:

ICSI is a treatment for more serious male factor infertility where either very low sperm count, sperm motility or sperm shape/morphology (and sometimes all three) are present in a man and normal fertilization of an egg unlikely or impossible, even in an IVF setting. It involves the manual selection of a single sperm by micropipette and injection directly into a harvested egg. Before ICSI there was very little treatment that could be offered to couples with severe male factor other than donor sperm or adoption. There is often still no explanation as to why some men have such infertility to this day, with current testing.

Some will have microdeletions of part of the Y chromosome or other genetic disorders but the majority are unexplained. Varicocoele surgery, vitamin supplements, loose shorts, avoiding hot baths have all been tried and perhaps make some difference in selected cases but by and large there is very little treatment other than ICSI for significant male factor. This doesn't mean that they're not worth trying and that men don't pop vitamins and get their partners pregnant, it just means that when studies have looked at large numbers of men who took various treatments and compared them with those who didn't, the pregnancy rates are about the same. Men with very low sperm counts do still occasionally father a spontaneous pregnancy, but the rate is much lower than in couples where the man has a normal sperm count. ICSI greatly increases those odds.

As we were preparing ourselves for the possibility of IVF, we got very lucky and had a spontaneous pregnancy. Unfortunately, our baby had a lethal birth defect and there was not going to be a happy ending. We had to start again. This meant that upon entering IVF, we had all the emotional baggage that goes with infertility along with the misery that is unique to those who have lost a pregnancy. There are many women who go through far worse before IVF, but whatever your situation, pain is pain. I would never advocate comparison or ranking struggles, although I will admit I often used to peek around the waiting room of my clinic and wonder why the very young-looking lady with the snazzy red shoes was there, or why blue-shirt woman looked so sad that day. But I'm quite nosy. Most people read the magazines, or at least pretend to read them.

How to Have Hot Flushes at Twenty-nine During IVF:

The IVF process, to begin at the beginning, usually involves some combination of the following elements:

Caution! Science content:

To understand the nuts and bolts of IVF, it helps to have a quick refresher of the ideal menstrual cycle. Cycle day one is always considered the first day of full flow. This is followed by several more days of bleeding as the lining of the womb (endometrium) is shed in the presence of low estrogen and progesterone levels.

The brain is able to sense the level of estrogen is low, and in response a hormone called FSH (follicle stimulating hormone) is secreted, causing several egg follicles in the ovaries to begin to grow and make estrogen. As the estrogen rises, the FSH falls and the follicles compete for the decreasing amount of FSH until only the strongest follicle is left.

This dominant follicle is ovulated at mid-cycle when it produces so much estrogen that it triggers the brain to send a large surge of LH (lutenising hormone). Once the egg has been released, the follicle becomes a corpus luteum and secretes progesterone (a hormone important in preparing the endometrium for a baby and supporting pregnancy, hence progesterone).

The brain continues to send LH signals to keep the corpus luteum functioning until around 14 days post ovulation. If there is no pregnancy, then at this point the LH is withdrawn, the corpus luteum breaks down, estrogen and progesterone fall and the endometrium begins to shed. If pregnancy DOES occur, the HCG from the early embryo acts to keep the corpus luteum producing progesterone until the placenta is able to take over.

• Down-regulation

Down-regulation is the first phase of a standard IVF cycle. It involves, usually, several weeks on the oral contraceptive pill to both prevent ovulation and control timing of the cycle. In the last week to two weeks of the time on the pill a drug of a type known as GNRH agonists will also be taken. Common examples of these drugs are Lucrin/Lupron and Synarel. Lupron is an injectible medication whereas Synarel is sniffed and they have different dosing frequencies per day, but the net effect is the same. They both cause the brain to release all it's FSH and LH stores and keep them depleted so that premature ovulation does not occur and stimulation can be precisely controlled. Without down-regulation, as you can see from the previous paragraph, there would be a risk of premature LH surge and ovulation (a bad thing in IVF) since IVF creates more egg follicles than the normal number and consequently higher estrogen levels.

• Stimulation, a.k.a the dreaded needles.

They're really not so bad. Many are subcutaneous, especially with the more modern drugs and come in fancy injection pens. You'll be the life of the party, promise. In the stimulation phase, the Lupron or Synarel continues to be taken daily, in order to prevent premature ovulation. At the same time, artificial versions of FSH are injected in order to stimulate the ovaries to make more eggs than usual. This dose can be adjusted based upon the results of blood tests and ultrasound scans during this phase of treatment to make sure enough follicles are going to continue with IVF but not so many that the woman is at risk of a problem known as OHSS (ovarian hyperstimulation syndrome). The average duration of this phase is 10-14 days. At the end of the stimulation phase, ovulation is artificially triggered using an injection of HCG (this can substitute for the natural LH surge because HCG and LH have similar structures and the same actions on the ovary). Because the timing of the trigger before retrieval is critical so that A: mature eggs are harvested, but B: are not ovulated and lost, it is important to follow your clinic's instructions precisely. The standard timing is to give the shot around 36 hours before retrieval.

• Retrieval

This is the part of the process that involves a minor surgery, usually carried out under sedation. Using ultrasound guidance, a needle is passed through the walls of the vagina and into the adjacent ovary. Each follicle is aspirated, and the eggs are sorted out from the fluid by the embryologist. The whole process takes about half an hour. The eggs will then be mixed with the man's sperm, or injected into each egg with ICSI.

• Transfer

Whether you have a day 2, day 3 or day 5 transfer largely depends on your country of residence, local protocols and is also influenced by the number and quality of embryos you have. As a rough guide, embryos should have about 4 cells on day two, 8 on day three and be a blastocyst by day 5. Pregnancy rates are higher for day 5 embryos than day 2 embryos as they are more likely to be genetically normal.
The transfer process itself is much like a pap smear, with a very fine catheter containing the embryo(s) threaded through the cervix and into the uterus. The embryos cannot fall out after transfer as they are tiny and settle into the endometrium.

• Luteal support

Since there has been a down-regulation phase, the body will (if left to it's own devices) fail to support any potential pregnancy because there is little or no LH to stimulate the ovaries to make progesterone. Therefore, progesterone is given after transfer in one of several forms (via pessary into the vagina or via injection into the muscles of the buttock) until a blood pregnancy test is carried out around two weeks after transfer.

• Blood pregnancy test.

Piece of cake if you've cheated and peed on a stick and got a positive result. Horrid if you know you're not pregnant.

(In an aside, there are other IVF protocols such as antagonist cycles and flare cycles designed for poorer responders, I've not discussed those here simply for the sake of clarity)

So, how does all of that feel?

Personally, I would say that down-regulation feels like an early taste of menopause complete with hot flushes and horrid sinus headaches. The stimulation phase is better as hormone levels improve and humanity is restored. Every scan is a little scary because dosage is always a bit of a guess, especially in the first cycle where there is no previous response to compare with. Our first cycle went well. We had great fertilization rates, thanks to ICSI manually banging the sperm into their destination. We had lots of good embryos.

We didn't get pregnant.
I bled before the beta.

How IVF Might Make You Lose Your Mind at Thirty:

So we tried again, using some of our frozen embryos.

Caution! Science content:

Because of my natural disinclination to ovulate, we opted for an artificial cycle. Unfortunately I am one of a small number of women for whom that doesn't work, and I started bleeding within a few days of transfer (well before the embryos could have begun to implant) and did so despite increasing doses of progesterone until we abandoned the cycle.

Obviously, I didn't get pregnant that time either but it was by far the hardest emotionally.

It is one thing for IVF not to work, but go according to plan, that's expected. We all know that success rates are far from 100%, even in the best of circumstances. It is heartbreaking when the whole cycle goes comprehensively pear shaped.

Finally, after nearly three years of trying to achieve a viable pregnancy, I put on my best stirrup socks and we had one more go at a frozen cycle with a change of protocol to include me ovulating. Then I almost completely failed to do that critical part. I think I have the record at my clinic for the longest frozen cycle, given I was nearly cancelled three times and finally ovulated on cycle day thirty-something. I cannot describe the tension at this point. Nail-biting is too much of a cliche and not strong enough worded, unless you're referring to perhaps an elephant's nails.

I got my transfer of two okay'ish embryos and we added a bunch of progesterone supplementation. I then cynically forgot about the whole thing, went to the pub, ate sushi and drank red wine in fits of misery, convinced that none of it mattered, anyway. I got my first positive pee-stick at only a week post transfer.

How to Have IVF Twins at 31:

My beta was very high.So was the second, and the third. By the fourth beta I got enough of a hold on my fear to stop harassing the phlebotomists to take my blood.

At the six week scan there were two heartbeats.

I spent the entire first trimester in terror that I would miscarry. I yearned to have the reassurance of my head in the toilet, talking on the porcelain phone but apparently I am immune to HCG. Despite conspicuous absence of any symptom other than ravenous must-have-toast-in-bed-at-3am hunger and truly painful fatigue, I stayed pregnant. The moral of the story is that a lot of symptoms do not guarantee a healthy pregnancy and an absence of them does not mean all is lost. If you're not vomiting, be pleased.

At the twelve week scan there were two normal babies.

I started contracting at twenty weeks, but that (and the risks of multiple versus singleton pregnancy) truly is another story. I type this with twins complaining in the background that it's, most emphatically, no longer nap time.

Summary? If you're struggling with infertility or doing IVF, talk to somebody. You are comprehensively not alone. There's a fantastic online community out there who've all been where you are now.

On to the next step - See my article on Twin Pregnancy Complications

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