Making Babies : The Boom in the Infertility Business Is Raising Hopes, and Increasing Criticism

In his spotless embryology lab at the Center for Reproductive Medicine at Century City Hospital, David Hill is peering into the viewer of a formidable-looking microscope, trying to make a baby. On a monitor next to the scope is the vastly magnified image of a woman’s egg--smaller, in reality, than a tiny speck of dust--and of the microscopic suction rod holding it in place. Right now, Hill’s attention is on the semen sample next to the egg. With his right hand, he’s manipulating controls that send a needle far finer than a hair chasing after what looks to be a batch of teeny, wriggling long-tailed polliwogs.

“The best sperm tend to go off to the edge and go around and around the drop like little race cars,” Hill says as he hunts down a pack of them. “It’s very fortuitous for embryologists.”

When he’s zeroed in on the sperm he wants, Hill draws them up into the needle by sucking on a rubber mouthpiece that’s connected to a slender hose and clenched between his teeth--an oddly low-tech note in this whole sophisticated operation. After he’s drawn some 50 sperm into the needle, he moves it over to the egg and presses down against its translucent outer shell (the zona pellucida ). Under the pressure of the needle, the egg squashes in on itself alarmingly, like a beach ball poked with a stick. But as soon as Hill punctures the zona pellucida , deposits a fraction of the sperm and retracts the needle, the egg springs back into shape. Beneath its cloudy shell, the sperm buzz madly about like trapped insects.

The procedure he’s just completed is a subzonal insertion, usually known by its friendly acronym, SUZI. Eggs and sperm that Hill manipulate in this way can’t, for one reason or another, achieve fertilization on their own. So he’s helping them bypass the arduous trek to conception. The sperm-injected eggs (usually a total of seven or eight for each couple) go into an incubator and are maintained at body temperature for 14 to 18 hours. Depending on the number that make the leap to embryo status, about four of the best quality will be loaded into a catheter and inserted into the woman’s womb.

“I can’t wait to come into the lab, open up the incubator and see whether any of our efforts have resulted in decent embryos,” says Hill. “It’s just like opening a little Christmas present. I never get tired of it.” In Hill’s sterilized lab, surrounded by the tools of his trade, it’s easy to lose sight of what’s actually happening. For couples who come to Century City, as to a fast-growing number of similar clinics around the country, these procedures represent a last chance to achieve a desire as old as human history: that of giving birth to a child. On behalf of these couples, Hill is waging a daily battle of technology against nature. And despite a swelling arsenal of controversial new techniques and procedures, nature usually wins.

THREE YEARS AGO, JOHN TAYLOR (this name and those of the other patients have been changed) got the call from his doctor, just before a weekend business trip to New Orleans. After months of trying unsuccessfully to conceive, John and his wife, Leslie, had sought medical help. Now they were awaiting results of his sperm test. The voice at the other end of the line had bad news. “The doctor told me I had absolutely no sperm,” recalls Taylor, 36, a television lighting designer.

“The two of us stood in the kitchen and bawled our eyes out. I was destroyed. I felt emasculated. I come from a large family, and the fact that I’d never be able to have my own children--never, there wasn’t a hope in hell--was devastating.”

At the end of his weekend trip, in a bizarre twist of events, Taylor returned to hear that there had been a mix-up at the lab, and he did have a sperm count. But it was low, the doctor warned him; pregnancy would still be problematic. “If the guy had been standing there, I’d have decked him for putting me through all that,” he says. “But I was also pleased. At least he’d given us back some hope.”

Today, $20,000 poorer and their insurance coverage for infertility exhausted, the Taylors wonder whether there was much point in those hopes being raised. Both partners have undergone surgery to correct reproductive-tract problems; each has tried fertility drugs. They’ve tried timed insemination, with John’s sperm inserted directly into Leslie’s uterus when ultrasound scanning showed she was ovulating. Twice they’ve attempted, and failed at, “test tube” conception at Century City. To cut costs on the pricey medication a woman takes during such attempts, they’ve journeyed to Tijuana to purchase their drugs at cut-rate prices.

Running the gantlet of these treatments has “put an incredible strain on our marriage,” says Taylor. “Frankly, I’m surprised we’re still together. In many aspects, our lives have been on hold with this thing for three years.”

In a few months, the Taylors will return to Century City to try a new procedure developed in Belgium that Hill has recently begun working on. The ultimate refinement of existing sperm-injection methods, it involves shooting a single sperm directly into the heart of an egg and seems to produce higher fertilization rates than multiple-sperm procedures such as SUZI; the Belgian clinic that first used it is now claiming pregnancy rates of more than 30%.

This could be the Taylors’ winning ticket in the baby lottery. But Leslie, 38, a small, jeans-clad TV director who sits curled on the sofa in their North Hollywood home, is tiring of the demands of the pregnancy chase. “I only want to try direct injection once,” says Leslie. “John wants to try it twice. I’m emotionally and physically beyond it. I’ve been on hormone injections for three solid months; I feel fat and bloated and like I could cry at the drop of a hat. Why is it that we cannot conceive a child? Why?”

“It can make you feel guilty,” says John. “You look back over your life, you say: ‘I’ve always tried to be a decent person. Did I do something wrong? Is God trying to punish me? Was it my lifestyle?’ ”

He’s not willing to give up, however, and his determination is carrying both of them. “All through this, we’ve had a willingness to fight, not to take the first defeat and say, ‘OK, it’s over,’ ” he says. “When you start something like this, you’ve got to finish. Otherwise you spend the rest of your life wondering ‘What if?’ I’m still not convinced we’re finished.”

To Leslie, he adds, “I won’t ask for more than two tries. But you go in every time thinking, this is the time it’s going to work.”

More often than not, however, you’ll be wrong.

INSIDE THE ADMINISTRATIVE OFFICES AT THE CENTURY CITY REPRODUCIVE clinic, which occupies part of a floor in this small private hospital, are homey touches: stuffed animals nesting on file cabinets, a sign that reads “Never give up!” On the outer walls hang photos of children conceived as a result of treatment here and letters from their grateful parents. There is praise for the “incredible staff” at Century City, and the word miracle shows up often.

Each year, more than 300 couples come here seeking children. For many, it’s a court of last appeal, after months or years of lower-tech efforts such as drugs or surgery have failed. In general, those who choose high-tech conception follow a similar regimen. A woman begins with daily injections of powerful hormone-regulating drugs to stimulate her ovaries to mature more eggs than the single one that normally matures each month. If the therapy succeeds, the crop of eggs--about 10 on average but in some cases more than 30--is “harvested.” While a patient is under local or general anesthesia, a doctor inserts a needle either vaginally or through an incision in the stomach to suck the eggs from her ovaries.

In regular in-vitro fertilization (IVF), eggs are then combined in a petri dish with the sperm sample, fresh or frozen, that a man has dutifully provided. In gamete intra-Fallopian transfer (GIFT), developed as a slightly more “natural” alternative to IVF--eggs and sperm don’t unite in glassware, but are inserted together into the Fallopian tubes. The resulting embryos are transferred into the uterus, the Fallopian tubes or, sometimes, both. At many IVF centers, extra embryos now can be frozen, meaning a woman doesn’t have to go through the stressful process of an egg retrieval at each attempt.

Louise Brown, the first baby conceived through IVF, was born in Britain in 1978. Three years later, the first American high-tech baby was born at a Norfolk, Va., clinic. Since then, the infertility business in the United States has mushroomed into a $2-billion-a-year enterprise, much of its expansion spurred by the development of assisted reproductive technologies, including IVF and the many different methods it has spawned for manipulating eggs and sperm outside the body. It is, at best, an imperfect science--expensive, unregulated and relatively untested, especially in the area of long-term effects.

But the market for reproductive technologies is sizable. According to the National Center for Health Statistics, about 2.3 million married American couples are infertile (meaning they haven’t been able to conceive after a year or more of trying). For up to 15% of them, according to the American Fertility Society, high-tech approaches are considered the only hope. With the U.S. government disinclined to allocate research dollars to a politically touchy area such as reproductive technology, this country has lagged behind Australia and parts of Europe--but not too far. There are now about 350 U.S. infertility clinics, including at least two multi-state chains; at least 45 reproductive clinics that perform IVF and other assisted technologies are crowded into California alone. More than 33,000 assisted-reproductive-technology procedures were initiated in 1991, the last year for which figures are available, up 30% from 1990.

Originally used only to treat blocked tubes, assisted reproductive technologies are now applied to a range of female infertility problems, including endometriosis, ovulatory disorders and the catch-all condition of “unexplained infertility.” More recently, researchers have zeroed in on male infertility. Women had long been accorded the lion’s share of the blame when a marriage was barren, but when reproductive specialists peered closely into their petri dishes, they discovered that the man was wholly or partly responsible for a couple’s problem 40% to 60% of the time.

For some men, approaches that range from eschewing hot tubs to undergoing corrective surgery will do the trick. But others have sperm that are so few in number, sluggish, malformed or otherwise defective that doctors could do nothing but point them toward the nearest sperm bank--until recently. In the late 1980s, embryologists found it was possible to aid recalcitrant sperm in fertilization by opening the egg’s outer shell to give the sperm easier access. This type of “micromanipulation,” known as partial zona dissection, was followed by SUZI. Then, in 1992, came the Belgians’ encouraging announcement of intracytoplasmic sperm injection, or ICSI (pronounced ICK-see by those in the field), the no-nonsense technique in which a single sperm is propelled to the egg’s center.

“It’s actually somewhat surprising the technique works,” admits Jacques Cohen, scientific director of assisted reproduction at New York City’s Cornell Medical Center and a pioneer in the development of micromanipulation. “We used to think there was a certain sequence of processes that was absolutely necessary before the sperm was able to fertilize the egg. Now we know that’s not true; those processes can be completely surpassed.”

As these dazzling technologies establish themselves as the wave of the future, troubling issues surround their use. Most conspicuous are the ethical dilemmas that seem to grab headlines weekly. There is much outrage at the idea of 60-year-old women becoming mothers and apprehension that scientists might soon start using eggs from aborted fetuses to produce babies--meaning that a child could have a biological mother who was never born. And last fall, two U.S. scientists “cloned” a human embryo, making an exact genetic copy of the origi-nal and raising the specter of an assembly-line baby-manufacturing industry.

But at the moment, these issues don’t apply in clinical practice--or apply to only a tiny handful of those who visit programs. (Realistically, not many 60-year-old women crave new motherhood.) For most infertile couples, the considerations are more mundane: In 1991, only 15% of individual attempts at test-tube conception produced what’s known in the field as a “take-home baby”--with figures higher or lower depending on the procedure and the patient involved.

If success rates are low, however, prices are not. A completed attempt (some women drop out early because they don’t respond to initial hormone therapy) ranges from $8,000 to $13,000 or more. Lumped into the category of “luxury” treatments such as tummy-tucks or orthodontia, assisted reproductive technologies in many cases are not covered, or only minimally covered, by insurance. And there’s no money-back guarantee.

In worst-case scenarios, patients run up huge tabs in repeated futile efforts to have a baby. “The door never, ever completely closes on an infertile couple,” acknowledges Hill. “There’s always the latest snazzy technique to rekindle hope. They can end up at the end of the line childless and financially depleted.”

Contemplating this scenario, a small but vocal number of critics, several of them on Capitol Hill, have raised their voices in a growing chorus of complaint. Too often, they say, the assisted-reproductive-technology field is battening on emotional desperation. “The technology doesn’t work,” says Ann Pappert, who’s working on a book to be titled “Cruel Promises: Inside the Reproductive Industry,” and one of a group of experts who attended a 1990 World Health Organization policy conference on IVF. “A lot of couples go into it thinking: ‘All right, I know the reality but I’m going to be the exception.’ I’ve heard that over and over and over again. The whole technology is presented in a manner that encourages them to think that way. A lot of clinics, the way they talk to the patients sort of pumps them up to keep going back. It’s a business, and like any business, you have to keep your clients coming.

“How many people would go to an IVF clinic if they read that 85% of couples go home without a baby?” she asks. “It’s not that I think clinics should only emphasize the negative, but there isn’t a balanced picture presented. If you go to your OB-GYN, does he have a wall of baby pictures? It’s a form of emotional manipulation.”

Advocates of reproductive technology see things differently. Diane Aronson, executive director of the Somerville, Mass.-based national infertility consumer group RESOLVE, came to the organization years ago with her own problems. “These couples may be in a vulnerable position, but that doesn’t mean they’re not thinking, rational folks,” she says. “Plenty of people decide, ‘IVF is not for me.’ That’s their option. But everyone should have the right to become informed about IVF, to assess the risk and evaluate it for themselves.” The question, though, is whether couples have a chance to make a truly informed decision. Does the data exist to help them weigh whether the short- and long-term risks are worth the potential benefit? Many in the field admit that the answer is no.

IN 1989, THE CANADIAN GOVERNMENT ASSEMBLED A ROYAL COMMISSION to come up with guidelines and funding recommendations for the country’s use of reproductive technology. The commissioners reviewed hundreds of studies from international research on the use of reproductive technologies for infertility problems. Last year, the they concluded that only one procedure--standard IVF for treatment of blocked tubes--had been proven in studies to give women a better chance of birth--about 10% per attempt--than no treatment at all. It recommended that no other form of the procedure get health-care coverage.

The commission didn’t say whether IVF works for other types of infertility, or that procedures such as GIFT or micromanipulation are not effective. But, says Dr. Patricia Baird of the University of British Columbia in Vancouver, the pediatrician and geneticist who headed the inquiry, “we were really rather disturbed by the quality of the studies out there. Many of them have methodological weaknesses or small sample sizes. There’s a real hodgepodge of women being treated, so you can’t judge what the success rate is for different categories of diagnosis. There may be categories for which it’s really not doing any good, and we need to sort that out, because IVF is invasive and expensive, and there are risks involved.”

She adds: “It seems to us that everything except IVF for blocked tubes should be offered in the context of research trials, in which women are told these aren’t proven treatments. They shouldn’t have to pay, and they should have full information and informed consent.”

The World Health Organization also has criticized the profit-driven proliferation of reproductive technology in countries around the globe and called for more clinical trials. Ask Dr. Maria Bustillo, current president of the Society for Assisted Reproductive Technology, if the United States should begin offering these in the context of clinical trials, and she laughs.

“I’d love it,” says Bustillo, who is the director of reproductive endocrinology at Mt. Sinai Medical Center in New York. “I’d love to be able to go back and do some really basic studies. It would be wonderful if people didn’t have to pay these high costs, when we don’t yet have the data to give them answers. But we can’t even get money for doing basic research on endometriosis. Where would we get the dollars to do this?

“A lot of things in medicine related to women’s health get started and adopted without sufficient study; the purse strings have not been controlled by women.”

But without the data that clinical trials would provide, reproductive centers are operating in a questionably gray area. For example, programs typically tell couples that their odds of giving birth stay the same for each IVF attempt, up through the fourth try (after which birth rates are known to dip precipitously). That may, in fact, not be so. A 1992 study by a Yale University professor, frustrated at his own and his wife’s failure with multiple attempts, suggests that the chance of pregnancy drops even before the fourth try. Of 571 women who started treatment at Yale, 13% got pregnant on the first attempt, 10.7% succeeded on the second go-round, 6.9% on the third and 4.3% on the fourth. Edward H. Kaplan, professor of management sciences and of medicine at Yale, who authored the study, is cautious about applying his results to other clinics, but he believes that “you could end up spending a whole lot of money trying to get pregnant, when the chance is really very small.”

Roberta Geist, 43 and a real estate agent, has spent a whole lot of money--more than $30,000--trying to get pregnant. She’s tried GIFT once and IVF once. At the moment, she’s lying in a Century City recovery room after her third egg retrieval; she’s preparing to try IVF again. Geist’s chances of pregnancy, she’s been told, are 10% to 14%. “While you have your period, you can still have a child,” she says hopefully. “This should work.”

Married at 38, Geist discovered after a year of trying to conceive that her tubes were blocked, her hormonal levels not optimal. “My husband won’t let me adopt,” Geist says. But she very much wants a baby. “I have that maternal instinct now,” she says. “I want to be a mother. I’d love for this to work. If it doesn’t, I don’t know, I’ll deal with it, but . . . .” A nurse standing nearby gives Geist a hug. “This is going to work,” she says.

It doesn’t. In fact, a month later, after her fourth failed attempt, Geist gave up on the idea of genetic motherhood and was going to try again with a donor egg.

Further complicating the picture for patients confronting the assisted-reproductive-technology labyrinth is the dramatic fluctuation in take-home baby rates from clinic to clinic. Rates can vary from less than 5% at some programs to a high of more than 30% at others, according to Dr. David Meldrum, director of the Center for Advanced Reproductive Care at South Bay Hospital in Redondo Beach. “These are very complex procedures, with many different variables,” Meldrum says. “The research hasn’t been done yet that will show you, you must do this particular thing at this particular time to get the best results. Without that knowledge, each program varies in the small details that make the difference between success and lack of it.”

He adds: “I’ve visited programs having great difficulty. They have individuals trying extremely hard to have a good outcome, they’re very well trained, they’re in agony, and yet it’s difficult to put your finger on exactly where the problem is.”

Couples can improve their odds by using groups like RESOLVE or the resources of the American Fertility Society to get success rate data on clinics that register with the society (most do). But checking on a particular clinic’s rates in that manner still won’t reveal how many of those who signed on at the clinic actually took a baby home, because the group presents such rates in terms of how many births a program has had, per egg retrieval, rather than in terms of births per started attempt.

“About 15% of women don’t get to egg retrieval, but those failures are discounted as if they never happened,” notes Michael Katz, a supervisory investigative specialist with the Division of Service Industry Practices at the Federal Trade Commission. “The (American Fertility Society) position is that the whole process doesn’t start until the egg is recovered. Our position is that the process starts when the consumer begins kicking over dollars; those drugs cost quite a bit of money.”

In recent years, the FTC, virtually the only agency to watchdog these clinics, has chastised several for representing their success rates in a misleading way, exacting promises from each to practice truth-in-advertising. But that’s virtually as much outside regulation as the industry has been subject to. Although a voluntary lab accreditation program was recently initiated by the Society for Assisted Reproductive Technology, nothing currently mandates that IVF labs be licensed or prove their competency in any way.

That could change. In 1992, Congress approved a bill scheduled to go into effect at the end of this year that gives each state the option to require that its IVF programs be licensed according to a national standard. It also demands that such clinics annually report success rates--including numbers of started attempts as well as of egg retrievals--to the government. Still, Rep. Ron Wyden (D-Ore.), who sponsored the initial bill, refers to it as “baby steps,” and some complain that because clinic licensing won’t be federally administered, the law has no teeth in it.

Such minimal scrutiny, combined with a technology evolving at warp speed, and stiff competition (billboards, radio spots, ads in upscale magazines designed to win business) to attract the minority of infertile couples who can afford assisted reproductive techniques, leaves a margin for abuse.

The new ICSI procedure could be a case in point. In Britain, embryologists who want to use it must prove their competence, then apply for a treatment license. In the United States, any lab that wants to offer the technique can do so. Last fall, the procedure won its 15 minutes of fame here, touted in headlines and on “Donahue” and “Eye to Eye With Connie Chung,” as the panacea for male infertility. “In big urban centers, people will call around to clinics asking, ‘Do you offer it?’ ” notes Barry Behr, director of the human embryology and andrology lab at Stanford University. “If you say no, they’ll call elsewhere. It’s a rat race; you almost have to stay one-up on the program down the road to get business.”

As the hype flew, embryologists from around the country took off to Brussels to do a workshop at the clinic where ICSI had been developed. They returned to the United States with certificates to hang on their walls, stating that they’d taken the course. Yet, says micromanipulation pioneer Jacques Cohen of Cornell, “I’m afraid it is going to be used quite wrongly by most programs. It’s one of the most difficult technologies I’ve ever been involved with. A lot of people think you can just take a needle, put a sperm in it and stick it in the egg. But you need the expertise to apply the procedure correctly.”

Century City’s David Hill, who spent several days studying the procedure at Reproductive Biology Associates in Atlanta, where the first U.S. ICSI baby was born last fall, readily admits that he’s still straddling a learning curve. The fertilization rates he’s getting aren’t better yet than those with SUZI. “It is more challenging than other micro-manipulation procedures,” says Hill, “but we won’t charge extra for it until I’ve gotten three pregnancies. As I feel more comfortable with it, we may slowly, slowly start using it in lieu of SUZI.”

Not all clinics may be that circumspect. Behr also fears that some programs will move straight to prescribing this more high-tech, and pricey, treatment for infertile couples when lower-tech solutions might do instead. That sort of practice, he adds, is relatively common. “It’s one of the big controversies in the field today: At what point do you resort to these aggressive, invasive procedures?” he asks. “Some labs claim success using these aggressive treatments, while others can have success without them. In my mind, it’s when you don’t have to resort to pulling out every stop that you’re doing a good job.”

TODAY IS A GOOD DAY AT Century City; there have been two positive pregnancy tests. Although the chance of a miscarriage during assisted-reproductive-technology pregnancies is 25% (slightly higher than the percentage in the general population), positive tests are still cause for rejoicing. “I have a whistle I blow when someone gets pregnant,” embryologist David Hill says. “I used to take Polaroids of myself doing handstands, but I stopped because of my back.”

Hill’s concern for the patients he works with is evident. “Why aren’t they getting pregnant?” he says of the Taylors. “I wish I knew. If I could bleed a pint of my own blood to get them pregnant, I would do it. In this business, that’s not an infrequent feeling.”

Now sitting behind his desk, Hill is contemplating another troubling subject. Early last year, a collaborative study by epidemiologists from around the country suggested that the hormones used to stimulate women’s ovaries to release extra eggs might raise their risk for ovarian cancer. “Let’s assume for the sake of argument that there is an inherent risk,” says Hill. “Now, I happen not to believe it. I think no study yet clearly shows that association. But let’s say there was an association. This may still be something patients are willing to undertake, as long as they have a realistic estimate of the ratio of risk to benefit.”

The problem is, the information doesn’t exist to help patients make that assessment. Moreover, Robert Spirtas, chief of the contraceptive and reproductive evaluation branch at the National Institutes of Health, disagrees that this particular study should be discounted. He admits that the research had methodological flaws because the author had limited data. Still, he says, “the study raises an issue that we had really better look at” and notes that the institute plans to fund its own study on ovarian cancer and fertility drugs, which millions of American women have now taken.

To date, the potential risks of reproductive technologies have gone virtually unexplored. In 1990, the World Health Organization sharply criticized the infertility community for doing more research on “new and expanded uses for the technology” than its effects on women using it, or on their children.

“This is one vast clinical trial, and no one is monitoring it,” says author Ann Pappert. “No one has a clue about what the long-term effects of these technologies will be on the babies or on women, and nobody’s doing much to try to find out. The whole history of reproductive medicine is filled with these breakthroughs that, 10 or 20 years down the road, fill hospitals with patients having breast implants or IUDs removed, or DES problems (related to the drug given to pregnant women in the ‘50s that caused cancer in some of their daughters). The truth is that instead of waking up after the fact, we should stop now and see if we’re creating another problem.”

With 23,000 high-tech babies born in this country, the American Fertility Society puts the birth-defect rate in these children at less than 3%, a figure equivalent to that in the general population. Preliminary data from Australia, however, suggests that the rate of certain defects may be elevated in high-tech babies. Moreover, about one in three assisted-reproductive-technology babies is a multiple birth--twins, triplets or, rarely, a higher number--a result of transferring several embryos at once into a woman’s reproductive tract. Children of multiple births are significantly likelier to suffer a range of health and developmental problems that can be a consequence, as pediatrician and geneticist Patricia Baird puts it, “of being born too soon and too small.”

And the advent of micromanipulation has raised an entirely new series of concerns. For some years, scientists have subscribed to a theory of natural selection to explain why 200 million or more sperm are in the average ejaculation when only one is needed to fertilize the egg. The thinking has been that it’s the hardiest sperm that helps create a human being. But when an embryologist assumes godlike stature by arbitrarily selecting that single sperm from a marginal batch, it stands the concept of natural selection on its head. Critics fear that the children of ICSI could be the products of a conception not “meant” to occur.

IVF practitioners disagree. “Natural selection is baloney,” scoffs Michael Tucker, scientific director of Reproductive Biology Associates. “The female reproductive tract is not an assault course, OK? It’s not simply that Sparky Sperm, the biggest, meanest, toughest one, runs the marathon and gets to the top of the egg first. Other than the simple fact that sperm move toward the egg, the fertility event is close to being random.”

Still, Tucker concedes it would have been preferable if direct injection could have been tested in animals before being used in people. Earlier forms of micromanipulation were evaluated on non-human subjects, but ICSI is tricky to perform with animal sperm and eggs. In Belgium, where efforts are under way to track ICSI babies into young adulthood, rates of genetic defects seem to be no higher than in the general population. And for the most part, geneticists agree that a sperm can be malformed or sluggish without those attributes affecting its chromosomal content. Still, they point out that the generation of male children produced by micromanipulation is likely to endure its own infertility problems.

Patricia Olds-Clark, a Temple University medical school geneticist who is studying a mouse model of infertility, says: “Their sperm are carrying genes that won’t allow the sperm of their sons to fertilize in a normal way. And what’s true in mice is going to be true in humans.”

Moreover, Cornell’s Jacques Cohen admits that there may be “problem groups” for whom micromanipulation is riskier. “Patients with unexplained fertilization failure who come to micromanipulation because regular IVF didn’t work may have an increased incidence of congenital malformations,” he notes. “But those patients are rare, and they are counseled accordingly.” At least, they are at Cornell. Whether other clinics tell similar patients of this risk is not clear.

THE SOCIETY FOR ASSISTED Reproductive Technology’s Maria Bustillo has heard it all before. She knows that when the negative side of the assisted-reproductive-technology balance sheet is totaled up, it smacks of a conspiracy being perpetrated by avaricious doctors on hapless couples. But she doesn’t buy that point of view.

“We make a mistake if we just blame the providers of this technology,” she insists. “A lot of this is patient-driven. You have a couple in front of you, she’s 43 with a borderline FSH level (a hormonal measure) and you tell her till your face is blue that her chances of having a baby are less than 2% with IVF. And she goes through with it and gets an embryo or two, then wants to do it all again. Do I withhold that, as a doctor? If I do, they may go and get worse treatment somewhere else.”

In fact, infertile couples themselves remain among the most ardent defenders of their right to persevere in the face of slender odds or possible risks. Between 1990 and 1992, Maria DiPaulo, 40, of Queens, N.Y., and her husband, Stan, 41, tried IVF seven times, thanks to insurance that paid all but $4,000 of their $70,000 in medical bills. The two knew their chances would plummet after attempt No. 4. But, says Maria, “I wouldn’t have cared if it was just a 1% chance.” She was also aware, since she repeatedly mainlined hormones, that “there could be repercussions in the years to come from all the drugs I took. But I guess I think about today; I don’t worry about that far down the road. You get so set on doing whatever you can to make this pregnancy happen that risk isn’t an obvious factor anymore.”

The DiPaulos, who recently adopted a little girl, say that as frustrating as their experience was, it was ultimately a positive one. “I think we never could have adopted if we hadn’t gone through all this,” Stan says. “It meant a lot to say we did everything we could.”

Then there’s Terry Matthews (her real name), 33, a New Hampshire travel agent who was born with only one ovary and lost the other to a cyst at age 24. Matthews, who tried to adopt but couldn’t find an available birth mother, was told that, using a donor egg, she had a 30% to 35% likelihood of success--a decent gamble. But she says slimmer odds wouldn’t have deterred her. “When you make these decisions, they’re not based on facts and figures; it’s pure emotion,” she says. “I don’t know how low they would have had to have gone for me to say forget it--10%, 5%? I don’t know. This was the only chance I had to have a child.” In November, 1992, on a second IVF attempt, she gave birth to a boy, from her sister’s donor egg.

Ultimately, not even the sternest critics believe the IVF industry should grind to a halt. “I’m not calling for a moratorium,” says author Pappert. “I just think there needs to be a hell of a lot more work done on determining the safety margin and on deciding who really needs it. And there needs to be more supervision.”

As for the Taylors, their determination to try ICSI hasn’t wavered, but their focus is shifting slightly. As they prepare to return to Century City, they’re also beginning the paperwork for adoption proceedings. “You grow up, as a woman, envisioning yourself going through the process of giving birth to a child that is biologically yours and your husband’s,” says Leslie. “I think that physical void will probably always exist, but from what I understand, when they put a baby in your arms, it’s yours.”

Adds John: “It’s difficult. We’re definitely going to give it another shot. But time keeps passing. We want an end to this. And I think this year we’ll see that. One way or another. I think by the end of the year, we’ll have a child.”