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Double Duty…Why Two Is Not Always Better Than One

It would be nearly impossible to count the number of times patients tell us the following regarding how many embryos to put back into the uterus: “I want two…it’s like two for the price of one!” “I want to be one and done!” “It’s like getting a twofer!”

And while we understand the desire for two (trust us, the thought of minimizing the number of times one is pregnant does sound appealing), twins are not just double strollers, matching onesies, and names that start with the same first letter. Twins and triplets-plus can be complicated, not only for the babies but also for the mother. Therefore, serious thought needs to be put into how many embryos are put back into the uterus.

Old-school fertility doctors routinely transferred several embryos into the uterus at one time; twins, triplets, and even quadruplets were sort of the “cost of doing business.” Back in the day, our IVF techniques weren’t so great. The procedures were new, and there were a lot of unknowns. To increase a patient’s chance of getting pregnant, multiple embryos were put in. Although even then, “the more the merrier” wasn’t our motto, (women are not meant to carry litters!), we were limited in our ability to identify which embryos had the best chance of making a healthy baby.

Fast-forward 20-plus years, and we are actually really, really good at this stuff. Not only do we know exactly what a three-day-old embryo needs to grow in versus a five-day-old embryo (can you believe it they are already picky eaters at this age!) but we also actually have the ability to check them and make sure they have the right number of chromosomes!

Now, while we can’t tell if they will look like you or your partner or go to Harvard or Yale, we can take a few cells and check to make sure they have the correct number of chromosomes. (The magic number is 46!) When this technique is done and a healthy embryo is found, we almost routinely only put one back in because even this guy or gal more than half the time makes a baby.

If you are considering an IVF cycle or are maybe even in the midst of one, make sure to have a long and serious discussion with your doctor about the number of embryos to transfer back in. Nowadays, not every IVF center is the same; many have the ability to grow embryos in the laboratory to day 5, rather than the traditional day 3. Although two days may seem inconsequential when it comes to most things in life, for an embryo, it’s a big deal. Just these 48 hours gives the embryo time to develop and the embryologist who is watching the embryo develop more information to pick the one that has the best chance of making a baby!

If you are lucky enough to have several A-plus embryos and your doctor only recommends putting one back in, the others can be frozen. Yup, we said frozen. Don’t worry; frozen embryos are not like frozen chicken! Embryo freezing has come a long way, and now in many centers, frozen embryo transfers have a better chance at making a baby than a fresh one. Simply stated, you won’t lose anything from freezing the extra embryos and putting only one embryo back in at a time. Sticking with the “one and done concept,” many couples get all the embryos they will ever need in one fresh cycle, thanks to good freezing techniques!

It’s sometimes hard to imagine that anything can go wrong in twin pregnancies. Nowadays, our schools and parks are teeming with twins; it really has become all the rage! But take it from us, not every twin pregnancy ends in a cute Anne Geddes photo. Twins have a higher chance of almost all risky pregnancy complications. On the fetal side, these include stillbirth, preterm delivery, and the serious problems that can come along with having a preterm baby: neurologic, cardiac, pulmonary, gastrointestinal, and serious developmental issues. Additionally, a high percentage of twins will experience some delay (motor and verbal skills) in the first two years of their life that requires treatment.

On the maternal side, women carrying twins or more have a much higher chance of serious medical complications. These include diabetes, high blood pressure (preeclampsia), heavy bleeding, hyperemesis (significant nausea and vomiting), Cesarean Section, and post-partum depression. Although most twins and most moms of twins will be running (actually, probably sprinting) and laughing in no time, there are a number of twins that will suffer permanent consequences from prematurity. The risks are real and should not be ignored.

And partners of those who have twins don’t get off easily, either. Sure, they don’t have to endure the insane stretch marks, the prominent varicose veins, and crazy swelling that multiple babies in one uterus at one time can bring, but let’s face it, double the work comes with added stress on the relationship. Studies have shown that divorce/separation rates are higher in families of multiples. Having a baby is not easy, sleepless nights and long days can be beyond difficult; imagine multiplying that by two!

We live in America too, and trust us, we get it. Other than pounds, for most of us, more or bigger always seems to be better. Why have one of something when you can have two? While we are not going all one-child-policy on you, we are advocating having one child at a time. It will be healthier for you and healthier for your unborn children. While twins are adorable and the bond they share is unlike any other sibling relationship, we are big fans of taking it one step at a time if possible.

When building a family, slow and steady is the best and safest way to get to the finish line.

Keep on Climbing: The Clomid Stair Step Protocol

When you have gone through about 40 of those ovulation predictor kits without ever seeing a smiley face, a dark line, or even a hint of a peak reading, you are likely experiencing ovulatory dysfunction. And when you don’t ovulate, you don’t release an egg. If you don’t release an egg, you can’t get pregnant. No matter how wide open your tubes are, no matter how fast your partner’s sperm can swim, and no matter how welcoming your uterus is, no egg = no embryo. However, the good news is that, in most cases of ovulatory dysfunction, if you can achieve ovulation, you have a pretty good chance of getting pregnant. The only trick is finding something to trick your ovaries into ovulating. Don’t worry; we have a lot of tricks up our sleeves!

It’s pretty unlikely that if you are a female between the ages of 20 and 50 that you have not heard of Clomid. The “C” word is often batted around in ladies’ locker rooms, girls’ dinners, or women’s outings. You have almost certainly have had a friend, a coworker, or even a sister who have taken it.  It is one of the most commonly prescribed oral fertility medications and therefore is no stranger to anyone experiencing fertility problems. In fact, Clomid is most commonly used to induce ovulation in women who don’t ovulate (or ovulate as frequently as airplanes land on time at LaGuardia airport!). It can also be used to achieve “super” ovulation (a.k.a. ovulating more than one egg) in women who ovulate regularly but are not getting pregnant. Although Clomid is “super,” it isn’t a slam-dunk. Some women don’t ovulate in response to Clomid and ultimately may require multiple rounds (a.k.a. dosing cycles) of Clomid before an egg is ovulated.

Clomid belongs to a family of medications called SERMs (selective estrogen receptor modulators). And like most families, they don’t agree on everything (or anything)! In some areas of the body, they bind to receptors and exert a pro-estrogen response, while in other areas of the body, they bind to receptors and exert an anti-estrogen response. In women who don’t ovulate, Clomid will bind to estrogen receptors in the brain and alter the release of the hormones responsible for sounding the alarm clock to the ovaries—wake up, it’s time to ovulate! Here are some important bullet points to remember when considering the big C:

Clomid is typically given for five days (five days = 1 round of Clomid); in most cases, it is started on day 2 to day 5 of the menstrual cycle. We can practically hear your next question: nope, it does not matter which day you start! The goal is to start when the ovaries are at their baseline (a.k.a. bottom of the stairs) so that we are most effective in getting a follicle to respond.

Clomid comes in 50 mg tablets. So, simple math: when your doctor prescribes 100mg, you need to take two pills a day; 150mg, you need to take three pills a day; and so on and so forth…. However, like most medications, our goal is to find the lowest effective dose. Although the line in the sand with Clomid can vary based on the physician, most fertility doctors won’t give more than 200mg per day. The reason for the red light at this dose is that, above this dose, you will pretty much only get side effects without much success.

Clomid doesn’t always work (achieve ovulation) on the first attempt (or the first dose). And here are the stats to prove it!

  • 52% of women will ovulate on 50mg.
  • An additional 22% of women will ovulate on 100mg.
  • An additional 12% of women will ovulate on 150mg.
  • An additional 7% will ovulate on 200mg.
  • An additional 5% will ovulate on 250mg.

Those who ovulate at lower doses are much more likely to get pregnant than those who require higher doses to achieve ovulation. When one dose doesn’t work (that is, you come back to your doctor with no signs of a follicle growing or ovulation), don’t despair. You can simply “stair-step” up to the higher dose without missing a step. In these cases, a period brought on by Provera is like a pause. Sometimes, you need them, but oftentimes, you don’t (who doesn’t like a good run-on sentence; let’s face it, punctuation and deep breaths can be way overrated)! While there are certainly clear indications for Provera, it is no longer required between Clomid and/or Letrozole (another oral ovulation induction medication) cycles.

When a specific dosage of either oral ovulation induction agent is not doing the trick (a.k.a. inducing ovulation), you can simply step up the dose. For example, if your doctor prescribes 50 mg (one tablet of Clomid/day for five days), and your ovaries are hanging out in the pelvis saying, “That’s all you got?” you can immediately start a five-day course of Clomid 100mg. And if that doesn’t do the trick, you can proceed directly to Clomid 150mg without passing go. Clomid can be affected by obesity. Simply stated, women who have a higher BMI are more likely to fall into the group of women who either do not ovulate or do not ovulate but don’t get pregnant. Bottom line, Clomid works better in concordance with a good diet and exercise plan.  

Clomid can make you feel like crap. Although most women tolerate the medication without so much of a peep to their doctor, side effects are fairly common. The most frequently reported include mood swings, hot flashes, and bloating. While more serious side effects do exist (visual changes), they are pretty rare. Clomid cannot be given indefinitely. If you are going to see the double line on the EPT stick after taking Clomid, it is most likely to come in the first 3–6 cycles. If it doesn’t happen during this time, it’s probably best to move on to a different type of treatment. Clomid can cause you to have twins. As much as double strollers, double diaper duty, and double feedings seem fun, our goal is one healthy baby at a time. Although the likelihood is fairly low (about 8% of Clomid cycles result in multiple gestations, with the majority being twins), it is important to discuss this with your doctor and vocalize your concerns about multiples early.

Although the stair “master” was designed with Clomid in mind, the same applies to Letrozole (common alternative to Clomid). You can stair step from Letrozole 2.5 to 5 to 7.5 in the same way you do Clomid 50 to 100 to 150. In fact, recent data suggest that Letrozole may in fact be more efficacious than Clomid in getting women to ovulate. Additionally, the side effects with Letrozole are a bit more tolerable, and the risk of twins is lower. So if Clomid doesn’t work for you or your ovaries, there is another staircase that should get you to the same destination!

Who doesn’t love to skip a few stairs on the way up to the top? However, in this “flight,” it’s better to take each step at a time. While the top is ovulation, how far you have to climb to reach it will vary—some may peak with a mere 50mg of Clomid, while others will take it to the top with 150. If you “jump,” you may over respond to the higher dose (#twins). And although it may seem that two is better than one (it would be nice to only have to be pregnant once!), multiples introduce much more risk. Just make sure you are holding on to the banister, walking in a single-file line, and keeping your head up. If you follow these instructions, we can get you to the summit safely!