On induced lactation

Claire, Michelle, Rebecca, Pam, Josey, Meg, Sloper (OMG, how did I miss out on your second pregnancy?!?!), thank you so much for your inputs.

I started reading up on induced lactation. Reglan is a no-no because it can cross the blood-brain barrier, and has one potential really scary side effect, tardive dyskinesia. My brother actually had that as a child.

Domperidone appears to be safer. Still, it can have cardiac effects---it can prolong something called the QT interval, and hence cause arrhythmia, which could potentially cause your heart to stop(!!). Here is a blogpost on the subject on the Skeptical OB blog, though I would say, this post does not seem to be wholly objective. The truth most likely is that this drug is safe in the majority of women, and would be dangerous for a smaller subset. Obviously it is more dangerous if you are mixing it with other medications that also prolong the QT interval, or you have underlying conditions that you are unaware of. The evidence for both intravenous and oral Domperidone causing arrhythmia comes from studies they did in people over 70 years of age.

But what genuinely scares me about this drug is the fact that the baby may get a tiny bit of it through breast milk, and if the baby has any underlying cardiac issues (one unverified source mentioned that 1 in 100 babies born have some sort of cardiac issue), this could be a bad combination. It is probably safe for 99 out of the 100 babies, but what if you are the 100th one?

So...if you are taking it, exercise caution with respect to dosage, be aware of your other medications, and I would suggest talking to your doctor too. I was also a little freaked out by Claire mentioning that her liver enzymes were elevated. So all in all, I'm going to give induced lactation a pass.

Human milk banking exists in Mumbai. However, the milk is pasteurized, which destroys most of the good stuff. I AM going to try to use the milk bank to find a wet nurse though, and if all else fails, supplement the goat milk formula with banked milk.

But all this is a ways away. I want to start doing stuff, but there is no way I will before I get to the "safe zone" of beyond 28 weeks, which I feel I am crawling towards one slow inch at a time. I'm sad to say that I'm not somebody who stops to smell the roses and celebrates what I have today, instead of thinking about tomorrow. I can't celebrate that the J has completed 22 weeks of pregnancy today...all I can think of is how much more time has to pass before we are in the relatively safer zone of 28 weeks and beyond.

But this is folly, because once you decide to have a child, there is no safe zone anymore. After birth, you worry about SIDS and diphtheria and the flu. You worry about Autism. Then one day you worry about your child being bullied at school. You worry about predators----it never ends.  Somebody described parenthood as having your heart walking outside of you, unprotected and vulnerable, for the rest of your life. And here we all are, eagerly signing up for all this.

Merry Christmas everybody. I'm so very happy for everybody who has gotten what they wanted for so long this year. For the ones who are still waiting or have had their hearts badly damaged, all I can say is that I am thinking about you. There are no words to make it better.

Checking in: Week 21

I did some more investigations on surrogacy options in India today, and I'm starting to get a much clearer picture of things. I wish I had acquired all this knowledge months ago, but that is not how it works. Sometimes, even the less than ideal choices we make can lead us someplace good, and sometimes, doing everything correctly and logically will still not garner success.

Still, others will benefit from what I have learnt, and that makes me pretty happy.

One thing I did learn today--finding a human milk source in India will be extremely difficult. Everybody knowledgeable in this area is telling me that getting the surrogate to do this is a bad idea. I atleast want the colostrum, and I hope to god I can get that.  

Now, I have to seriously consider induced lactation. People who started this....what was your timeline? How long were you on the pregnancy hormones and domperidone before you stopped the hormones and the milk production began? I totally want the crash course and not the long drawn out process.

Finally: a question about the final stretch in the 3rd trimester: what gets done in each appointment? From my conversation with the surrogate handler, every checkup, all we can get done is the doppler to hear the heartbeat. That is it. There seems like there should be more, right?

Goat Milk Formula??

As I talked about in my last post, most of the formula choices available today have the capacity to induce food allergies, are nutritionally very far away from human milk, and even the organic choices are riddled with additives that were far from ideal, like the palm oil that forms soaps in the baby's gut and neurotoxic solvent-extracted/synthesized stuff like DHA, lycopene, and lutein.

So here I was, literally wringing my hands. I then remembered a book I had read a long time ago where a monk used goat milk to feed an abandoned baby. Historically, whenever the mother's milk was not available, goats milk was maybe the first choice. Based on that very vague memory, I started to search for goat milk-based formulas.

I was very pleasantly surprised. Goat milk use in baby formulas appears to be a  growing trend. There are two formula brands (Holle's in Germany and  KaniKare in Australia) that manufacture goat milk-based formulas, but both, to different degrees, suffer from the issues mentioned above. Holle's is definitely the better choice of the two though. If I was ever going for a store-bought formula, this would be the safest option.

First, let us talk about goat milk itself:

Protein content: Its protein (and sodium content) is much higher than that of human milk, so if you gave it to your baby straight, you could create kidney problems. You have to dilute it out. But---once you dilute it, it comes pretty close. Goat milk protein apparently forms "softer curds" and is easier to digest than cow's milk. In support  of this, babies who are fed goat's milk have more frequent bowel movements than do babies fed cow's milk. Not obsessed with pooping patterns yet, but I hope that the day will arrive when this becomes one of paramount importance to me.

Fat content: Its essential fatty acid profile seems to be better than that of cow milk, but not as close to that of human milk. This is easily fixed as well.

Allergies: It has extremely low/undetectable levels of alpha-1 casein (the principal culprit behind cow milk allergies).  It does contain another protein (as does cow milk) that can trigger allergy: beta-lactoglobulin. But I'm guessing that is a much less common/severe allergy. But what this means is that a subset of babies allergic to cow's milk could also be allergic to goat's milk.

Nutrients: It has high levels of potassium and selenium. It has seriously low levels of folic acid and Vitamin B-12, so if you feed your baby this formula, you have to add these back.

In a nutshell, if you went with goat's milk formula, you would have to add back a few things and choose your proportions of water and milk powder carefully. This bit is EASY. I'd much rather whip up formula at home than go with the store-bought stuff, given what I have learnt.

This is a great recipe for a homemade goat milk formula.

A good source of powdered goat's milk may be the Meyenberg brand. If you mixed this up with the coconut oil (I read up on this, it seems like a really great idea even for regular cooking), the olive oil, lactose/turbindo sugar, probiotics, and a good vitamin/mineral source (blackstrap molasses or a multivitamin), and it sounds like you would have many bases covered. In theory.

Note that you would have to add all these things back only if you were formula feeding before one year of age. After the one year mark, you could dilute the powder out less, and have to add back less as well.

Overall, what impressed me was how happy *most* parents who tried this formula sounded: read the amazon reviews and the Mt. Capra reviews (though that sounded more mixed). Overall, in most cases, the allergies were fixed, it did not smell like a chemical soup, and most people seemed to report formula guzzling and weight gain and happier babies.

So yeah...this route makes me a lot happier than the organic cow milk formula route, and it seems like something I could live with. If anybody reading tries this, please DO give feedback of how it went. Still want to try to get human milk for as long as possible.

BUT: One advantage that this presents over the human milk route--In India, I cannot eat organic, and neither can whoever acts as the wet nurse. The fruits and veggies and the milk we drink are laden with god knows what. If I went this route, it seems fairly certain that the goats would be consuming less pesticides than I currently do, if you believe Mayenberg. Got to always see the silver linings, right?

Planning all this makes me realize how badly I want to be a mommy and do mommy stuff.  Please god, let it happen.

First parenthood-related research expedition: the search for the best formula

As many of you know by now, I'm an information ferret. My digging for information is not going to end when I have a baby (note I said when, not if!); rather, it is going to intensify.

In my case, I know that unless I get really lucky in my quest for brea.st milk, I will have to start formula feeding from a really early point. My first foray into parenting-related research: finding a decent formula option. Twenty minutes into my research, I was horrified. Everything I was finding had some issue or the other.

• Cow-milk based formulas have the potential to trigger allergy due to the presence of alpha S1-casein, and its nutritional profile makes it much harder for the baby to digest.
• Soy-based formulas are something I would never consider anyway: the nutritional profile of unfermented soy is not ideal, and more importantly, most of the soy available today is genetically modified and has been sprayed that godawful pesticide Roundup
• Wheat-containing formulas have the capacity to trigger gluten allergies. I don't know WHY gluten allergy is so common today, as compared to 50 years ago. Clearly, there is something different with the wheat grown in the world today, or our reaction to it. The why of it will be a post in itself one day.
• Then I considered an elemental formula like Neocate...only to find that instead of lactose, they add corn solids to sweeten the bloody thing.  

Not only are the nutritional profiles of all 4 of these formula choices problematic, even if you go organic, they have some insane additives.

The more you read about the food industry and how fake and profit and lobbying-driven it is, especially in the USA, the more depressed you get. 

DHA supplementation of baby formulas sounds like a good idea right?  Your baby would get this vital fatty acid that it needs for optimal brain development. Except---your baby does not need it. Except the DHA in most baby foods is extracted from algae using hexane, a neurotoxic solvent. What they should be adding is  adding DHA from a natural source, but that is too darned cost ineffective for them.

Lycopene in tomatoes is great. So if you saw it in your baby's food, you'd be happy. BUT---but the version in organic infant formula is produced synthetically by the chemical manufacturer BASF.  A three-stage process is used to produce synthetic lycopene, and involves the solvent dichloromethane and the solvent toluene.  Toluene is a neurological toxin derived from benzene.

The source for all this information is this FABULOUS article written by the Director of the Cornucopia Institute, which serves as an organic food industry watchdog. 

Basically, even the organic versions of regular formulas for the most part have nutritional profiles that differ from that of human milk, and they could be contaminated with trace quantities of stuff like hexane and toluene, and many contain ridiculous and unnecessary additives like carneegan. This is where you want to grab the food industry people (scientists/executives, etc) and whack them for doing the stuff that they do. Is it all for profit? Do they simply not stop and think? If you read the article above, this woman also talks about the evolution of baby formulas, of how their ingredients could change over time, and this is a key point. The product you see today may not be the one that is there like one year later.

So what is a better, practical alternative? Well I found one, but that deserves a post of its own. Coming soon. 

A glimpse of the realities of surrogacy in India

The 19w1d scan went off wonderfully. My baby is a cheeky monkey...he/she kept alternately yawning and sticking its tongue out at me. No issues were spotted, the bloodflow to the placenta (as measured by the doppler) was great, and the cervix was closed at 3.4 cm. All good news.

Now, J and I have had a rather closer relationship than what is recommended between a surrogate and the mother. Everybody (lawyers, doctors) encourage you to keep a contact to a minimum. The reason behind this is that India's surrogates are women from lower socio-economic strata, and the mothers appear vastly wealthy to them. Hence, the theory is that if they can extract money out of you, they will. This is an extremely ugly equation, and I've tried my best to sidestep it entirely. I don't care if the surrogate takes money from me. I had always planned to give her far more than the amount she had been promised, and indeed, I have been giving money to her every  time I see her. My gynecologist called me a bleeding heart...to her, these are greedy grasping women who see this as a business. 

I don't see it in this way...the way I see it it is these are women who are trying to make a better life for their families, and they have never had the luxury of being honorable and principled. It is hard to be that way when you have so little. So if my surrogate tells me small lies to increase my sympathy for her and get some money out of me, I honestly don't give a damn.

But on the day of the ultrasound, J may have upped her game. She told me that she was being evicted from her home, and was forced to go live with her sister in a place on the outskirts of Mumbai. Bleeding heart me was immediately horrified and I started thinking...how can I fix this? How can I get her housing?

She claimed she needed a hefty deposit for a new place. At this point, even my sort of unworldly mom was like well, she is playing you. The only person who can corroborate whether this is indeed real  is the handler, and she is a woman from the same community...she will lie for her if necessary, and yes, she did claim that J had to move in with her sister the very next day. 

I want to find out if this is true or not, but I have no way of doing so: the handler is not taking my calls, and I have no way of corroborating anything.

I also realized what an uphill struggle everything is when I want something out of the ordinary. J's delivery the last time was at the same hospital, with the same doctor. When I first asked her, she told me she had given birth at full term. Recently I asked her what week it was, and she said 32 weeks.  The way she tells it, she was induced: I was horrified: why would you induce at 32 weeks? She claims the baby was a very high weight (like nearly 8 pounds), which does not add up for a 32-week delivery. Hearing all this, I just wanted to get the medical summary. Easy right? Nope. I ran into one unexpected wall, when the doctor who had managed the last pregnancy told me she could not get this information, because it was medically unethical for me to see it. I then asked, well, can you just get the information and sum up the scenario? She said "nope, ask the surrogate." The surrogate claims she has no paperwork. Trying to get her to access her own medical records from the hospital will be, well, Sisyphean.

Right now, there is no point in pushing. I just have to pray that everything goes well, because the simple things that you can influence in other places cannot be managed here.  If  J turns out to have gestational diabetes (which may explain the induction and the large baby), she is not going to do anything to control it. I have to beg her to take her vitamins, and for the last two ultrasounds, I literally had to bribe her to show up. And despite what it sounds like, she is sort of a decent person...just unmotivated and wants to hang out at home while she gestates the baby, and not be bothered by pesky blood tests because she truly does not get what any of this is all about.

I should add...a lot of what I am going through here may be avoided if you go via an agency like Surrogacy India. They provide housing (for the surrogate and her children apparently), transport, and all in all may do much more. I'll be profiling them, and one other agency.

Writing all this out was cathartic. Everybody around me is telling me to just stop thinking about all this, and that is what I'm going to try to do for a while and see how the cards play out.

Week 19....

First, I had NO idea that Disqus was such a pain, and I'm sorry I subjected you guys to it for so long. It is gone now, never to be reinstated. On comparing blogger commenting and WordPress commenting, there does not seem to be too much of a difference. WP IS nicer in other ways, but when I think of how much else I have to do when I move, I sort of whimper and think it is not worth it. So I'll *probably* stay here. So commenting is easier, and as a favor to you all (I hate it when I have to do it on other sites), I've turned off the word verification thing. Hope I am not immediately bombarded by spambots or whatever else that mysterious feature protects against.

Pregnancy news: J will be 19 weeks along tomorrow. She apparently went for an hospital visit last Thursday and everything was fine. She is not having an easy time of it though: while her hemoglobin levels are just below the the lower edge of normal, which is apparently good for a pregnant person, she tells me that this pregnancy has been much rougher on her than her last pregnancies, with constant dizziness as well as nausea.  One reason could be the crazy high beta HCG levels...the levels in almost all my pregnancies has been really high: one clue about how high came in the dual marker scan at 12 weeks; they express the levels as "multiples of the population mean" or MoM. So if you have a beta-HCG MoM value of 1, your levels are at the population mean. In this pregnancy, the beta-HCG MoM was 2.15, which may be the reason she is feeling so crummy. I hope it is nothing more sinister than very high pregnancy hormone levels.

The one thing that I've been freaking out slightly about is the placental grade. Classically, you are supposed to start with a grade of 0 in the first trimester, move to 1 in the second trimester, stay as 2 in the second trimester and most of the third trimester, and hit 3 only just before you deliver. The placenta was grade 1 in the first trimester, and grade 2 already by 17 weeks. I expressed my concerns to the fetal medicine specialist, and she told me not to worry, that the grading system is obsolete; now what counts is the placental blood flow as measured by the doppler. And that, apparently, was normal. We go in for another scan this week, as recommended by the fetal medicine specialist.

I now have to start thinking about feeding this baby, and how to come up with breastmilk from a safe, tested source. I'm also starting to weigh the pros and cons of induced lactation. Every time I start to think about planning for when the baby comes, I'm paralyzed with fear: what if I start doing stuff and something goes wrong? But as the weeks pass, I do have to put that behind me.

In other news, I found this excellent Fertility Authority article on multiple embryo transfer that I thought was worth sharing. What they said about the shortsightedness of American insurance companies in refusing to cover IVF and thus pushing people to transfer multiple embryos and then having to pay for the staggering medical costs arising from complications in twin/triplet pregnancies was spot on...talk about penny wise and pound foolish! I wish they at least covered transfers as a compromise.

Considering a move (updated)

I'm currently considering the WordPress plunge...I've exported most of the contents of this blog to a new blog there (the easy bit), and I'm still feeling it out and seeing how I like it.

If I do like the fit of it, I'll complete the move. This process has been initiated  for two reasons: a) that newspaper article and b) It is *so* much easier to comment on WordPress, especially from a mobile device. Question: Just how difficult do people find Disqus? Have you ever felt like commenting but have given up because of how painful the process is? I've had a few people mention this to me in passing, and I want to get an idea of whether this is a real issue

If I do move, people could get the new address from Mel's website, or you could email me for it. I should reiterate, I'm just trying this out. There is a lot to do while trying to move a behemoth of a blog from one site to another, and I may just throw my hands up and stay here if  I feel the easier commenting is not worth the hassle.

Update: I decided to first try the path of lesser resistance: Disqus has been deleted. The only reason I will miss it is because it allows you to directly respond to a particular comment, which the commenting options on Blogger do not seem to allow. Does its removal make commenting easier? Would people prefer WordPress to Blogger commenting? If you can, please let me know, because it will help me decide whether to stay here or move.

Time it is a-crawlin

Somebody asked me when I'll be able to share everything I've learned about surrogacy, and I answered, only after this process is done for me. And I'm praying it does not get done for atleast 3 and a half  more months.That is so far away, and time, it seems to be crawling forward.

I have such a long way to go before making it into the safe zone. Even at the the best Indian NICUs, 24 weeks is probably considerably less promising than it is in the western world, where it is not very hopeful to start with. At 28 weeks, you possibly start to have some chance of making it. At some point, I think I'm going to put together a list of studies of what exactly are the realities faced by a baby born at 28 weeks. It is definitely something people should think about before deciding how many embryos they want to transfer.

Yesterday, the risks of pregnancy sort of struck close to home. One family employee's wife is, from the sounds of it, facing intrauterine growth restriction and pregnancy complications with a twin pregnancy. Here is a girl who was not infertile and really young, and should have had no issues with pregnancy. Her doctors told her that had she been carrying a singleton, her chances would be better  She is 28 weeks along, but the thing is she probably wont get to be at the hospitals with a good NICU..apparently her doctors told them that things did not look good. Hoping things end well. Gave her husband a Vitamin D sachet, for what little it its worth, because with a twin pregnancy with no supplementation, she was bound to have been badly deficient.

At my end, the only think I need to worry about continues to be Vitamin D. J cannot take the 2000 IU Vitamin D pills (she claims they make her throw up, but says she can down calcium and iron, which I find rather contradictory). I don't want to keep continuously giving her sachets, and the key is taking it regularly. So now I'm trying to have Vitamin D oil drops sent from America. As things continue to progress (you note that I have gone from saying "if" to "as," which represents a huge leap of faith for me), I will need about a gzillion things off Amazon, which I will somehow have to have sent to India. God I miss Amazon prime.

Once we make it past the 20 week mark (2 weeks away), I'll have to start thinking about fun stuff like telling people at work and how to arrange to feed my baby. At least the latter should make for an interesting post!

16w6d: Detailed anatomy scan mostly done!

I got us in today instead of having to wait, and OMG, the relief is indescribable.

My biggest concern was addressed: her cervix is closed at 3.2 cms, as determined by a transvaginal scan.

We did the detailed anatomy scan, and everything seems fine. I kept trying to cheat to see the baby's gender, the doctor laughed and told me that I had no chance of figuring it out. I am going to try again at the 19-20 week scan when we measure femur length. Am not too optimistic of my chances.

It is both a blessing and  a misery that I am not carrying this pregnancy. I'm saying it is a blessing because I probably would have implanted the 4 embryos that 2 surrogates did not implant, and unless we greatly lucked out, we would not have transferred the embryo with the mojo first. Its a blessing because my stress levels would have been through the roof through the entire process. It *may* be a blessing in that I am an untried entity when it comes to carrying a pregnancy longterm, while J is a proven deal.

It is a misery because my baby is nearly 17 weeks along and I have not felt him/her yet. Its a misery because trying to get J to take her vitamins is well...challenging. Nobody else is making sure she eats well...I've been giving her bags and bags of dry fruits (nuts, dates, stuff like that) to make sure she gets some bio available micro-nutrients into her. I have to beg her to eat meat because her B-12 levels are low. Getting her to this ultrasound took 3 scheduling attempts, and a little strategic bribing.

Based on my experience of surrogacy in India, few people are this hands on;they assume everything would be managed the same way they would manage their own pregnancies, and show up 9 months later to get the baby. This is what the medical establishment here advises as well.

I'm incapable of doing that...one of the reasons I moved back to India was to make sure that if I went this route, I could try to monitor the situation. I don't know if that will make any difference, or help at all, but I could not have done it any other way.

I want to meet this baby so badly, but definitely don't want that to happen for atleast the next 18 weeks. I keep counting down the time left once a day.

Taking the sensible approach to treat infertility

This post was prompted by two things:  another blogger's accounting of her painful response to lupron during a FET, and yet another multiples pregnancy that may just end in the unthinkable

All in all,  I am struck by how often  doctors just follow a set protocol without being thoughtful about the situation, the patient's problem, the patient's comfort, and the long-term safety of both the mother and the child. If the doctors can't think about all these things, then the patient should, because ultimately, they are the ones facing it all. 

There are many roads to infertility. All we can do is identify the problem and treat it intelligently. When I say treat it intelligently, I mean choose a path that minimizes the number of injections you have to take, the hormonal overload you face, the number of FETs you have to do, and importantly, choose a path that allows single embryo transfers so you do not have to face the higher risks associated with a twin/triplet/quad pregnancy.

Here are some practical examples:

• If you have a high-ish antral follicle count and a normal-ish cycle, choose the antagonist protocol over the long agonist protocol: The antagonist protocol is infinitely more "natural" than the agonist. Overall, most studies fail to show any benefit of one over the other.  The antagonist protocol is infinitely kinder to patients: you have to take a far fewer number of injections (Doctors, yes, this DOES matter). You can skip lupron. You have a reduced risk of OHSS. Knowing all this though, many doctors prefer the long protocol to the short protocol simply because it has been around longer.
• If you can identify a relative date of ovulation, even with +/-3 days of variation, choose to do a natural FET over a medicated FET. That way, you don't have to start your pregnancy already having been on lupron followed by estrogen followed by progesterone injections, you simply start with Beta-HCG (RMA-NJ has a trial on this) followed by progesterone, and transfer 3 or 5 days after ovulation. Many doctors are now going with a natural FET now. Incidentally, this study found better results with a natural cycle as opposed to a medicated cycle. This does not surprise me, because mother nature is the best architect, and giving somebody three hormones to mimic the complex natural process should logically be the less efficient approach. I don't know why REs prefer a medicated FET.  One fertility center basically said that some doctors like the medicated cycle better because it is less of a hassle with respect to scheduling. Needless to say, I don't respect doctors who would pick medicated FETs for solely this reason. 
• If you end up with a large number of embryos, then do your best to pick the best one in the bunch from the getgo, so you do not have to do 5-10 transfers to find your two good ones.  There are two things you can do for this: let your embryos grow till day 5 (most of which arrest are shown to be chromosomally abnormal) and test the rest. This part is up to your doctor. The embryoscope has some utility in this weeding out process to allow you to transfer your best embryo first. But it is not a conclusive/fool proof test by any means.  To really know which of your embryos is okay, you need to find a doctor who has the technology to offer a trophectoderm biopsy with CGH microarray testing. Note that a Day 3 biopsy and FISH testing are useless. Day 3 biopsies are bad for two reasons: Most embryos are actually chromosomally abnormal at day 3, and if you test at this point, you may throw out a good embryo (the doctor at RMA-NJ told me that a lot of the embryos that they had discarded as "abnormal" through day 3 testing/FISH turned out to be normal when tested at day 5 with CGH microarray: they had been "rescued"). The second reason is that the biopsy itself can damage the embryo, given that you are pulling out 1 cell out of 8. 
• Avoid transferring multiple embryos: To do this, you have to let the embryo grow in the lab till day 5. This is where the patients may balk: if a low number of eggs are obtained, then most patients are reluctant to even grow their embryos to blasts. They don't want to see their embryos arrest in the lab, and somehow feel that if it goes into them, it may have a better chance. Here is the problem with that idea: right now there is little to no evidence to show that the womb poses any advantage over the petri dish. If you transfer all 3 of your day 3 embryos or two blasts at one go, you may win the battle but lose the war. I've lost count of the number of people on the blogsphere I've seen this happen to.  I've seen some people pull through through the skin of their teeth, after being on bedrest for months, and enduring unbelievable stress. Compared to that, a failed IVF cycle is a walk in the park.  If you can...grow your embryos to blasts, biopsy them on day 5, find out which one is chromosmally normal, and transfer that (pregnancy rate: 66.4%). Failing that, transfer one blast at a time without biopsying (pregnancy rate: 47.9%). 

The first two things I've talked about here, picking a more natural IVF, choosing strategies that minimize the number of injections you have to take (it is really easy), and picking a  natural FET is doable for many, and most people would have no issues with these things if they fit the necessary patient profile.

The third thing is a comfortable place to be in: If you have 12 day-3 embryos, you can easily make the decision to grow them further, and most people do. The testing is up to your doctor anyway. On the day of transfer, you have to make the harder decision of transferring one or two. Remember, a day 5 blast has about a 50% chance of implanting.

The fourth choice is the hardest. What if you get only 3 fertilized eggs? Making the decision to wait and grow those in the lab for 5 days, knowing that all of them may arrest at day 3 or 4,  and facing the reality of going home empty handed from your IVF is the hardest decision to make.  But therein is the gamble. You could transfer all three embryos on day 3, be ecstatic when you have a positive pregnancy test, and 20 odd weeks later, lose two or three babies. It has happened so many times, and I'm writing this post because I am very, very tired of seeing it happen. Everybody thinks that this could not possibly happen to them, or they choose not to think of it at all when going for embryo transfer, but really, they should. Not all doctors have a single embryo transfer policy, and they should. Because gambling with lives like this is not acceptable.

Despite my preaching, and my knowing all this, I gambled too. I wanted to transfer only one blastocyst at a time, but my doctor froze my embryos in pairs even after I specified that I wanted an elective single embryo transfer. I could have done a single embryo transfer and frozen the second embryo. I did not, because I was too afraid that freezing twice many be damaging. I green-lighted the transfer of two embryos to one surrogate, and prayed only one would implant, and I got lucky. My OB-GYN, who regularly sees surrogates, told me that she considered all surrogates high-risk. My mouth fell open then, and I asked, "Even the ones carrying singletons?" She said yes. They are apparently high risk for many reasons, not all of which that I bought completely.  As we move into the second half of pregnancy, I am terrified of pre-term birth. And that is with a singleton. If there were twins now, my stress levels would be much higher, and my fears would be perfectly valid. 

Take home message? Think long term, not short term. So hard to do, I know, but so prudent.