The Babymakers: Cost And Conscience In The Fertility Industry
The women in Dr. Robert Hahn's plush, immaculate office wear a wardrobe of expressions: congenial hopefulness, weary anxiety, steadfast determination. On the walls are large, soft portraits, one of a woman suckling a baby, the other of American Indian women on horseback, holding their young children. Parenting magazines and children's books are stacked neatly in baskets or on end tables.They are reminders -- and none of these women need reminding -- of the potent possibility infertility specialists like Hahn offer: a baby, finally. A living dream realized in the face of stiff odds, thanks to rapidly advancing medical technology that has outdistanced what could be imagined a generation ago.The media offer reminders, too, with their fondness for happy stories about "miracle" babies. When a Colorado couple had test-tube quadruplets last December, the daily newspaper ran a front-page article and large color picture heralding "a tiny bundle of joy -- times four." When a 51-year-old Maryland woman gave birth to triplets born of her daughter's eggs in March, reporters swarmed Union Memorial Hospital in Baltimore. "We had three TV stations who all wanted to come in and film the birth live," says hospital spokesman Pete Kerzel. "Baby stories are great stories. Baby stories sell."Other stories aren't so palatable. Stories about the majority of couples who try assisted reproductive technology (ART), and, after spending years and a small fortune, leave empty-handed. Stories about couples who succeed extraordinarily, and then must decide whether to abort one or more embryos to curb the considerable risks of carrying triplets, quadruplets or quintuplets. Stories about women who carry such pregnancies to term only to deliver premature babies whose survival and long-term health necessitates weeks in neonatal intensive care units, at a staggering cost."Most of these couples really don't know the downside of it," Hahn says. "They've been infertile all their lives, and they can't think past that positive pregnancy test."Nor, it seems, can fertility clinics, which compete fiercely for the patronage of couples willing to spend tens of thousands of dollars in the quest to procreate. The burgeoning, unregulated fertility industry has created an ethical quagmire as clinics seek to boost generally low success rates, even if it means generating high-risk multiple births."It's money, prestige," says George Annas, ethical advisor to the Alabama-based American Society for Reproductive Medicine, whose affiliate branches include the Society for Assisted Reproductive Technology (SART). "That's why there's pressure on all these groups to have a high success rate.""There have been all sorts of things offered by various companies in competition with each other -- money-back guarantees, all kinds of advertising," says Denver medical ethicist Fred Abrams, a member of Gov. Roy Romer's Commission on Life and the Law. "There are still plenty of ethical doctors out there, but the incentive is to treat this more and more as a marketplace commodity."CLINIC COMPETITION SPAWNS MULTIPLE BIRTHS A barrel-chested man with a crinkly smile, Robert Hahn seems to inspire trust in patients. For the minority who aren't helped by conventional treatments like fertility drugs, artificial insemination or surgery, Hahn offers in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT) and other, less common technologies (see sidebar).The procedures begin identically: Fertility drugs are given to stimulate the ovaries; after the multiple eggs mature, they are "harvested," typically through laparoscopy or ultrasound aspiration, both surgical procedures. Associated risks include painful, enlarged ovaries and the usual hazards associated with anesthesia and surgery.Usually, more eggs are retrieved than are needed for a single ART procedure or cycle; extras often are fertilized and frozen, or cryopreserved, for possible future attempts at pregnancy. The number of eggs or embryos transferred to the woman's body depends on several factors, including her age and the quality of the eggs and sperm. Each transfer increases the chance of pregnancy, but also the risk of multiple gestation."We're always in kind of a balancing act of trying to get the couple pregnant vs. producing a multiple birth," says Hahn, who typically transfers three or four eggs or embryos. Sometimes, he transfers more; triplets and quadruplets are well-represented in a smiling photo gallery mounted on an office wall.Hahn claims that 25 percent of the IVF cycles he performs, and 35 percent of the GIFT cycles, result in a live birth. That's an improvement over 1993 data his clinic reported to SART, which shows lower IVF success rates: Of 28 procedures initiated on the most promising candidates - women under 40 with no male infertility factor involved - four, or 14 percent, produced live births, all single babies.Other doctors boast greater success, but at a cost. A well-known Denver, Colorado clinic, The Center for Reproductive Medicine, in 1993 claimed a 53 percent IVF success rate with younger women, more than 2.5 times the national average of 20 percent. But, of 64 deliveries, 21 involved twins, three involved triplets, and one was quadruplets. In addition, 18 women underwent selective reduction (abortion) to reduce multiple gestations from ART procedures at the clinic that year."I am very aware of clinics ... that don't hesitate to put in five, six, seven, eight eggs or embryos, and they might end up therefore with a higher pregnancy rate than some, but they're going to have a higher multiple-birth rate," Hahn says."Every program has to decide how far they're willing to go to enhance their success rate," says Dr. Brad Hurst, an endocrinologist at the University of Colorado's reproductive clinic. "I think it's unfortunate that triplets, quads and quints are considered a success, because for the couple, it can be just a lifelong disaster."But competition between centers that offer IVF is typically "quite fierce," Hurst says. "When patients shop around for success rates, that's the number that tends to be in the forefront."'I DIDN'T REALIZE THE RISK ...' "When we went looking for an infertility doctor, we went looking for bottom-line results," says Colorado mother Melanie Vyvlecka, 29. "We didn't think to ask, 'How many times did the couple have to face reduction?' ... I didn't take into account all the people who lost their pregnancies with higher-order multiples."When Melanie found out she was pregnant with four of the five embryos transferred during her third IVF attempt, she cried. Husband Jim, too, was upset. Still, they couldn't accept selective abortion. "If I lost the pregnancy, it would have been a higher will than mine," Melanie says. "Reduction is not something I was comfortable with ..."You're so euphoric after five years of trying, and you just have this sunny little outlook. I didn't realize the risk I was putting them at, and how much risk I was at."The Vyvleckas' quadruplets, three girls and a boy, were delivered 12 weeks prematurely Dec. 22, after Melanie's kidneys started to fail. The newborns spent more than two months in a neonatal intensive care unit, where they were put on ventilators and fed intravenously. All have since come home. "They were at high risk for having lots of problems, but we've been very lucky, and they're all fine," Melanie says.Still, the experience was sobering. "I put my life at risk and I put my babies' lives at risk," she says. "I'm a strong advocate now of not transferring more than I want to carry."Nationally, about 25 percent of ART procedures result in multiple births, usually twins. Multiple gestations, particularly with triplets and more, are high-risk situations for both mother and babies, because the likelihood of maternal distress and premature birth skyrockets. According to a hospital spokeswoman, twins have a 50 percent chance of early delivery; triplets and more, close to 100 percent. Premature, low-birth-weight babies stand an increased risk of impaired neurological development, respiratory distress and other setbacks. While most outgrow their problems, others die or suffer lifelong difficulty."The more premature a baby is delivered, the less likely it is to be healthy, and the overall expense of the hospital stay for the children who are a result of multiple births -- it's just mind-boggling," Hurst says.Those facts trigger mixed feelings among maternal/fetal specialists who witness the sometimes hefty physical, emotional and financial costs of successful infertility treatments."My big ethical dilemma is really the fact that we're spending huge amounts of money that perhaps could be directed elsewhere for better obstetric care," says Memorial Hospital perinatologist Dr. Sterling McColgin. "If you spend half a million dollars to take care of triplets in the nursery, you could have spent that half million to establish an indigent clinic and take care of 50 patients who are pregnant."Still, he says, "I try to not involve myself with a lot of ethical issues, because you're dealing with patients who very much want the pregnancy. By the time I see them, they have undergone the ART, and they're just tickled pink that they are even pregnant. It's hard for me to be the taskmaster and say, 'You really shouldn't have done this.' ""Most of the people who take this route and go this far are very well-educated people; they know the risks," says another specialist in high-risk obstetrics. "So, who are we to argue with their choices? But we put up with the ethical dilemmas at the end."CASH SHORTAGE BUMPS MANY OFF 'MERRY-GO-ROUND' The biggest reason couples risk a multiple pregnancy comes down to one word: money.Insurance companies pay the steep costs of newborn intensive care, which average $2,000 to $4,000 a day, and for the Vyvlecka quads, hit $750,000. Most health insurers also cover treatment of medical problems that might, secondarily, cause infertility -- blocked fallopian tubes, for instance, or endometriosis.But few pay for infertility treatments per se. For couples who want children they can't seem to have, that's a grim fact, because a single ART cycle, including drugs and surgery, can cost $7,000 to $10,000."Frankly, the main limiting factor comes down to economics for most people," Hahn says. "Some people say, 'We can only do this one time, and I'm 38 years old and all we care about is getting pregnant, so put in every egg you get.' "Excluding Melanie Vyvlecka, five women interviewed for this story reported bills of $8,500 to $70,000 for ART attempts. Three have become pregnant; one had a child on her third IVF attempt. She and her husband, both real-estate developers, now are trying IVF for the seventh time."I know that I've said to him after each time, 'I'm not doing this anymore' -- not really money-wise, but emotionally," says the woman, who has two children by a previous marriage. "I get real upset when it doesn't happen. But I say that every time I go in, and look -- I'm back there again."Colorado Springs licensed professional counselor Mary Heintz, who tried IVF twice before quitting, says it's often hard for women, in particular, to stop infertility treatments. "It's like a merry-go-round, and they just keep going," she says. "It can be a real strain on a relationship. It can become the driving force, that every month, this is the focus ..."There's also the reality that in vitro and technologies like that don't have a very high success rate, and you're going through a very intense process with not that big a chance of success."One newly pregnant 29-year-old woman, whose insurance has helped pay for repeated endometriosis surgeries and two GIFT procedures, says it's important to set limits."Most people just keep trying and trying and trying and putting themselves in financial ruin over it," she says. "You need to sit down and draw yourself guidelines, and between the two of you, decide. Once you get involved in it, you can get caught up in it and you just don't think straight."Couples obsessed with bearing a child are vulnerable to the coaxing of a doctor who may not have their best interests at heart, she adds: "They get so much encouragement from the medical industry, that if you do it one more time, that one more time may be the time."But Hahn sees a growing ethical consciousness among infertility specialists. "I think there's much more of an awareness that we need to kind of police ourselves, and use our heads and consider the ethics in this," he says.Annas doubts that will be enough. He envisions a time when the United States comes more in line with other developed countries, where government-licensed fertility clinics are forbidden to transfer more than three eggs or embryos, and couples don't have to pay for infertility treatments out of their own pockets."Both SART and the American Society for Reproductive Medicine have called for some oversight mechanism for fertility clinics, because it has turned totally into a business," Annas says. "Now, everyone realizes there's a lot of money to be made here ... and they can't just do self-regulation." SIDEBAR'TEST-TUBE' TECHNOLOGY OFFERS SEVERAL OPTIONSby Cate TerwilligerEstimates of infertility -- commonly defined as the inability to become pregnant after a year of unprotected intercourse -- vary widely. The National Center for Health Statistics says that in 1988, about 8 percent of married couples with wives of childbearing age, between 15 and 44, were infertile. More recently, the American Society for Reproductive Medicine put the number at 10 percent. Doctors who specialize in treating infertility often quote higher numbers -- 15 to 20 percent.Common treatments for infertility include therapy with such drugs as Clomid and Pergonal, which regulate and stimulate ovulation. Doctors also may use artificial insemination or perform surgery to treat conditions that impair fertility, including blocked fallopian tubes or endometriosis, or, in men, a damaged varicose vein in the testicle.More aggressive -- and expensive -- treatments are lumped in the category of assisted reproductive technology. The most common -- IVF, CRE, GIFT and ZIFT -- begin the same way: Fertility drugs stimulate the ovaries to produce extra eggs, which are "harvested" when mature. From there, the procedures vary:IN VITRO FERTILIZATION (IVF): Literally, "in glass" fertilization, this procedure spawned the world's first test-tube baby in 1978. The harvested eggs are fertilized by sperm in a laboratory dish. Several of the resulting embryos are transferred by catheter to the uterus. IVF was originally developed for women with damaged fallopian tubes; it now is the most commonly performed of the assisted reproductive technologies.CRYOPRESERVED EMBRYO TRANSFER (CPE): Extra embryos frozen after a past ART cycle are thawed, then transferred to the uterus during a natural ovulatory cycle. Embryos frozen up to three years have produced healthy babies; no one knows how long frozen embryos remain viable.GAMETE INTRAFALLOPIAN TRANSFER (GIFT): Unfertilized eggs are injected, with sperm, into the woman's fallopian tubes, where fertilization may occur. GIFT was developed in 1984 for couples who have unexplained infertility.ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT): A hybrid between IVF and GIFT, this procedure includes in vitro fertilization, after which embryos are transferred to the woman's fallopian tubes and move into the uterus. ZIFT often is used for couples with male-factor infertility.Any of the procedures may be performed with donor sperm. Donor eggs are an option for women who are unable to produce viable eggs, or who may pass on hereditary defects. (Carefully screened egg donors are typically paid $1,500 to $3,000 to undergo one cycle of fertility drugs and egg retrieval.) Finally, a surrogate mother -- usually paid a negotiated fee of about $15,000 -- may agree to carry an embryo, born of her own egg or the legal mother's, to term.