This morning the two follicles on my right ovary were at around 17.5 and 16-ish mm, while the two on the left were around 15 mm. At first Dr. SF said that we'd drop down my dose tonight (exact dose to be determined based on today's bloodwork), trigger tomorrow, IUI Monday. Then he amended that to say that if my E2 was much over 1000 we might trigger tonight and do IUI Sunday, to bring down the chance of multiples. I reminded him that I have no tube on the left, so those follicles on the left are much less likely to come to the party, but he's also concerned about excessive fluid and bloating if those follicles get too huge.
Then he stopped and said, "Wait, let's really talk about this." He put down the stack of printouts and u/s pictures and looked at me. Ordinarily, he said, he would push it one more day, to get that lead follicle over 18 mm before trigger and maximize the chances of pregnancy. However, doing so will also increase the chance of multiples. Generally speaking, he does this knowing that selective reduction is there as a "safety valve," in his words. "But if a triplet pregnancy would be a complete disaster for you and you don't want to consider reduction, then it might be better to take the conservative route and do the Ovidrel tonight," he told me.
Well, yes, a triplet pregnancy would be a disaster for me. A twin pregnancy would be a disaster for me, frankly. But I also want this to work. And what it comes down to is the choice that all of us undergoing IF treatment make in some form or another: Minimize the chance of multiples, or maximize the chance of pregnancy?
I told Dr. SF I was leaning toward being more conservative, but I would have to talk to my husband. He agreed and added, "This [gesturing toward the ultrasound screen] is about as good as we're going to get," in terms of having a good chance at pregnancy without scary chance of multiples, though he also pointed out that what doctors see on the u/s screen isn't a perfect predictor of what's going to happen once you trigger, as I know Jody can attest to. He finished by saying that if this cycle doesn't work, he will probably push us to reconsider IVF.
I went ahead and scheduled the IUI for Sunday, then the whole way home I thought and thought. I thought about how upset I would be if I didn't get pregnant, and how sick and tired I am of the shots and the early morning appointments and the endless disappointment. And I thought about how devastated I would be if I saw three or even two sacs on the ultrasound screen a few weeks from now, and how even though a twin pregnancy in me is probably roughly equivalent to a triplet pregnancy in a woman with a normal uterus, and a triplet pregnancy is probably equivalent to quads or quints, I don't know if I would have it in me to reduce. And I talked it over with my husband, and the answer was pretty clear: Trigger tonight. Reduce the chances of multiples, even if that means reducing the chance of pregnancy.
I feel pretty confident in the decision. I was even getting nervous thinking about how even with two less-than-optimal-size follicles on my good side, there is a very real chance of multiples, but I reread this (an old study, but I don't feel like digging to find something more recent, though this one also looks interesting) and it looks like the chance of HOM starts to drop off after age 35, which is good news for me and my aging ovaries. (I know that we are still playing with fire here, but I need to tell myself whatever it takes to be able to sleep at night, OK?)
Nurse called to confirm my Sunday IUI and apparently my E2 this morning was 1009. Not scary high (it is, in fact, about what I had the cycle I got pregnant, so I'll probably have a good bit of bloating next week), but enough that I feel even more confident that we're doing the right thing. As much as any of us can have confidence in any of this, anyway. I swear, sometimes I feel like reproductive medicine is equal parts science and voodoo.