Rachel mourns the lost children,
A frequent complication of IVF is multiple gestation, the situation in which a woman finds herself pregnant with more than one child. In order to increase the likelihood of pregnancy following IVF multiple embryos are invariably created: some are transferred to the mother, while others are frozen against possible future need. The number of embryos transferred depends on the age of the mother: the older the woman, the more embryos are transferred. For example, the recommended number of embryos for a woman aged 40-41 is 3-5, depending on the stage of the embryo (Lentz, G., Comprehensive Gynecology, 6th ed. (2012), ch, 14. p. 891, table 41-13).
Most fertility clinics are unwilling to transfer only a single embryo: the stated reason is concern that this increases the probability that the mother will need to undergo multiple cycles of embryo transfer in order to become pregnant. However there is another factor at work. The success rate of fertility clinics is generally assessed based on the average number of cycles taken to achieve pregnancy for all patients. The greater the number of embryos transferred, the higher the likelihood of pregnancy, and the better the clinic's statistics.
If all the transferred embryos develop, the woman may find herself pregnant with twins, triplets, quadruplets, or quintuplets. In this event the obstetrician will advise the abortion of “extra” embryos, describing this horrifying moral dilemma with the benign label, “multifetal pregnancy reduction”. The “necessity” for this form of abortion and its technique is described with chilling nonchalance in Gabbe's widely-used textbook, Obstetrics:
The increasing use of ovulation induction and assisted reproduction has resulted in a growing number of multifetal pregnancies with three or more fetuses. Because the risk for pregnancy loss, preterm delivery, and long-term morbidity for children who are products of multiple gestations is directly proportional to the number of fetuses being carried, first-trimester multifetal pregnancy reduction has been advocated as a method to reduce the risk for prematurity and associated morbidity and mortality. Currently, the method of choice is injection of a small dose of potassium chloride into the thorax of one or more of the fetuses, either transabdominally or transvaginally, under real-time sonographic guidance. [...] Multifetal pregnancy reduction (MPR) is an outpatient procedure. It is usually performed between 11 and 13 weeks [...]
Gabbe, S., Obstetrics: Normal and Problem Pregnancies, 6th ed.. (2012 Saunders, Elsevier), p. 679.
As the citation indicates, it is not only in vitro fertilization that has given rise to this tragic situation: all forms of assisted reproduction that induce ovarian stimulation run the risk of causing multiple gestations. The following article in the New York Times describes the anguish experienced by a couple who found themselves pregnant with sextuplets after the relatively simple procedure of intrauterine insemination (a form of artificial insemination) following hormonal stimulation of the woman's ovaries to produce multiple oocytes.
21st Century Babies; Grievous Choice on Risky Path to Parenthood
Keira and Richard Sorrellses’ triplets at eight months, clockwise from top, Lily; Zoe Rose, who has died; and Avery. Even though two fetuses were eliminated, Mrs. Sorrells had a troubled pregnancy and the babies were premature.
It was the last piece of advice Thomas and Amanda Stansel wanted to hear But their fertility doctor was delivering it, without sugarcoating
REDUCE, or you will lose them all, he told them.
For more than a year the Stansels had been relying on Dr. George Grunert, one of the busiest fertility doctors in Houston, to produce his industry’s coveted product — a healthy baby. He was using a common procedure called intrauterine insemination, which involved injecting sperm into Mrs. Stansel’s uterus after hormone shots.
But something had gone wrong. In April, an ultrasound revealed that Mrs. Stansel was carrying not one but six babies, and Dr. Grunert was recommending a procedure known as selective reduction, in which some of the fetuses would be eliminated.
The Stansels rejected Dr. Grunert’s advice and, since then, their vision of a family has collapsed into excruciating loss: the deaths of three children after their premature births on Aug. 4. More than two months later, the three other infants remain in neonatal intensive care, their futures uncertain. One of them, Ashlyn, is near death.
“I feel like we bonded with all of them, the short time they were here,” Mr. Stansel said. “We were able to hold them before they passed away.”
The birth of octuplets in California in January placed the onus for large multiple births on in vitro fertilization, a treatment in which eggs are joined with sperm in a petri dish and returned to the womb for gestation.
But the procedure the Stansels used is actually the major cause of quadruplets, quintuplets and sextuplets — the most dangerous pregnancies for both mother and children. While less effective than IVF, intrauterine insemination is used at least twice as frequently because it is less invasive, cheaper and more likely to be covered by insurance, interviews and data show.
Multiples can occur when the high-potency hormones frequently used with the procedure overstimulate the ovaries and produce large numbers of eggs. Parents are then left with the kind of tough choices the Stansels faced: whether to eliminate some of the fetuses or keep the babies and face extraordinary risks.
“I think, and so many of my colleagues think, it’s a primitive approach,” said Dr. Sherman Silber, a fertility doctor in St. Louis. “The pregnancy rate is lower than IVF, and you don’t have control over multiples.”
In treating women who are having trouble getting pregnant, most doctors try low-potency fertility pills first, then intrauterine insemination with the hormone injections and in vitro fertilization as a last resort. Some insurance plans require women undergoing fertility treatments to have several rounds of intrauterine insemination before they will pay for in vitro fertilization. Because of the cost, other plans cover intrauterine insemination but not in vitro.
But a recent study led by Dartmouth Medical School suggested that because IUI often requires repeated tries, it would ultimately lower both costs and the risk of large multiple births if many patients avoided the procedure and moved straight to IVF.
Unlike IVF, intrauterine insemination is not tracked by any government agency, so there are no official statistics on how many pregnancies result from it. But other studies and the Centers for Disease Control and Prevention have found that IUI and other similar treatments cause more large multiple births than in vitro fertilization, contributing to the nation’s 12.7 percent rate of preterm babies.
Experts agree that at least 20 percent of the pregnancies are multiples. Most are twins, but one 1999 study found that 8 percent of the pregnancies with injectable hormones and insemination were triplets and quadruplets. The more babies, the greater the risk. Quadruplets, for example, have a more than 10 percent chance of dying in infancy.
Pregnancies with quadruplets or more are unusual, and shocking when they occur.
Jon and Kate Gosselin, who already had twins, had wanted just one more baby, but IUI resulted in the sextuplets made famous on the TLC program “Jon & Kate Plus 8.” The same thing happened to Jenny and Bryan Masche, stars of “Raising Sextuplets,” the TV program on WE, the Women’s Entertainment network.
Mrs. Masche became seriously ill from acute heart failure brought on by her pregnancy, but she has recovered. The Gosselins have separated under the stress of raising multiples. But the Masche and the Gosselin sextuplets are the success stories. They are healthy.
Women who have gone through large multiple pregnancies with poorer results say the shows give viewers a misleading picture by failing to present the wreckage left behind in many cases — babies who are stillborn, spend months in the hospital undergoing painful procedures that require morphine or suffer from long-term disabilities.
Multiple babies who arrive very early require the highest level of acute care for a longer time than any other patients. Despite the lower cost of IUI on the front end, many doctors point out that insurance plans bear higher costs when IUI goes awry and large broods are born.
“We have families that have babies here for three or four or five months, and they’re having discussions with their insurance companies because they have reached the lifetime limit of their medical coverage,” said Dr. Scott Jarriel, a neonatologist who works at the Woman’s Hospital of Texas and treats the Stansel babies.
An Unwelcome Surprise
The Stansels’ decision to use intrauterine insemination was based largely on finances. The treatment can cost as little as $2,000 to $3,000, compared with $12,000 to $25,000 for in vitro fertilization.
Mrs. Stansel’s insurance would not cover IVF but would pay for six rounds of IUI. She consulted Dr. Grunert in April 2008, just over a year after the Stansels were married.
Mrs. Stansel, 33, first tried clomiphene, a fertility pill, but that did not work. Then she moved to the next step, a popular injectable drug, Gonal-F. The drug stimulated her ovaries in preparation for intrauterine insemination.
She became pregnant with twins after her first round of IUI. But she miscarried on Sept. 24, 2008, at 18 weeks.
Within months, Mrs. Stansel underwent another round of intrauterine insemination, but in January she learned that it was an ectopic pregnancy, one that develops outside the uterus.
The Stansels decided to try again.
Before conducting their third insemination procedure in March, Dr. Grunert was monitoring Mrs. Stansel’s ovaries with ultrasound. He saw only two developing eggs mature enough to potentially be fertilized.
Instead, six fetuses developed.
“It was obviously a shock,” Dr. Grunert said, “hopefully a once-in-a-lifetime experience.” Dr. Grunert has been in practice for 30 years and said it had never happened to him before.
Dr. Richard P. Dickey, a specialist in the New Orleans area who has conducted research on hormone use in reproductive medicine, said that IUI is normally a safe procedure. But, he said, some doctors prescribed excessive doses of the hormone injections, which could overstimulate the ovaries.
Or they use the injections before trying a cheaper oral drug that produces fewer multiples, Dr Dickey said. The drug is less successful than the injections.
A round of oral drugs is available for $20 and does not require extensive monitoring. A round of injectable drugs costs $1,000 or more. Clinics can make additional money when the injectables are used because they require the use of repeated ultrasounds and other testing, which can add up to $1,000 to $2,000.
“There’s a money factor, unfortunately, in this,” Dr. Dickey said. “There is a factor of not paying enough attention, and doctors aren’t sufficiently aware of the dangers of multiple pregnancy.”
Deciding to Eliminate
Three years ago, Keira Sorrells, an interior decorator in Monroe, Ga., had found herself in a predicament similar to the Stansels’. After intrauterine insemination, Mrs. Sorrells learned that she was carrying quintuplets.
She said she was in shock at hearing the news and ill prepared for the next step. Before he had even closed the door to his office, her fertility doctor suggested selective reduction to Mrs. Sorrells and her husband, Richard. “We had never heard of it,” Mrs. Sorrells said.
“I think there’s a huge problem in the reproductive technology industry,” Mrs. Sorrells said. “I was told the chances that I would have triplets were less than 1 percent. There was no talk of being faced with a decision like that until the day that we had the ultrasound. Then you have two weeks to decide. And you don’t get counseling from anybody.”
In the next two weeks, Mrs. Sorrells and her husband struggled to make a decision on whether to eliminate fetuses and, if so, how many. The specialist gave her 50-50 odds that her babies would survive and said twins or a single baby would be safer.
The process of “selective reduction” involves injecting potassium chloride to the heart region of the fetuses, which then generally disappear on their own, absorbed into surrounding tissue.
Hoping to save as many babies as possible, Mrs. Sorrells decided instead to eliminate two of the fetuses, reducing her pregnancy to triplets. Even then, her pregnancy was troubled. She developed pre-eclampsia, a complication of pregnancy that includes rapidly increasing blood pressure.
On Dec. 20, 2006, at 25 weeks and 5 days gestation, Mrs. Sorrells had to have an emergency Caesarean section.
The most severely ill of her three premature daughters, Zoe Rose, was born with multiple problems. Zoe died last year of a drug-resistant staphylococcus infection at age 14 months — nine of them spent in a neonatal intensive care unit. The Sorrellses’ two surviving daughters, Lily and Avery, are doing well despite their extreme prematurity and four-month stays in neonatal intensive care.
The Sorrellses have formed the Zoe Rose Memorial Foundation with the goal of helping parents who have premature children.
Dr. Brian Kirshon, a doctor in Houston who specializes in high-risk pregnancies, says some couples do not understand the implications of multiple births, even when the risks are explained.
“I think a lot of them don’t really understand the risks of prematurity, the risks of losing their babies, the risk of long-term complications, blindness, deafness, cerebral palsy, development delay when they have extremely premature babies, or the ultimate risk of losing their marriage,” Dr. Kirshon said.
Taking Another Path
When Dr. Grunert discovered that Mrs. Stansel was carrying multiple fetuses, he handicapped her odds of delivering six healthy infants at practically zero.
Eliminating some of the fetuses would give the others the best chance for survival.
Dr. Mark I. Evans, a doctor in Manhattan who is among a small group nationwide that specializes in selective reductions, estimates that 1,000 to 2,000 reductions are performed annually in this country, usually in the first trimester. Doctors generally discuss reduction as a possibility in pregnancies with triplets or more.
Many opponents criticize selective reduction as a form of abortion. And for many parents who elect to carry all of the fetuses, the decision often hinges on religious convictions. There is also a chance, up to 5 percent, that selective reduction will be followed by a miscarriage of all the fetuses, according to the American Society for Reproductive Medicine.
For the Stansels, the decision was influenced by their membership in the Church of Jesus Christ of Latter-day Saints. The church generally opposes abortion. After learning that Mrs. Stansel was carrying sextuplets, the Stansels decided to meet with church elders and consult with a reduction specialist.
“It just never felt right,” Mr. Stansel said. “We prayed many nights. A lot of sleepless nights. Originally we thought we might do the reduction. We chose to carry all six and, we believe, let God do what he’s going to do.”
On July 3, in her 19th week of pregnancy, Mrs. Stansel was admitted to the Woman’s Hospital of Texas for monitoring, under the care of Dr. Kirshon, an expert at delivering multiples. By early August, she began having contractions that did not stop with medication and threatened to rupture her cervix.
“There wasn’t anything we could do,” Dr. Kirshon said. Instead, Mrs. Stansel delivered the sextuplets on Aug. 4, about 14 weeks premature. The babies were born so early that no medical care would have been rendered unless the parents requested it.
Dr. Jarriel, the neonatologist, said the survival rate of babies at the stage they were born was about 60 percent to 65 percent. If they survived, the Stansels were told, there was a 100 percent chance that they would have problems.
But the couple asked the hospital for the most extraordinary measures to save them.
“We wanted to do all we could for them, to save them,” Mr. Stansel said.
“Give them that chance,” Mrs. Stansel added. “That’s the doctors giving their statistics. God doesn’t work in statistics.”
The babies — Ashlyn, Braden, Dallin, Haley, Kaitlyn and Rachel — ranged in weight from 12.3 ounces to 1 pound, 1 ounce. They were each less than a foot long.
Dallin was the first to die. Blood seeped into his lungs from an open heart valve, the Stansels said. Kaitlyn soon followed. Braden lived for two weeks before an infection entered his trachea and killed him.
“He fought hard,” said Mr. Stansel, 32. “His lungs just got so inflated, they crowded out his heart.”
The three were buried on Aug. 22 in Austin, Mrs. Stansel’s hometown, in a single casket. “They came into the world together, and they’ll leave together,” Mr. Stansel said.
The three remaining Stansel babies have been in precarious health in the neonatal intensive care unit.
The couple has been making daily visits to the hospital and are now able to hold the girls for a short time. All three of the infants are still attached to ventilators and feeding tubes, which deliver their mother’s milk.
Rachel, who now weighs 3 pounds, 7 ounces, is doing better than the other two girls and is slowly being weaned off intravenous nutrition. On Thursday, Haley, who now weighs about three pounds, underwent surgery to remove a bowel obstruction.
Ashlyn, the most severely ill, was experiencing kidney failure Sunday. Her father said in an e-mail message that he did not think she was going to make it.
“Our heart breaks for her,” her parents wrote in a posting on a blog they are keeping.
The blog has drawn thousands of comments from supporters. But some critics have also written, saying the Stansels should not have continued the pregnancy knowing the poor odds. Some cited the pain and suffering of extremely preterm babies.
“I knew the babies would come early,” Mr. Stansel said in a recent interview at the couple’s suburban Houston home, near Humble. “I knew they’d be in the NICU. I knew there would be challenges.”
Mrs. Stansel added: “I don’t think I realized how tough it would be.”
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