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The High Costs of Fertility
By Catherine Winter
November 10, 1997
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The birth of septuplets is an extraordinary thing in humans. Even smaller multiple births, such as twins and triplets, are far less common than singleton births are. But the number of multiple births in the US has been climbing for the past two decades. Between 1971 and 1994, the number and percentage of multiple births quadrupled. About 1000 triplets were born in 1971; about 4,500 were born in 1994. The major reason for the increase is modern treatment for infertility - particularly the use of fertility drugs. Multiple births tend to be celebrated as miracles. But fertility specialists say bearing more than one infant at a time is an unwanted side effect of treatment.

Most of the triplets and quadruplets born in the US today are conceived with the help of fertility drugs. Without drugs, the chance that a pregnant woman will have more than one baby is around one or two percent. With drugs, the probability climbs as high as 25 percent. The vast majority of those are twins, but larger multiples occur, too. Infertility specialist Dr. Robert Stillman says drugs can help infertile people have the babies they desperately want. But the side effect - multiple births - can be risky for the mother and the infants.

Stillman: The uterus is only so capable of carrying a certain size and oxygenating and feeding - through the placenta - a certain number of babies. Beyond twins and triplets the risk of early delivery is considerable, and therefore the risk of complications to an infant from prematurity is greater.
Stillman says even twins are at greater risk for birth defects - such as cerebral palsy and blindness - and death. He says doctors try to help a couple have one infant at a time. But doctors have only so much control.

The most common fertility treatment is a course of drugs that can make a woman produce extra eggs. Normally, a woman produces one egg per cycle. A doctor using a conservative dose of a drug could increase the number to two or three eggs in a cycle - but the drugs are capable of making the body produce 20 or more. Having more targets for sperm increases the chance of pregnancy, but it also increases the risk of twins. Doctors can keep the number of eggs low - but it's an inexact science. And many fertility specialists worry that there's pressure on doctors to use the drugs too aggressively.

Dr. Janet Hall works with the national center for infertility research at Massachusetts General Hospital in Boston.

Hall: There's a lot that goes into an infertility treatment cycle. There's a lot of expense of the drugs. Much of this is not covered by insurance. And the other part of it is that every cycle is a big deal for patients. They have to take time off work. They have to have a lot of doctor visits, so all of that really pushes, I think, both patients and physicians to try and maximize the chances of getting any pregnancy out of every single cycle. The problem is that when we take that approach, the risks of multiples can go along with that.
Dr. Hall says multiple births aren't just dangerous - they're expensive. She studied the cost.
Hall: In 1991, the total charges for a family when a singleton was delivered were about $10,000 compared with $38,000 for twins, and over $100,000 for triplets. For triplets it's close to $40,000 per baby.
Having twins or more is tough for couples emotionally, too. Studies have shown parents are more likely to be exhausted, depressed or anxious, and may be more likely to divorce. But patients are often willing to risk multiple births if the alternative is no children. Dr. Norbert Gleicher surveyed infertility patients and found a majority would welcome twins or triplets.
Gleicher: What our study also demonstrated is that the patients we queried were actually extremely well-educated. From the responses of the patients it was quite apparent that they made their choices knowing fully what the risks were.
It's possible for doctors to remove some embryos from the uterus - leaving more room for one or two to grow. Medical ethicists oppose deliberately producing lots of embryos assuming you'll just remove some later, but they say it is appropriate when couples accidentally conceive too many.
Dr. Gleicher: Fortunately we don't see it very often, but I can tell you that quintuplets are certainly not a rarity. Fortunately most couples understand the risk and will agree to selective termination to reduce the number. You never hear about those in the media. You also never hear about those who decide to carry them and then lose them.
Like many doctors, Gleicher worries that the septuplet pregnancy in Iowa will lead people to think that a large multiple birth is a success story. He says his goal is always to produce just one healthy baby at a time. Fertility specialists say they're getting closer to that goal as they get better at their craft - and that will mean fewer multiple births in the future.