Introduction

Why are so many baby strollers, built for two or even three, rolling up and down the avenues of major cities? The short answer: infertility treatment.

During the past 20-25 years, largely due to such treatment, the incidence of triplets, quadruplets, and even higher-order multiple births has increased 400%. Medicine’s success in combating infertility is a boon to would-be parents, but it has come at a cost–medical, moral, and financial–that everyone considering it must evaluate.

This article describes the two types of infertility treatment that give rise to multiple births, explains the risks, explores the major ethical issues, and passes along practical advice on how to choose a reputable physician and program. The focus is on reaping the rewards of these technologies while minimizing their harmful consequences to mothers and their babies.

First There Were Seven and Then There Were Eight

Remember the McCaughey septuplets, the babies born to Bobbi and Kenny McCaughey? Everyone was captivated by a modern fairy tale that combined the wonders of technology with the kindness, warmth, and neighborliness of a 1940s movie. An army of medical personnel, on hand during the delivery and follow-up hospital care, was succeeded by an army of devoted neighbors and friends who coordinated meals, laundry, transportation, babysitting, and housecleaning. The babies appeared healthy. The McCaugheys really did seem to have “a wonderful life.”

Stories about the Chukwu octuplets, born in Texas about 1 year later, were very different in tone, and not only because one of the babies, who weighed a mere 10.3 ounces at birth, died a week later of heart and lung failure. The media reaction was less celebratory and more ambivalent. Media hesitation to discuss the medical risks involved in so-called high-order multiple births, which had been obvious when it dealt with the McCaugheys, evaporated within days of delivery.

The Twin Causes of Multiple Births

Both Bobbi McCaughey and Nkem Chukwu had taken fertility drugs. Such drugs are given for two reasons: ovulation induction (to enable someone who does not ovulate regularly to do so) and super ovulation (to enable a woman who does ovulate, but has had difficulty becoming pregnant, to produce multiple eggs). High-order multiple births are linked to both treatment goals, but primarily the first. When using such drugs, it is good medical practice to do ultrasound scans to monitor the number of eggs present. If the number is too high, the woman may be advised to refrain from sexual intercourse.

Alternatively, by using in vitro fertilization (IVF), eggs can be fertilized outside the body. The resulting embryos are then implanted into the mother. Age is a factor here: Implanting more embryos in younger women increases the risk of multiple births. Generally, the better the technical abilities of the infertility specialist, the fewer the embryos required to be implanted.

The Risks

For individuals (and their mates) who really want to become pregnant, it can be difficult to coolly consider the risks that attend to giving birth to several infants–risks to both mother and babies. For women, overstimulating the ovaries can have medical complications. Carrying multiple fetuses increases the risk of potentially fatal blood clots during pregnancy and delivery, as well as the likelihood of miscarriage.

Premature babies face a broad range of increased risks, which include potential complications immediately after delivery and later problems such as learning disabilities, mental retardation, blindness, and chronic lung problems. For instance, doctors are currently evaluating whether two of the McCaughey septuplets may have cerebral palsy. There are also potential psychological effects of having parents who may be stretched beyond their capacity to cope.

Why Doctors and Patients Go Ahead Anyway

But many women (and couples), even knowing the risks, choose to take their chances. They have unprotected sex when they have produced many eggs, or they ask their doctors to implant four, five, or even six embryos after IVF. Both drugs and IVF are expensive and, for most people, these procedures are not covered by insurance. They therefore want to maximize their chances. And, of course, there is the intense desire to become a parent.

Clinics have incentives, too. Patients choose specialists with the highest success rates. However, giving too much of a drug or implanting too many embryos, which may not be in the best interests of mother and child, can result in deceptively good statistics for unwary consumers. Some physicians feel that if they are faced with a high-order multiple pregnancy, selective reduction–giving some fetuses a lethal injection of potassium chloride to increase the chances for the ones that are left–is a fallback position. For religious reasons, for Bobbi McCaughey and Nkem Chukwu, it wasn’t.

Ethical Issues

The April 21,1999, episode of Chicago Hope, “And Baby Makes Ten,” depicted multiple births as ethically problematic. There are many concerns, some of which are troublesome or have moral implications, including the following:

• First, informed consent: Before treatment begins, doctors must describe to couples the risks to mother and baby, as well as the likelihood of success and how that success is measured. The so-called take-home baby rate–the percentage of treatments that result in a healthy baby–is key. Various options should be fully and frankly explored.
• Second, selective reduction: Couples should be asked, before treatment, whether this could be an option for them. If not, more conservative treatment may be considered.
• Third, the doctor’s duty: Doctors have a responsibility toward the babies as well as toward their mothers (and fathers). A woman’s (and man’s) wish to maximize the chances for a pregnancy must be balanced against the babies’ welfare.
• Fourth, cost: The cost of caring for these children can be extraordinarily high. The cost for the octuplets had reached $2 million by the time they left the hospital. Although fertility treatment expenses are usually paid by the individuals undergoing treatment, the babies’ medical care is covered by insurance. Many people question whether it is reasonable for society at large to bear such high costs as a consequence of the decisions of individuals.

Questions to Ask When Choosing an Infertility Specialist

In addition to understanding the specialist’s approach to the ethical issues just described, there are other questions to ask. Eric Widra, MD, director of Reproductive Endocrinology, Georgetown University Medical Center, and an associate at Shady Grove Fertility Centers, suggests four criteria:

• Are there fellowship-trained reproductive endocrinologists working there? (These are doctors who have had obstetrics and gynecology training, along with additional training in infertility and developmental disorders of the reproductive tract.)
• Are the doctors board certified (after taking written and oral exams)?
• What are the success and complication rates?
• Can the practice offer complete services, including IVF, 7 days a week?