Limitless Possibilities: Twin Selective Reduction

Being an infertility vet, you get to hear a lot of harrowing stories and meet some incredible women who have had to make difficult choices along the way in their quest to build their family. One that has come up a few times is selective reduction -- a process that reduces the number of fetuses in a high-order gestation, usually triplet and up. It is rare, however, to pursue selective reduction when carrying twins, as twin gestations have become much more common these days. While there are still risks involved with twins, doctors are far more knowledgeable about the necessary precautions to be taken in order to facilitate a healthy pregnancy and delivery. 

The process of selective reduction involves injecting potassium chloride into the heart of the fetus(es), leading it to stop. It is probably one of the hardest decisions one can make: how do you choose which one of your babies should die? In some instances, the results from a prenatal screening makes the choice more obvious (albeit, still as painful), while others leave that decision to the random selection by one's doctor (position and access to the babies). 

I have had friends who were faced with this heart breaking decision; all of whom opted to reduce from triplets to twins. So when I came across this article in the New York Times Magazine by Ruth Padawer -- "The Two-Minus-One Pregnancy" -- I was amazed to read that twin reductions are also common. Similarly to the silence we experience when going through infertility, there seems to be an even greater taboo when it comes to opting to reduce a twin pregnancy to a singleton.

I leave it to you, dear followers, to draw your own conclusions, judgements  and questions when it comes to this specific type of selective reduction, but here were some of my thoughts that I'd like to put out there:

• Not everyone who chooses to reduce a twin pregnancy to a singleton pursued infertility treatments, but for those who did, is the stigma attached to the twin to single fetus reduction not a reminder for the REs to transfer fewer embryos -- ideally a single embryo -- rather than transferring 2,3,4 or more in order to ensure implantation?
• While the final decision of how many embryos to transfer is left to the patient and her doctor, many infertility patients who are receiving either limited or no insurance coverage (i.e., paying out-of-pocket for each treatment) request that at least two or more embryos be transferred to increase the odds of success and not having to undergo any further treatments. If insurance companies covered IF treatments, would fewer women find themselves in this difficult position of having to terminate one or more of her fetuses?
• As infertility patients, do we take the risks of high-order multiples too lightly seeing so many twins and triplets strolling down our neighborhoods or on TV? While each failed cycle leads to the next, are we too quick to want to "complete" our family in one shot and not taking the time to evaluate our physical, financial and emotional limitations? (I am not referring here to women who transfer a single embryo that then splits up.)
• A lot of the language used by the women interviewed for this story refers to their desire to be the "the best mom possible" for their children. Some of these women already had children while others were simply overwhelmed with the idea of parenting twins. Either way, they deemed that having a singleton would allow them to "perform" at the highest standards. I wonder how much of our societal pressures to be "super moms" affected the decisions to pursue selective reduction? Is being an "imperfect" parent truly that horrible? Aren't' all generations brought up by so-called imperfect parents and somehow turn out okay? 

I leave you with a quote about the duality of choices by bioethicist Josephine Johnston from this riveting article that continues to stir in my mind as I put it in various contexts:

 “In an environment where you can have so many choices, you own the outcome in a way that you wouldn’t have, had the choices not existed. If reduction didn’t exist, women wouldn’t worry that by not reducing, they’re at fault for making life more difficult for their existing kids. In an odd way, having more choices actually places a much greater burden on women, because we become the creators of our circumstance, whereas, before, we were the recipients of them. I’m not saying we should have less choices; I’m saying choices are not always as liberating and empowering as we hope they will be.”

I look forward to reading your comments. 

Complimentary Treatments: Infertility Yoga

In case you missed it, The New York Times had an article about the benefits of yoga for those undergoing infertility treatments.

While complimentary Eastern practices were for many years discredited by Western medical establishments, it seems that these days they have become an integral part of infertility treatments.

Acupuncture for one has been scientifically proven to help increase success rates for IVF patients. For others, acupuncture has improved FSH levels, blood flow and overall health.

Herbal supplements, on the other hand, may or may not help with infertility treatments. Some attest that it may actually counteract the intended results of fertility drugs.

As for yoga, besides its clichés of making you more Zen, at least for that hour, it helps keep your mind and body active. The physical aspect of the practice is not to be underestimated, especially when you are restricted from doing any vigorous exercises while undergoing IF treatments. Your body is no longer your own when you're doing IVF, but with yoga, you have the opportunity to do something that has a physical component to it and hence, hopefully give you more control over how you feel about yourself.

I think it's a wonderful thing that clinics are combining Eastern practices with their Western methodologies, but at times it seems disingenuous. Many of these clinics offering complimentary treatments fail to incorporate them in an organic way. The offices and general attitudes of the staff are still very rigid and clinical; devoid of anything that makes you feel at ease or whole. Maybe the future of IF centers will take on a more integrated approach expressed both in the available treatments and attitudes.

While relieving stress and having a positive attitude is essential when coping with infertility, I know it can be very difficult to take the time for yourself. Additionally, you can quickly find yourself caught up in trends that make you feel as though you are not doing enough to increase your chances for success. I fear that this article may insight such feelings. Certainly attending an infertility yoga class can be beneficial, but it is not the only thing that's going to give you access to a more peaceful place. You could attend regular yoga classes (with more modified poses) or just take a class that will tap into your pre-IF self (it's in there somewhere, I promise). Attend a cooking class, a book club, a writing class, or simply close the door for 30 minutes everyday and meditate. The point is, try to get out of your own head for a little bit everyday and surround yourself with supportive people.

Stress And Infertility

How many times have we heard "Just relax, it will happen" and have felt the urge to smack that person? Well, for me, there were too many instances than I could count. When you're struggling to conceive, naturally or via the help of an infertility clinic, stress just becomes a big part of the whole equation. I don't see how you can possibly avoid it when each month hinges on that evil HPT to tell us whether we've finally done it.

A new study shows that apparently there is a direct correlation between stress and one's chances of conception. Women who had high levels of the enzyme alpha-amylase (a biological indicator for stress) were 12 % less likely to conceive each month than those who had low levels of the enzyme. In fact, even low levels of the enzyme were indicative of hampering one's chances to get a BFP. I'm not sure how statistically significant the result of this study is, but it's certainly worth taking notice.

Statistics are all well and good, but when practically all women who suffer from IF seem to be Type-A, managing and accepting stress becomes a great challenge. We just seem to be surrounded by things and people that remind us of our struggles and our pain. Stress, at that point, almost becomes a nefarious coping mechanism. It's difficult to even make time to find outlets to relieve our stress, but if we can finally look at stress relief as yet another tool to help us conceive, perhaps we won't see it as such a futile exercise. I don't think that being stress-free will be the magical bullet that will finally allow you to conceive, but in the spirit of coping with IF in the most ideal way possible, finding ways to reduce your stress is worthwhile.

Some fertility clinics are better than others at providing stress reduction guidance. Whether you are able to tap into the resources offered by your clinic, or you're just going to research it on your own, there are numerous ways that you can relieve some of the tension and anxiety that's eating at you (and at your fertility). For one, yoga and meditation. The ability to breath and reconnect with your body will have a long term benefit (even when you finally do have kids) when coping with stress. As I've suggested before, seeking therapy is essential when you're unable to get out of your own head. A third party perspective and guidance may give you a renewed sense of acceptance of yourself. Lastly, this might actually be the perfect time to explore a hobby or interest you've had -- take a cooking class or an art class. Anything that allows you, even if for a couple of hours, to get back in touch with your old self; you remember her don't you? She's still in there, I promise.

How do you cope with the stress of infertility? Please share, as this may help others who are struggling.