Perinatologist

I saw my Perinatologist today. They've totally re-done their offices. I remember that they were doing that when I was in the hospital on bed rest, but I had never seen the result - my post partum follow up was in the other office, so I missed it. The second Dr. P walked in the room, a flood of emotions washed over me, which I didn't expect. I thought I would be nothing but happy seeing him, which I was, but I was also sad and overwhelmed. How many women have to go to a perinatologist to consider getting pregnant? How many women have ever even SEEN a perinatologist? And here I was, hugging mine, like an old friend. Well, he is an old friend. He went through a lot with me. He saved my babies, more than once.

We chatted for a bit, about our kids, mine and his. Life. Et cetera. "And life is so dull and boring for you that you thought, golly, you'd like to have more, so here you are in my office today," he segued. I took a deep breath.

So I explained that I'd been to a new RE, that we'd had the discussion about elective single embryo transfers, that this is what I wanted to do, that I don't want twins. But... of course, the RE I saw had never done elective single embryo transfers. And I wasn't going to even consider a two-embryo transfer without marching myself into Dr. P's office and finding out what was in store for me if I found myself pregnant with twins (even though the thinking is that even with a two embryo transfer, odds are that I'd have a singleton implantation - there's still that risk, so who knows).

He asked how my overall health has been since the pregnancy. It's been good, actually. My blood pressure is low, I'm down 50+ pounds from my pre-pregnancy weight. My cholesterol/triglycerides are normal, my fasting blood sugar is in the 60's, I've had a few bouts of mastitis and a couple of colds, but that's about it. Oh, and the migraines suck. But that's normal for me. He noted that my mental health might not be so stable, but that's another story...

First, the good news, since my weight is down significantly, my blood pressure risk (e.g. preeclampsia) goes down somewhat. (though I had low blood pressure going into my last pregnancy and still developed preeclampsia (not so surprising giving the HOM factor). Of course, risk of preeclampsia increases with: 1. preexisiting history and 2. multiple gestation ... so twin pregnancy would increase the odds.

Bad news, my weight loss will not change my risk of preterm labor, which is obviously the highest risk I'd be facing, particularly with any kind of multiple pregnancy.

So let's go through this step by step:

Singleton Pregnancy:
He doesn't forsee any specific problems with a singleton pregnancy per se. He does think that I should limit my activity earlier than most pregnant women. That I shouldn't lift anything over 10 pounds, even in the first trimester. No picking up my kids, period. I should watch for signs of preterm labor, but he isn't suggesting that I'm at a serious risk for it, but he knows that I know my body really well and he knows that I'll know what to look for if a problem does arise. Obviously, any signs of preeclampsia and I'm to tell my doctor immediately. He says no problem on a VBAC. No problem on going to my regular OB for a singleton pregnancy. I can continue taking Topamax - I asked about the risk of cleft palate and he said the research hasn't panned out, in fact, and he doesn't think that the risk is really there. If I can reduce my dose, great, but he's seen people on much higher doses of it, even in the first trimester without any issues and he's reviewed the literature on it pretty closely. He'll still see me throughout my pregnancy, concurrently with my regular OB, for monitoring, but doesn't believe there's a significant risk associated with a singleton pregnancy, except that I need to reduce my activity sooner than most.

Twin Pregnancy:
Okay, this is where it gets dicey. Let's come back to this one.

HOM Pregnancy:
Not okay. He would absolutely not recommend I try to have another HOM pregnancy. While mine turned out with a happy ending - I started contracting at 15 weeks, and landed in the hospital at 17 1/2 weeks for contractions. Even with an HOM pregnancy, this is extraordinarily early; very few of his patients experience contractions that early, even with HOM pregnancies. Worse, I wasn't just having contractions early, I had cervical changes - my cervix went from 4.1cm to 2cm to 1cm in the course of a couple of days. Contractions + Cervical Shortening/Effacement = the technical definition of preterm labor. Not okay. Contractions by themselves are not the enemy. Contractions that affect cervical integrity are.

If I have another HOM pregnancy, I am guaranteed to have early admission to the hospital for the duration. And nearly guaranteed to have preterm labor as badly if not worse than last time. And no guarentees as to outcome. Likely to have repeat preeclampsia. No telling on the cholestemia. No telling on the placenta previa, though the odds are higher with the higher number of multiples. I can kiss a VBAC good bye. He is concerned that I wouldn't be able to carry HOMs as long as I carried them the first time, but admits he doesn't have a crystal ball.

Obviously, I'm not seeking to have another HOM pregnancy, but if I were to find myself in another "whoops, it's HOMs!" situation, he would highly recommend a reduction given my history. This is coming from the man who told me in my last pregnancy that I did not need to reduce - the first doctor in a long procession of doctors who had been telling me that I absolutely had to reduce, who finally told me that I could carry all of my babies. He was right - I did it, and they all, thank heavens, are healthy 15 months later, but it was a long struggle to get there, and no one knows it better than him (except, maybe, me...but actually, I think he knows better than me - he knows more about the medical details of what was going on than I do). While he does do reductions, he does not push for them. He is, primarily, a maternal-fetal specialist. He does not prefer to do reductions when they are avoidable or unneccessary. So... basically, an HOM pregnancy is out. This is fine with me, because if I get pregnant with another set of HOMs, I'll walk off a bridge.

So what about that Twin Pregnancy?
Okay, so what if I ended up with twins? Again, note that my goal is a singleton. Just as my goal in my last attempt was a singleton. Best laid plans of mice and men, and all. But if I'm faced with a "game day" decision and my RE says to me, "well, we've got a bunch of shitty-to-mid-grade embryos, so let's put back 2-3 embryos instead of just one, shall we?" Do I risk it, knowing that the possibilities are: 1. Neither would implant, resulting in no pregnancy; 2. One would implant and the other wouldn't, resulting in a singleton pregnancy; 3. They would both implant resulting in a twin pregnancy; or (heaven forbid) 4. one or both could split, they all implant, resulting in an HOM pregnancy with monozygotic multiples. (Odds, of course, are against number 4, so we'll rule that out for now). So what if we made a game day decision to transfer two and ended up pregnant with twins?

This is where it gets dicier. Dr. P. basically said that I'm looking at a significantly increased risk of preterm labor. I'm likely to start contracting much earlier than typical (many women with twins never experience contractions before they go into labor - but that's unlikely to be the case with me). I'm unlikely to avoid cervical integrity issues. I'm definitely looking at bed rest, which is not something that he normally tells a woman pregnant with twins from the outset. How realistic is that for someone with four kids and a full time job? he hypothesized. I said it just couldn't be done at home. It just couldn't be. I told him that in my last pregnancy with even just one kid at home, it was a mistake to stay on bed rest at home for so long, and I should have let them admit me - he agreed. (This was not their fault, they left this up to my judgment on what I could handle, and offered to admit me multiple times, and I said I didn't want to do that to my husband and leave him home with an almost-four year old and a wife in the hospital - now we know for the future that if the hospital is even mentioned, that's where I go - do not pass go, do not collect $200.) He agreed that if I had a twin pregnancy that when (not if) I went on bed rest, I would likely be admitted outright.

He danced around it a bit, but finally came to the reduction issue. "This would be a much easier discussion if you weren't totally opposed to the reduction discussion." And I asked whether reduction was ever even considered for a twin pregnancy. Normally not. And he knows I'm against reduction in general. And he normally would never bring it up if someone walked into his office with a twin pregnancy, and any twin mother that mentions reduction to him gets talked out of it. I finally asked him outright: With my history, if I came to you with a twin pregnancy, what would you tell me to do? While he wouldn't tell me to reduce outright, with my history, he'd want us to consider it as one of our options on the table. He stressed to me that my height is simply not the only factor that played into my uterine contractions and preterm labor - many other short women with HOMs never have the problems I had. I was the exception to the rule, and I had an exceptionally difficult pregnancy. With a twin pregnancy, while I may not be facing as difficult a time as with an HOM pregnancy, I would likely be facing many of the same risks, would most definitely be facing bed rest, quite possibly in the hospital, and I'd be weighing that against the fact that I have a full time job and a gaggle of kids and how to handle the logistics of all of that. He is not saying I couldn't carry twins. But he is not convinced that I could carry twins to a safe gestational age without significant bed rest and intervention. And, he asked, is that realistic? Is that fair?

He also knows me. He knows that it's unlikely we would ever consider a reduction of twins to a singleton.

Bottom Line
So what's the bottom line? The bottom line is that Dr. P says I'm young enough that I have a high likelihood, even with PCOS, of having high enough quality embryos that I should push hard for elective single embryo transfers, even if I'm being pressured on Game Day to consider two. What he suggested was three cycles with single embryo transfers and if I'm getting nowhere, then consider two. But under no circumstances should I consider more than two. My goal should absolutely be a singleton pregnancy, without question. This, of course, was my goal for personal and financial reasons, but I've now confirmed that it must be for medical reasons as well.

There is a piece of me that is a little shell-shocked from today's appointment. I guess I partly thought I was being a bit alarmist about my pregnancy. I half-expected him to say, "Oh please, Lady! You think you had it rough? You got nothing on most of my patients! You can totally handle a twin pregnancy!" Turns out, he was more serious about avoiding a twin pregnancy than I was. For far more serious reasons.

"I still think you're a little crazy - but I wish you the best of luck. You know I'm thinking of you and I wish you an uneventful, healthy, singleton pregnancy."

I am crazy. I know this. But I promised him that if he got to see my gorgeous children every day, he would understand why I want to make more (ONE at a time). He completely understood.