Chez Perky

Sextuplet Followup

I've received a lot of insightful comments on the Sextuplet post. I've purposely remained relatively silent since my initial post because I've been thinking about it and trying to absorb all of your valuable insight. One sad, but unfortunately predictable update is that one of the Morrison Sextuplets died on Thursday.

Minnesota Sextuplet Dies
By AMY FORLITI
The Associated Press
Thursday, June 14, 2007; 9:21 PM

MINNEAPOLIS -- A sextuplet born prematurely to a Minnesota couple has died,
and his five siblings were in critical condition, hospital officials said
Thursday. Bennet Ryan Morrison died Wednesday night, and the other babies
remained in critical condition Thursday at the neonatal intensive care unit at
Children's Hospital in Minneapolis...

I know that the Morrisons must be suffering a tremendous grief right now while still fighting and praying for their five other children. I admit that my initial reaction to their story was disapproval, not of them as a couple but of their doctors. I knew that they had tried fertility drugs, and had assumed irresponsibility on the part of their doctors. But having read the information on their personal website, which is actually very well written, I see that this, was an unforseen error, not unlike my triplets, only on a much larger scale. Ryan Morrison writes:

After two failed cycles using Clomid, we tried the drug Follistim. Brianna’s first cycle with the new treatment looked great. She had two mature eggs that were ready to be released, and two immature eggs that probably weren’t going to be viable. There was a 25% chance of us having twins, a 3 % chance of us having triplets and anything else was laughable. ...

It was a month later when we discovered that Brianna was not carrying just one baby, but six.

Since then we’ve learned that Brianna had ovulated at least ten eggs. The doctors at our infertility clinic say that they’ve never seen anything like this before, and can’t explain why it happened. They strongly encouraged us to consider selective reduction, explaining that the risks of carrying and delivering six babies are too great. They said that reducing the number of fetuses now would increase the chance of survival for the the remaining fetusus as they develop, and would decrease the chance of long-term health risks for the babies that were carried to term. However, we knew right away that this is not an option for us. We understand that the risk is high, but we also understand that these little ones are much more than six fetuses. Each one of them is a miracle given to us by God. He knows each one of them by name and we will trust Him absolutely for their lives and health.

Oh, how I wish I had read that before I jumped to conclusions. Oh, how I wish I hadn't believed their doctors were so stupid and irresponsible. Oh, how I wish they weren't suffering watching their babies suffer. Oh, how I wish those babies had also made it to 30 weeks. And while I know that if I had been faced with sextuplets I would have reduced, I also know that it is because I probably would not survive a sextuplet pregnancy. I had to consult with a neurologist, a cardiologist and a perinatologist to determine whether it was safe for me to carry triplets, and the answer was triplets were probably okay, quadruplets would be pushing it. I know that if I'd been faced with sextuplets, I would have reduced. And I know I would have spent a lifetime wondering about the rest of those babies, even knowing that it was the exact right decision. I understand 100% why the Morrisons could not consider reduction, even though I do believe that by choosing not to reduce they accepted a risk to Brianna's life and to the lives of their babies. I hope that the very best outcome for the Morrisons can be achieved. I'm sure this is a tremendously difficult time for all of them.

The Masches, as you know, were luckier. Their babies made it to an astounding 30 weeks, 4 days. Jenny Masche, however, went into acute heart failure on Monday after the babies were born. She was stabilized and is not expected to have long term problems as a result, but I'm sure it was very scary for her and the rest of her family. I hope that she and the babies continue to do well. As lucky as they were, they have a long road ahead of them, as the hard part is only just beginning... once the babies are healthy enough to go home, they'll have to feed, and clothe and parent them. That's going to be a huge deal.

Someone brought this article: Babies Should Come in Ones Not Sixes to my attention. While a bit heavy on the vitriol, and obviously written by someone not familiar with the specifics of either story, it does raise a few points that no one else in the media seems willing to mention, so it might be worth a read. What bothers me most about the sextuplet stories, particularly the Masche story, is the glamorization it has received in the media. How fun it's looked in the eyes of the Today Show, and how "easy" they've made it seem. In her interviews on the Today Show, Jenny Masche has been wearing nice maternity clothes and makeup and looking stunning and healthy and happy and they've focused on crib building and other fun things, but have failed to mention the devastating possibilities of sextuplet pregnancies. I worry about the message that is sent with this kind of media coverage. People are already saying to me, "oh, don't worry about your triplets, I'll bet they won't even be in the NICU... look how big and healthy those sextuplets were!" I've had four separate people say that to me this week. I'm not kidding. I find this terribly problemmatic.

I want to address some of your comments, but this post is long enough, and I want to make sure that one comment in particular gets addressed. For the rest of you, if I don't get a chance to post about your comments specifically, please know that I've taken all of them to heart and I think about them constantly. I just am taking time to process it all. But this comment really does deserve to be addressed all on its own, from Anonymous:

I've been reading your blog ever since I found out I was pregnant with triplets. It was our first IUI cycle, they said I had one dominant follicle...then the u/s showed twins...one week later it was triplets. We decided to reduce, and our lives have been filled with anxiety and grief, but also hope that this is the right thing to do for us. Last week, at 11 1/2 weeks, an u/s showed quads. We are angry beyond belief. The woman having sextuplets that they were following on the Today show (let's glamorize it, shall we?), it was her first IUI. Suzanne (I read your blog now too!), your pregnancy was with Clomid. Insurance companies need to pay more attention to what is happening. Fertility clinics need to do a better job of monitoring situations. And people should be told very clearly about the possibilities (granted, my chances of getting preg. AT ALL for this IUI were less than 10%) before they begin treatments. TV and the media need to stop showing these pregnancies as "fun", and pay attention to the real problems. I honor the people who decide to go through with triplets or even more. For us, I have never felt so much sadness in all my life. My reduction is tomorrow. Tonight we say good bye to two of our babies and I will pray that they find another womb that will welcome them and be ready for them. I thank all of you for allowing me to lurk and read your blogs. You provide more comfort than you can ever know.

First, I want to be clear: Any decision that a person makes on reduction IS the RIGHT decision. No one else can tell you what the right decision is. That was the best advice that I received. I got such tremendous pressure to reduce from all sides, except my rabbi who was adamant that if there was a way to carry all three, I should do it. Ultimately, my rabbi determined that halachically (that is, within the requirements of Jewish law), I had sufficient reason to support reduction. But careful review of the medical factors led us to determine that there was not sufficient medical reason to reduce in our case. I was adamant that I would not consider emotional or financial factors in this decision, only medical and halachic factors. But for others, those emotional and financial factors are KEY factors. Everyone needs to determine for themselves where the line is drawn.

Anonymous, you made the right decision, for it was YOUR decision. I wish you much peace with your decision and much health and love with your twins. Please feel free to contact me directly if you ever need to talk more about this, but do remember, you did exactly the right thing for yourself and for your babies. I will be thinking of you, Anonymous. I wish I could do more than that.

Lessons Learned

Generally speaking, I don't freak out about bleeding. As you can see from my two previous posts, this did not ring true today. I started cramping, discovered I was bleeding (not lightly) and freaked the hell out. Normally I'm pretty calm about these things, realizing that if something's wrong, there's not a darned thing that can be done about it, and knowing that probably nothing is wrong. But today? No such sense of serenity. Nope, I called my husband and burst into tears as soon as he answered his phone. I was near panic when I called my OB's office, though I managed a facade of calm as I spoke with the answering service. I nearly burst into tears in the waiting room at the OB's office, something which would have utterly mortified me had it actually happened.

And what lesson have we learned, boys and girls?

Obviously I'm growing quite attached to my three little parasites, troublemakers that they are. There is absolutely no way I can reduce this pregnancy under the circumstances that I have. There is no way. I want to be clear that this is a personal decision of mine. This isn't judging any decisions anyone else has ever made or will make. Every circumstance is different. Every person has their own needs to weigh. I've done my risk analysis. I've weighed my issues. And what I realized was that today all I could think was that I might have lost one and I freaked the hell out. Which means that for me, reduction is not an option right now.

So at least that's settled.

Beyond that, I'm okay. The cramping has not abated, but the bleeding has calmed down. I feel a bit foolish for flipping out so badly, but on the other hand, that's why I have doctors. My doctors are all there to take care of me if things go wrong. And it's not like I won't be getting a bill for today's services, so it's not like I inconvenienced anyone. So here's the second lesson I've learned today: it's okay to be high maintenance. I hate being a high maintenance patient. I feel like a hypochondriac enough as it is. But the thing is, I am pregnant with triplets. Triplets are a high risk pregnancy. I am therefore, by definition, a high maintenance patient, like it or not. I will have to learn that I'm not going to be one of those cute little pregnant women who never has a problem and spends her last trimester walking a mile a day because I can't stand being cooped up or need to walk off that bloated feeling after I eat (there's a chick in my community who walked a mile every day up until the day before her delivery because she couldn't handle how full she felt after eating). That won't be me. I'm going to have to learn to accept help, and more importantly, I'm going to have to learn how to ask for help when I need it.

It's okay to be high maintenance. It's okay to admit I'm attached to the little monsters.

Deflated

I give up. I was very firm in my no-reduction position. I was clear, I had thought it out, I had researched it and researched it and researched it. I wasn't going to be pushed around.

And then I saw my OB this morning. I love him. I respect him. I trust him. These are all important things with an OB. He asked what I'd decided after talking to the perinatologist, and I told him I just really didn't think I could consider reduction. I didn't hear anything compelling enough to convince me otherwise, and I know I'm taking on a huge risk, but I think that the risks with reduction are almost as scary, nevermind the moral dilemma. I told him it isn't fair. I told him there was NO good option here... both options are rotten, and there's no way around it. I don't love the triplet idea. I want a big family and I'm all for welcoming three children into my life, but I'd be lying if I didn't say I'd much prefer to welcome them individually.

And my OB, who I trust more than just about any doctor I've ever had, looked at me with a look of such genuine concern and told me very calmly that he is very worried about my ability to carry all three. He's worried that if I try, I'll lose them all. I'm worried that if I reduce, I'll lose them all. See? No good options. I told him that the perinatologist had sort of brushed off the concern about my height affecting fetal weight, but he strongly disagrees, and I've got a study sitting in my bag that supports his position on this. Women under 165 cm are at a much greater risk of severely low birthweight triplets than women over 165cm. I'm 152 cm. He reiterated that he was still troubled by the 12 week loss I had in my last pregnancy, since there was no apparent cause for it (and they couldn't do genetics on the fetus, because it was mishandled by the ER). He agreed with me that there is absolutely no good choice in this matter and that there are risks on either side of the coin. He understood my concern of total fetal loss resulting from a reduction. He told me he would absolutely support me no matter what my decision, but he asked me not to make up my mind until after the nuchal fold scan and/or CVS (if we do the CVS). I think that's a fair and reasonable request.

And now... I just feel so defeated. So conflicted. So uneasy. I haven't really stopped sniffling since this morning because I just don't know what to do. No matter what I do, I'm going to second-guess myself. No matter what I do, I'm going to blame myself if it all goes South. No matter what I do, I don't know how I'll deal with the consequences. I am utterly, completely, miserably confused right now. And there is no one who can make this decision for me. Even my husband's opinion seems to be that he'll support whatever I decide, and he sees both sides of the argument, and he feels like it's my body that's going to have to deal with the consequences either way, so it's ultimately up to me. In some ways, that is the bottom line. While yes, it should be a joint decision... I'm the one who has to carry three if that's what we do, and I'll be the one physically carrying the burden of that decision. While it may seem like a cop-out... he's really right. Certainly I wouldn't allow him to FORCE me to have a reduction, so ultimately... it's true. It's my body, my call. Like it or not. Still, it would be nice if he would have a strong, specific opinion on the matter, so that I could either rebel against it or embrace it and blame him when it all goes wrong. ;)

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Oh yeah... I should mention... The OB couldn't hear the heartbeats with the doppler, maybe just a tad bit too early. I thought I heard it at some point, but it was brief and fleeting and he couldn't get a lock on it. So he took a quick look with an ultrasound, though I didn't get any pictures. He just wanted to get a quick peek to see if the heartbeats were all still there. They are indeed. Three of them. Three viable fetuses. The sacs have grown a bit and they're all squished up together. Anywhozit, I got my quick peek. Nuchal Fold scan at the perinatologist's office next Friday (the 20th).

Pictures and reduction discussion

This was the scan done at my last Shady Hell Appointment. Three sacs, three heartbeats, three of everything. Dr. Amazing was positively adamant that I must schedule a reduction. I understand to him triplets and high risk pregnancy equal failure. For that matter, I'm not so thrilled about having a triplet pregnancy. I wish I could have nothing but happiness over it, but I can't. I'm still worried about it. I'm happy that I'm pregnant, but I'm worried about the risks and hardships associated with triplet pregnancies. That being said, I don't know that I agree with Dr. Amazing's assessment that a reduction is the only logical option. I'm not even terribly convinced that it's the best option. It seems that no one wants to talk about the risks associated with multifetal reduction, but they really shouldn't be discounted. From what I've seen, the risks aren't insignificant and the studies I've found haven't suggested that the benefits of triplet reduction are significant enough to overcome the risks. (The benefits of quadruplet reduction to twins or less are stacked significantly in favor of reduction, but it is less clear with triplets)

What I didn't realize was how quickly I could get attached to the little parasites growing inside me. Nor did I realize how quickly they grow! In six days the growth was tremendous.

See how squished up against each other they are now? This isn't as clear a picture because it was transabdominal, so you can't see the little fetbryos inside in this picture, but you can see that the sacs were spaced out before and now they're all squished together. This scan was taken at the perinatologist's office on Monday. It was a very long, detailed scan made more difficult by the fact that I absolutely could not manage to empty my bladder enough to see Baby C with a transvaginal ultrasound (but all other views were much clearer). We could very clearly see the hearts beating, whereas before I had to squint and pretend like I saw that random blinking on the screen. Now it's very obvious and impossible to miss. Like I said in my last post, the heart rates were 171, 171 and 168. Baby C is measuring three days behind, which I understand isn't a terrific sign at this stage, but I didn't get a really straight answer about what the ramifications of that size differential really are. At the NT scan, I'll be seeing the head of the practice, so I'm hoping for more clear-cut answers.

The more I think about it, though, the more annoyed I am about my visit to the perinatologist. I didn't get to think about it much after the appointment, because we had a houseguest for the first days of Pesach, and I had other things on my mind. Now that I've had some time to think, I'm seriously annoyed. On the one hand, the doctor took a lot of time with us and answered a lot of questions. She even told me that there are some neuroleptics that I can take for migraine prevention. I'd previously been told that all neuroleptics are out because of risks of neural tube defects. I'm not sure I'm willing to take that tiny risk, but it was nice that she suggested some options. She calmed my fears about the bleeding and cramping and suggested that both are normal, particularly with higher order multiples. She said that the triplets they follow do very well.

That being said, she was most definitely in favor of reduction. Now I could be all about that position if she'd given me some specifics that I could really work with to get on board with her, but she really didn't. She gave me some generic statements about how uncomfortable I'll be with a triplet pregnancy. She talked about how twins deliver later than triplets, which is of course a good thing. She talked about the fact that there's a lower incidence of IVH with twins than with triplets (though the statistics I've found haven't been terribly compelling). She mentioned that the generic risks of pregnancy are lower with twin pregnancies than with triplet pregnancies. What she did not talk about at all was the risks of multifetal reduction. In fact, I have a hard time finding much literature on the risks, but there are associated risks. The risk of total fetal loss, for example, seems to be at best 3-5%. Not high, no, but it IS a risk. Some studies, in fact, put the rate of total fetal loss (miscarriage) at closer to 25 to 30%. That's nothing to ignore.

Then there's the question of real benefit. Average triplet pregnancies go to 32 or 33 weeks gestation in the US, depending on whose figures you use. Average twin pregnancies go to 36 weeks in the US. Triplet pregnancies reduced to twins still carry a higher risk of preterm labor than do natural twin pregnancies. Average gestation for triplets-reduced-to-twins pregnancies is 34 weeks. This is a significant and critical week, but the difference isn't as drastic as the shift from quadruplet vs. reduced quadruplet (to twins) pregnancies. Not even close. If I had quadruplets, this wouldn't even be a discussion.

As for my specific medical concerns, yes they are factors. In particular, the hole I have in my heart is something that should be monitored. But it doesn't appear to be a deal-breaker. Turns out my OB isn't crazy with regards to the whole short factor either... I found one study in which the conclusion stated: "The taller patient (>165 cm) may be at a significantly lower risk of very low birth weight neonates and very premature delivery as compared to the shorter patient (< 165 cm). Therefore, the factor of maternal height may be taken into consideration in multiple gestation pregnancy consultations." (I'm about 152 cm short) My husband is going to pull the full article from the medical library at work tomorrow. And yes, if you pile everything up together, there's a decent argument for reduction given my specific medical factors.

But I also think there's a rather significant argument against reduction and that's a discussion no one seems willing to have with me. I'm almost to the point of finding another perinatologist, except that when asking ANYONE for perinatologist recommendations, this practice is the name that ALWAYS gets brought up. The head of the practice is also the head of maternal fetal medicine at both of the hospitals that I would want to deliver at. They are arguably the best maternal fetal medicine practice in the area. But I'm still squeamish about them for some reason. I feel like my care there would be excellent no matter what decision I make, so it's not a question of my care, really. It's a question of why no one will have a discussion with me about the other side of this argument. That being said, my husband is checking with one of the nurses in the NICU at his hospital to see who she would recommend as a maternal-fetal medicine specialist, so I can get a second opinion. I intend to receive my care from the office I've already been to, but I'd like to have a consultation with at least one more doctor to see if I can get some straight answers.

The problem, of course, is that I'm running out of time.