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When fertility treatments become frightening
An imperfect science
There are no good statistics on how many reductions are done every year because physicians do not have to report them. Anecdotally, doctors say the number peaked in 2000 when, for example, Ilan Timor, M.D., director of the division of ob/gyn ultrasound at New York University in New York City, performed about 100. Now, Dr. Timor says, he generally does about 60 per year. Mostly, the drop is due to improved techniques, both for IUI (better ultrasound technology has made it easier for doctors to see how many eggs have been stimulated) and IVF (specialists are better able to determine in the lab which embryos are most likely to survive). Now ASRM’s IVF guidelines call for implanting one embryo in women under 30 and two in women between 30 and 35. Not all doctors abide, as evidenced in the case this past January of Nadya Suleman, the 33-year-old woman from Whittier, California, whose doctor implanted six embryos, which resulted in her giving birth after 30 weeks to eight babies after two embryos split. Needless to say, success rates for IVF have gone up. “The best embryos give the best chance of getting pregnant,” says Arthur Wisot, M.D., a fertility specialist with Reproductive Partners Medical Group in Los Angeles. “Adding embryos doesn’t boost the odds of conceiving, just the odds of having multiples.”
Success rates for IUI have climbed, too: Nowadays, most high-order multiple pregnancies are the result of fertility drugs, which stimulate ovulation so women conceive through insemination. This is an imperfect science: Despite higher-quality ultrasounds and blood tests, doctors can’t always be certain how many eggs will be released and fertilized. Still, many women choose IUI over IVF for financial reasons. Each IUI cycle costs between $500 to $2,000, depending on the fertility drug used, whereas IVF’s price tag can reach up to $12,000 per round. Only about 20 percent of health plans cover either, Dr. Wisot says, so for those who can’t afford IVF or won’t do it for religious reasons, IUI puts them at risk for conceiving a dangerously high number of babies — and facing the terrible choice that plagued Kristina. “If I’d known how many embryos I’d get, I never would have done the IUI,” she says. “I’d heard there was a chance, but I never imagined I’d end up with six. I mean, who does?”
Kristina, then an assistant at a car-financing group, was newly married when she got pregnant with her first daughter, Meghan. She was 23 at the time and figured it would be no problem to have one or two more babies before she turned 30. She was wrong. Soon after Meghan turned 2, the couple spent a year unsuccessfully trying to conceive on their own. Then they spent two years off and on with two different specialists who prescribed Clomid, a pill that stimulates ovulation — it made Kristina hyperemotional but didn’t get her pregnant. Her health plan didn’t cover IVF, so Kristina opted for injectable stimulants combined with IUI in her doctor’s office. Although the specialist warned Kristina the treatment carries a high chance of twins and possibly triplets, he said he’d only had one case of quadruplets in more than a decade of practice. And after the first round of treatment failed, Kristina was sure she’d be lucky to conceive. “He told me that if he sees more than four eggs, he won’t do the insemination,” she said. “So I wasn’t worried. Frankly, I was more worried that it wouldn’t work at all than that it would work too well.”
Multiple heartbeats
Ten days after her second IUI, Kristina took a pregnancy test. “It was positive,” she recalls. “Finally! I was so thrilled I never stopped to think about how many babies it might be.” At the doctor’s office a few days later, her hormone levels seemed high for a normal pregnancy, but it wasn’t until an ultrasound at seven weeks that the doctor first spotted three little heartbeats. Immediately, he referred her to a high-risk OB, who later brought up reduction — a heartbreaking discussion that may be most difficult for women carrying triplets. “The risk of four or more babies is so clear that it’s a relatively simple decision,” Dr. Sehdev says. “But there’s still debate about whether carrying triplets is that much worse than carrying twins. That’s the hardest for many women.”
Dr. Sehdev says counseling women pregnant with triplets can be more difficult than talking to those with four or more embryos, in part because moms-to-be often have stories about healthy triplets they’ve known. And in fact, as many triplets are born above the average gestational age of 33 weeks as below it — often leaving the hospital with no complications. “You never know which group you’ll be in,” Dr. Sehdev says. “Just because one couple had problems or didn’t, doesn’t mean another couple will or won’t.” Some patients come in recalling TV celebrations of high-order multiples soon after their births — which makes doctors cringe. “Couples ask why they can’t be like the family on TV,” Dr. Sehdev says. “But these shows never focus on outcomes for the babies. They never talk about the ones who won’t survive or who will have neurological issues for life.”
Still, there are women whose remorse after reduction is not easily forgotten. When Stacey Magliano, 37, a stay-at-home mom from Woodstock, New York, found out in 2004 she was carrying quintuplets, she says all she heard about was the worst-case scenario — disabilities, death and other complications. She says she reduced to twins despite her and her husband’s discomfort with abortion because she felt she had no other choice. Only afterward did she learn about the success stories — women with five embryos who made it past 30 weeks, families who happily raise multiples. Now, with a 6-year-old, 3-year-old twins and a 1-year-old, she says she regrets her decision to reduce. “I don’t think I made an informed decision,” says Magliano, whose babies were all conceived using infertility drugs. “A lot of people who go forward don’t have negative outcomes. I’d never do it again.”
Dr. Timor says most patients carrying triplets choose to reduce to twins, a procedure that makes up about 40 percent of the reductions he performs. But Kristina never considered it: “I told my doctor I didn’t need to think about it. We knew we’d keep three if that happened. A decision had been made.”
Everything changed when she found out she was carrying six. Through tears, she watched the tiny hearts pulsing on the ultrasound monitor, little black blobs inside six sacs, with no arms or legs yet. She carried the image in her mind for weeks as she struggled with what to do. Logically, she knew a reduction made sense, and the people she’d told — her husband, her parents and her best friend — all agreed. But in her heart, Kristina felt it was wrong, a betrayal of her beliefs and her babies. She spent hours scouring the Internet, occasionally finding the Web site of a family with quintuplets who seemed healthy and happy. At those moments, she’d think that she, too, could handle it. “I never let anything hold me back,” she says. “Why should I let this?” But the success stories were few and far between. Mostly, she came across heart-wrenching message boards on which women mourned the death of their multiples or traded stories about the struggles of handling ongoing disabilities in their surviving kids. All of it added to her torment. She’d waited so long to be pregnant, but now she couldn’t enjoy one minute of it. She didn’t bond with the babies, knowing some wouldn’t make it. Instead, she tried not to think about the six babies developing inside her — except to pray that some would spontaneously reduce. “Emotionally, that would have been better because it would have been out of my control,” Kristina says. “This way, I felt hopeless. I didn’t want to be making this choice. It was horrible.”
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