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2-for-1 is no baby bargain, doctors say

Couples struggling to conceive often wish for twins — or more. But new guidelines are urging fertility doctors to transfer just one embryo.
/ Source: Special to

For couples struggling to conceive a child, news of becoming pregnant with multiples following infertility treatment is often cause for celebration. Some even wish for it.

“I hear that frequently: ‘I want twins. I don’t want to pay for this again.’ The two-birds-with-one-stone thing,” says Dr. Robert Stillman, medical director of Shady Grove Fertility Center in Washington, D.C., and a clinical professor of obstetrics and gynecology at Georgetown University School of Medicine. “They see twins in a stroller at Starbucks and think, ‘I’ve been at this for four years. Why not just do this two at a time?’”

But the truth is that having multiples — even twins — comes with significant health risks, and the cost of their care can be staggering.

“For the mother, there’s an increased chance of gestational diabetes, which increases risk for diabetes later in life too,” explains Stillman. “And there are risks for hypertension, stroke and preeclampsia,” a potentially life-threatening condition in which blood pressure spikes in pregnancy.

Then there are all the many risks to developing fetuses — ones that can have lifelong consequences. “The biggest one is prematurity,” Stillman says. From that, a number of devastating problems can follow: cerebral palsy, blindness, bowel problems, learning disabilities, even malnutrition from sharing resources in utero.

All of these risks grow tremendously when a woman is having triplets or more: Where the preterm birth rate in twins is 50 percent, it’s 90 percent with triplets, most of whom will face complications requiring stays in a neonatal intensive care unit. Some may not make it: A twin is seven times as likely — and a triplet is more than 20 times as likely — as a singleton baby to die in the first month of life, according to the American Society for Reproductive Medicine (ASRM).

in Arizona and Minnesota make poignantly clear just how great the risks can be: Jenny Masche, who delivered three boys and three girls earlier this month in Phoenix, experienced heart failure shortly after delivering, though she is now stable. Brianna Morrison of Minnesota delivered four boys and two girls at 22 weeks’ gestation, but three of the boys have died and the remaining three babies are in critical condition.

Fertility experts are so concerned about these health threats that they’re taking new steps to reduce the risk for multiples, especially for couples opting for in vitro fertilization (IVF). As recently as the mid-’90s, doctors were commonly transferring three or four embryos from the lab into a woman's uterus in the hopes that at least one would grow into a healthy pregnancy. But as assisted reproductive technology (ART) has improved, the number of embryos that implant into the uterus and become a fetus has climbed — resulting in more multiples.

So last October, the still-worrying numbers of twin, triplet and higher pregnancies led the ASRM to recommend that doctors set tighter limits: put just one to two embryos in a patient under age 35; two to three in a woman ages 35 to 37; two to four in a woman 38 to 40; and three to five in a woman over 40.

A single shot at conception?
Not surprisingly, though, this approach isn't without controversy. When a doctor puts fewer embryos into a woman’s uterus she’ll obviously have fewer babies — and be more likely to have just one. But it can also mean that she won’t conceive at all.

Patients who've invested a lot emotionally and financially in having a baby may be unwilling to bank on a single embryo, and so they may shop around until they find a doctor who will meet their demands.

“Patient autonomy will win out,” says Stillman. “[Those] are their embryos and we’re just the care-takers. If the patient wants to take a risk, it’s our responsibility to discuss the risk.”

Of course, from a financial perspective, it may be no baby bargain to save $12,000 or so on a fertility treatment cycle and then have twins or triplets who require hundreds of thousands of dollars in medical care during their hospital stays and throughout their lives for treatment of complications arising from premature birth.

The lifetime medical costs of a child born with mental retardation, for instance, can total $1 million, while costs for cerebral palsy may top $920,000, according to 2004 data from the U.S. Centers for Disease Control and Prevention. Now multiply that by two, three, even four.

Still, some couples are willing to take the risks. Vicki, 37, of Pennsylvania, who declined to use her last name, chose to transfer three embryos last March after a previous IVF cycle was canceled when she didn’t produce enough eggs. She and her husband weren’t worried about twins, and her doctor told her the odds of triplets were just 1 percent.

“I was not really opposed to twins — I was OK with that. But we learned during our first attempt that the medication can’t always guarantee enough [eggs] to complete the cycle. Once we got to the point of transfer [the second time], we wanted to take full advantage of the opportunity to conceive,” she says. “And my doctor wanted to put all of the embryos back to give me the maximum chance of succeeding.”

She’s now due this fall — with a single baby — and she's thrilled.

Some couples find single embryo transfer, or SET, to be the right choice, though. Last October, Jessica Koszewski, 32, and her husband had to decide what to do with the seven good-quality embryos that resulted from their first round of IVF: Should they transfer just one, or more than one?

“In doing my own research about IVF ... I found the higher rate [of problems] is because of the high rate of multiple births,” Koszewski says.

“I just couldn’t justify risking [the child’s] future or their quality of life just because I wanted a baby bad enough,” explains Koszewski, now pregnant with her first child, due this summer.

Couples who choose SET may also want to avoid what Stillman calls the “terrible Sophie’s Choice” of deciding whether to abort one or more of the babies if they conceive too many.

“Selective reduction … puts people in a horrible situation,” says Stillman. “These are people who are distraught with the difficulty of getting pregnant and then they have to do what’s really an abortion to maximize the outcome of the remaining babies.”

The good news is that recent research is showing that doing a single embryo transfer can, in some cases, work as well as transferring multiple embryos.

A study in the March issue of the medical journal Lancet followed 400 patients in the Netherlands who got either a standard IVF drug protocol and had two embryos transferred or got less medication with a single embryo. A year later, the rates of babies born were comparable — 45 percent for the standard group versus 43 percent for the single-embryo group — but the milder treatment with a single embryo naturally cut the rate of multiples, as well as the overall cost.

Findings like these are likely to up the rate of SET (it now makes up just 3 percent of all ART procedures) since doctors can use this information to counter some patients’ serious skepticism about putting in just one embryo.

“The powerful thing is data. When you can show pregnancy rates are the same between single and double [embryo transfers], that’s the thing that convinces them, so patients realize they are not compromising,” says Stillman.

Crucial caveats
There are a couple of caveats, though. For starters, SET doesn’t work the same for all women; success depends a lot on picking the right patient — and the right embryo.

Dr. Mike Soules, a managing partner of Seattle Reproductive Medicine and a past president of ASRM, says the women for whom SET is most likely to end in a healthy pregnancy are those 38 or under with no failed IVF cycle, no history of uterine problems and with at least eight high-quality embryos. (He acknowledges that these are the “top 15 percent” and the ones most likely to get pregnant anyway.)

And embryo quality is key, says Dr. Geoffrey Sher, executive medical director of Sher Institutes for Reproductive Medicine in Las Vegas and the lead author of a January study in the journal Fertility and Sterility. “We found that if we put back a single embryo that was from a chromosomally normal egg … then there was an 87 percent chance that the egg would propagate into a normal embryo.”

That one embryo, he continues, went on to make a healthy baby more than 70 percent of the time in this trial, regardless of a woman’s age — a dramatic improvement over typical IVF success rates of roughly 25 percent — and without any of the risks of a multiple pregnancy.

So how do doctors pick the perfect embryo, the one most likely to grow into a son or daughter? That’s no easy task at this time, but scientists like Sher are working to come up with techniques that will hopefully lead to widespread tests to assess an embryo’s viability.

Currently, some doctors can use preimplantation genetic diagnosis to rule out genetic disorders such as sickle cell anemia and cystic fibrosis, though the approach is limited for determining the overall health of an embryo because it can't screen all chromosomes.

So researchers are trying to develop other approaches that would allow them to screen all chromosomes or test the culture solution that an embryo is grown in for biochemical markers that indicate good health.

Once it becomes easier, faster, more accurate and less expensive to pick one healthy embryo, choosing whether to do SET will become far less difficult, with better results.

A big part of that shift, says Stillman, is changing how success is defined: “The real measure of the success of an IVF program is the singleton delivery rate, not just the delivery rate.”