6 week ultrasound

Early Tuesday morning, M's uncle passed away.  Because I knew M and N would be busy planning the funeral and hosting family, I moved the ultrasound appointment to Texas Fertility.  Rick and I promised that we would FaceTime them for the entire appointment; they wouldn't miss a thing.

We arrived exactly on time-- 11:15-- and so went back almost immediately.  Rick got M and N on FaceTime and we waited for Dr. Vaughan to come in.  When he did, I gave him our relevant history-- including that I'd been bleeding heavily the day before-- and then we got started.

We immediately saw two sacs, and then, with just the slightest bump of the wand, we saw the third.  Three sacs.  We started with sac A, which was anterior and therefore furthest from the ultrasound wand and most difficult to visualize.  Even so, we could immediately see both the fetal pole and the heartbeat.  He couldn't get it to focus clearly enough on the heartbeat to get a rate.  The fetal pole measured 5w6d-- completely normal.

Sac B also had a clear fetal pole, with a heartbeat.  That pole measured 6w1d and the fetal heartrate was 104 beats per minute.

Sac C initially looked empty.  But no-- then we saw another fetal pole, measuring 6w2d, with a heartbeat at 109 beats per minute.

All in all, three completely normal looking little fetuses.

Oh, boy.

Dr. Vaughan said "Tim's going to be mad... at himself."  (Tim = Dr. Hickman.) Yep.  Triplets were definitely not the goal.  He rolled the dice, we depended on his advice, and now we are the 1% risk group.  Pregnant with triplets.

Now that we're here, though, to me, there's no option than to soldier forward and do everything we can to ensure the best outcomes for these babies.  As Dr. Vaughan reminded us, we are not assured of triplets.  There are many hurdles to overcome (including this bleeding, for which he saw no cause, but didn't seem to be overly concerned about).  This is no walk in the park, unless we're talking a really scary, twisty-turvy, obstacle-filled park.  But I do still have an image of three babies at the end of this journey.  Three toddlers running around the C house a couple of years from now.

Here we go...

Bleeding

I thought the ultrasound would be the only exciting event this week- unfortunately not so!  Yesterday, I was standing talking to someone at work when I felt three gushes of what I knew had to be blood.  Sure enough, I went to the bathroom and my underwear was soaked.  Bright red.  I packed up and went back home to spend the day in bed.

My first instinct was that bedrest and hydration was really the only thing I could do.  I got in touch with Andrea at Houston IVF (Barb is out of the office) as well as Gayle, and they agreed it was best to lay low and wait for my ultrasound, since it was just a day away.  The blood slowed down a bit when I was laying down, but it was still going strong anytime I got up to use the restroom.

Rick called to check on me at about lunchtime.  When he did, I stood up and ended up (sorry, this is gross) passing an enormous clot-- about half the size of my palm.  I'd never bled in a pregnancy until the last one, and I'd never, ever seen a clot like this except maybe after childbirth.  Not an experience I was looking for!  I (gross again) picked it apart with a pair of tweezers to make sure it was really just a clot-- it was.  And my bleeding continued to be "pure" blood-- no tissue or fetal sac or anything.

The bleeding slowed substantially after that, but it was still definitely "bleeding" rather than "spotting."  No cramping at all, which made me optimistic it was not a miscarriage, but instead a SCH (subchorionic hemorrhage, a common IVF side effect).

But I really didn't know if we should expect 0, 1, 2, or 3 babies at the ultrasound this morning.

Procrastinating

I have a million things to do and not one bit of motivation to do them, so here I am updating on... a lack of symptoms, I suppose?  I still don't feel any different at all-- it's easy enough to forget I'm pregnant (possibly with a litter).  I had the teeniest bit of fleeting nausea this weekend, but under any other circumstances, I wouldn't have even taken note.  I also have a tiny bit of spotting that seems to be ongoing, which I think is just slight irritation from the Crinone, or possibly a cervical polyp again-- not concerning.  I've been sleeping through the night (once I start the progesterone, I'm usually up at least once).  Pretty normal appetite-- more than usual sometimes, less than usual other times-- that adds up to "usual," right?

I had lunch with a good friend today who knows a local mom who carried spontaneous triplets to 38 weeks (and then exclusively breastfed them for 6 months-- I'm pretty sure there's an extra special merit badge for that).  If we do end up in Tripletville, that's another person at the top of my list for people to talk to.

I truly haven't been thinking about the 2 vs. 3 question too much for the last several days.  Logically, it seems all signs point to three.  So that's what I've accepted for now, though I think actually seeing three sacs on Friday will still be shocking.

I'm 5 weeks, 3 days pregnant today.  So far, so good.

More conjecture

I was sitting here this morning feeling calm, cool, and collected and decided that all this worrying about triplets is for nothing.  Surely it's "just" twins, I thought.

Then I went back and looked at the betabase numbers.  I don't think I'd actually done the math-- I just knew we were on the very high end of the reported range.  Well, turns out we're in the top .7% or so of about 1900 reported beta values for twins.  I have to laugh, really.  What else is there to do?  I also looked back at the SMO numbers and we are way, way over what anybody reported for even quintuplets, so that's just not very helpful.

So, most likely triplets.  Triplets that may naturally reduce to two (or even one, I guess).  Or triplets that may hang in there for the duration.  Listen up, babies.  I'm ready if you are.  I am handing you the next year of my life (realizing that this experience will not end at the moment of birth).  Be strong, grow well, let's do this.

We'll have the beginning of some answers a week from today, when we have the ultrasound.  According to the papers Barb sent over, there's a 50% chance of seeing heartbeats at 6 weeks, and by 7 weeks, they should definitely be there.  7 weeks is also the week by which most triplets reduce, if they're going to, so our fate is still a little open even after next week's ultrasound. 

I have complete faith that we can handle whatever life has in store for us.

Preparing

M talked to his brother, P, who has (one year old!) twins.  P really loved their doctor, Dr. Robert Carpenter.  Well, it turns out that I had been leaning toward seeing Dr. Carpenter based on my own research.  So that was a happy meeting of minds.

At M's urging, I called his office today to set up a phone consult.  *If* we find out there are triplets on the 29th, we will have a phone consult with Dr. Carpenter on April 9th.  That consult will be to discuss the risks of triplet pregnancy and the possibility of reduction.  I will say upfront that I am not at all in favor of reducing.  If there was a problem with one of the babies, yes, I would do it.  But reducing an otherwise healthy baby sounds pretty terrible to me.

On the other hand, I recognize that there are risks to me and to the babies if we proceed with three.  I just don't think we should have transferred three if we weren't prepared to take on that risk.  Well, I don't think we should have transferred three in any case, but we did, so here we are.

Dr. Carpenter's office sent us a packet of triplet pregnancy information.  Probably most interesting to me was this:

NATURAL HISTORY OF EARLY PREGNANCY — There is a significant possibility of spontaneous loss of one or more fetuses between the time of ultrasound diagnosis of the triplet pregnancy and delivery. As an example, a study of the natural outcome of 38 pregnancies in which three gestational sacs were identified with transvaginal ultrasound (TVUS) at 21 to 28 days after ART reported triplet, twin, and singleton delivery rates of 47, 32, and 18 percent, respectively, with miscarriage of all three fetuses in 3 percent [5]. Embryo reduction spontaneously occurred primarily within the first seven weeks of pregnancy and did not occur after the 14th week of gestation.
Similar findings were reported in a series comprised of 6149 singleton, 549 twin, 132 triplet, and 23 quadruplet pregnancies monitored by ultrasound examination [6]. Sonography was initially performed at 3.5 to 4.5 weeks after ovulation and repeated every two weeks until 12 weeks of gestation. Spontaneous reduction of one or more sacs occurred in 20 percent of singleton, 36 percent of twin, 53 percent of triplet, and 65 percent of quadruplet pregnancies. Most losses were prior to the ninth gestational week; miscarriage of all three sacs occurred in 6 percent of triplet pregnancies. In addition, multiple pregnancies that experienced spontaneous reduction delivered earlier than unreduced pregnancies with the same number of fetuses (eg, triplets-to-singletons delivered 10 days earlier than unreduced singletons, triplets-to-twins delivered 4 days earlier than unreduced twins).
 

So in both studies, 53% of triplet pregnancies naturally reduced to twins.  Those are decent odds.

I still have very mixed feelings about "wishing" or "hoping" one of the embryos will stop developing.  I guess I just hope that everything will work out the way it's supposed to.

This quote was interesting to me too:

While some data suggest that triplets reduced to twins have higher birth weights and longer gestations, other studies have indicated that the gap in morbidity and mortality of triplet gestations is closing.
 

So carrying triplets isn't as dire a situation as it used to be?

He does say the prematurity rate is 80-85%, with premature being born prior to 37 weeks (that seems like an awful lot of triplets born later than 37 weeks to me, when I thought it was pretty commonly accepted that 36 was the end of the road).  15-17% are born prior to 28 weeks (scary early).  Which puts about 70% in the 28-37 week range.  He cites some data about triplet pregnancy histories, but the years included in the analysis are 1946-1992, and that seems outdated to me.  In that group, though, mean delivery was in the 33 week range, which isn't terrible.  Not ideal, but not super scary either.

Anyway, Dr. Carpenter reportedly is The Guy for statistics and data, which you know is a good fit for This Girl.  So, if we do find out it's three (or more!) next week, we've got another good member of the team.

Hungry, hungry hippo

Oh, good gracious.  I am starving.  So hungry.  I ate breakfast this morning, but I don't think it was enough protein (I had leftover cauliflower soup and some clementines) and I could eat off my own leg about now.  I'm holding out for a few more minutes to go with some coworkers to a fish fry on the Capitol grounds.  Hurry, people.  I am (we are) hungry.

I truly have not one bit of a symptom otherwise.  I've been sleeping just fine, good energy levels for the most part, no nausea.  Yes, I'm not even 5 weeks pregnant, so I think that is to be expected.  But I figured with the enormous hormone levels, I might have it a little rougher.  Not yet!  I think it's been closer to 5.5-6 weeks that I've experienced symptoms in the past.

Trying to be more eloquent

So, yeah, that was a big number today!  A very big number.

Here's the thing.  As hCG levels rise, the doubling time generally slows (you can look down to my "Jackpot!" post below to see the charts).  Specifically, once it's over 1200, the expected doubling range drops to 48-72 hours.  Doubling at 32 hours for a number as high as ours makes me feel like it's much more likely to be 3 embryos, each pumping out some strong hCG levels (divided by three, our number today would have been 1,673-- still 4 times the median for a singleton).

So, yeah.

I'm thinking it's three.

At 18dpo, a beta of 5,019 is:

• 4.25 times the median for triplets
• 6.23 times the median for twins
• 12 times the median for a singleton
• Pretty scary, if you think about it.

In the past, my betas have been about 4-5 times the median.  I do like to crank out some hCG.  No doubt.