How Many Babies Is Too Many?

There was joy and relief in the jampacked delivery room at Long Beach Memorial Medical Center. Patty Shier of Westchester had just given birth to five good-sized, wailing, pink babies, probably the healthiest quintuplets ever born in the United States.

A few miles away in a Torrance medical office, seven months of worry began to fade from the face of Dr. Rifaat Salem, who had used in vitro fertilization to help Shier become pregnant.

Salem said he had transferred seven embryos with Patty and Scott Shiers’ consent, but against his better judgment. (Four to six embryos are typically transferred.)

Upon discovering that Shier was pregnant, Salem argued passionately against carrying all five embryos that attached in the uterus. He advised the couple to consider “selective reduction”--an abortion of one or more fetuses--to improve the odds of a healthy outcome for mother and babies.

In a frosty standoff a few weeks into the pregnancy, the Shiers affirmed their right to do as they wished.

“We felt God had given us these babies and he would give us the ability to take care of them. I think Dr. Salem thought that was a Pollyannaish view,” said Patty.

“It created tension among us in the beginning,” the soft-spoken Salem acknowledged. “When the ultrasound showed five, I was very nervous. I knew the outcome might be dismal, and I felt responsible. But Patty said, ‘Dr. Salem, you have explained the risks.’ There was nothing I could do but smile and support her. But inside I thought, ‘What does this mean?’ ”

Salem’s agony and the Shiers’ angst are typical of the private dramas that play out daily in infertility clinics as the number of higher-order multiple births--triplets or more--increases with assisted reproductive technology.

The rise is attributed largely to the use of potent fertility drugs as well as the advent of in vitro fertilization in 1978 and subsequent technological advances. Since 1971, the rate of high-order multiple births has more than tripled. The latest family to join that trend were Susan and Robert Hasson of Westminster, who had quadruplets last weekend.

Those figures represent live births, not pregnancies reduced by miscarriage or selective reduction.

The surge in births--and the fact that at least half of these infants suffer serious problems because of premature birth and low birth weight--has ignited a debate about whether it’s time to crack down on what all sides call the “Wild West” era of infertility treatment.

The American Society of Reproductive Medicine, much to the dismay of some infertility specialists, is considering the first guidelines to limit the number of embryos transferred during in vitro fertilization to four for women age 34 and younger, with more liberal guidelines for older women who are not as likely to become pregnant. Such guidelines are the law in some countries including England.

Some ethicists say limits on the number of embryos transferred violates a couple’s freedom.

And many infertility doctors argue that the guidelines would drastically lower the chances that a woman would get pregnant with even one baby and would increase, on average, the number of costly in vitro fertilization cycles required to produce a pregnancy.

All of the society’s recommendations would be voluntary. But health insurance companies are also applying some pressure on reproductive specialists to back off.

Salem, for example, helped produce healthy quadruplets only a few weeks after the Shier quintuplets were born in January, but is hardly bursting with pride. “I don’t want to be labeled that I produce multiples,” he said. “Insurers may not give me a contract.”

“It’s an economic issue,” said Dr. Alan H. DeCherney, the former president of the American Society of Reproductive Medicine, who will soon become chief of obstetrics and gynecology at UCLA. “HMOs are telling us, ‘We’re spending a fortune taking care of these premature babies.’ ”

But the issue transcends money woes, he acknowledges. Grumblings from perinatologists--doctors responsible for the fetus’ health--and neonatologists--who care for ill newborns--have reached infertility specialists.

“The guys who have to do these selective reductions are peeved. There is peer pressure, and [doctors] want to do the right thing,” DeCherney said.

There appears to be a gnawing feeling that anything that promotes higher-order multiple pregnancy is just too Orwellian; too counter to nature’s intent.

“I cry for women pregnant with so many embryos that it’s impossible to carry them. No one should have to deal with that,” said Lori Melcher, an Ohio woman who with her husband anguished over a slew of ethical and medical decisions before giving birth to healthy quadruplets in 1990.

Dr. Louis Keith, president of the Center for the Study of Multiple Births in Chicago, is more blunt: “The human mother isn’t meant to carry a litter.”

Daunting Odds

The issue of multiple pregnancy has been hidden by a darker cloud hanging over infertility treatment: the very low chance that couples seeking treatment will end up with even one baby.

In fact, about 75% of couples nationwide undergoing in vitro fertilization do not become pregnant in just one attempt. But for the 25% who do get pregnant, about one-third have two or more babies.

Specific treatments boost the risk of multiples. The use of fertility drugs, such as Pergonal, stimulate the ovaries to release more than the single egg typically produced during ovulation. With Pergonal, the ovaries occasionally burst with eggs. For instance, Michelle Haner of Chatham, N.Y., had sextuplets, each weighing about 2 pounds, in March.

With in vitro fertilization, the woman takes fertility drugs to increase the number of eggs. The eggs are extracted from the ovaries and placed with sperm. Some or all of the resulting embryos are transferred to her uterus. Those not used are sometimes frozen.

With these treatments, a potentially dangerous dictum has evolved: The more, the better. The more eggs produced, the more embryos transferred, the greater the chance of pregnancy.

Like many infertility patients, Patty Shier, 35, had endured several failed in vitro fertilization cycles, each costing about $7,500. While contemplating adoption, the Shiers decided to try a procedure to correct an immune system problem that was possibly causing Patty to reject the embryos. The next in vitro fertilization cycle yielded seven embryos, including two that seemed to be of poor quality. The others appeared to be what doctors call “viable.”

Five fetuses was the last thing they expected.

“It was so improbable that we didn’t even think it would happen to us,” Patty said one recent morning as she cradled her daughter Sarah in the family’s bungalow a few blocks from Los Angeles International Airport.

Studies show that among women under the age of 40, the chances of pregnancy go up with each embryo transferred from 7% or 8% with one healthy embryo to 45% with six.

“No one is going to go through the emotional trauma and cost of IVF for a 15% chance,” said Salem, who endorses the American Society of Reproductive Medicine’s move toward guidelines. “Europe and Japan have [limitations]. The American people are different. They want babies. They will take multiples, and they will pay for it.”

But the American way is simply too cavalier and too costly, says Keith, who also supports guidelines.

“In the United States, we have this Wild West mentality of shoot ‘em up and the more bodies the better,” said Keith, who recently wrote a textbook on multiple birth.

What initially appears as a success to a couple and their doctor is often a nightmare down the line, he says.

“For the infertility specialist, his criteria for success is to get her pregnant. The perinatologist’s criteria for success is to get the fetuses to viability [a chance to live at birth]. Success, to the neonatologist, is to get the kids out of the neonatal intensive care unit alive. The pediatrician’s criteria for success is to see that the damage isn’t too bad,” Keith said.

But the damage often is bad.

Women who give birth to multiples risk high blood pressure, uterine bleeding and complications from caesarean section. The major threat to babies are complications of premature birth: death, blindness, brain damage and learning disorders.

Multiple babies are six times as likely as single ones to have cerebral palsy and are twice as likely to have birth defects.

Little has been learned about how to improve the outcome of multiple pregnancies, which are rarely carried to full term, Keith says.

“We don’t know what causes the onset of premature labor and we don’t know how to prevent it in every case. That’s a major problem.”

Financial Impact

Health problems aren’t the only possible complication, some economists say. In an era when every dollar spent by insurers is given close scrutiny, there is growing exasperation with the cost of getting a woman pregnant, then paying for the outcome.

In a study of 13,206 expectant mothers entering Brigham and Women’s Hospital in Boston from 1986 through 1991, the average total charges for a single-baby delivery were $9,845, compared to $37,947 for twins and $109,765 for triplets.

The study found that 15% of the single-baby deliveries required intensive care and about 2% died before discharge. That is compared to a 78% intensive care rate for higher-order multiples, 13.7% of whom died before discharge.

The data also showed that if the 10 sets of triplets and 77 sets of twins produced by infertility treatments in 1991 had all been born as single babies, the savings would have topped $3 million in this one hospital alone.

Although hospitals and health insurers absorb most of those costs, families who take home multiples bear their own huge burden.

“It’s a real body blow to the family system in terms of the health of the parents and infants, the adjustment of older siblings, finances, housing, transportation and job security,” said Patricia Malmstrom of Twin Services, a parent support organization in Berkeley. “But our policy for the care of higher-order multiples in this country is ‘See if you can get a modeling contract.’ That’s what it boils down to.”

Malmstrom says she once received a call from a social worker in Los Angeles who had, among her caseload of needy families, four with quadruplets. The social worker had tried to get brand-name manufacturers to donate goods like baby food or diapers. “The response she got was that quads weren’t ‘it’ any more; that they couldn’t afford to donate ‘for just quads.’ ”

Twin Services recently organized a network of consumer, medical and social services experts in Southern and Northern California to assist families with multiples over the years.

The Shiers, meanwhile, have given up Patty’s income as a computer software specialist and will subsist on Scott’s income as a stockbroker. They are the recipients of donated clothes, strollers, swings, formula, diapers and meals and say their religious faith sustains them.

Still, the Shiers are exceptional, says Keith, who complains that the public story of multiples “has been buffed, toned, air-brushed and made to look wonderful. What distorts the issue,” he added, “is that the press is very eager to do a story on a mother of quints all of whom are 4 pounds or more, but they don’t find it very newsworthy to describe the cases where the babies are born very prematurely and die one by one.”

Others say attitudes like Keith’s are too pessimistic; that good outcomes are possible with the right medical care.

“Many parents feel totally pressured to reduce their pregnancy when they would not make that decision if they had better information or better hope of having a good outcome,” said Janet Bleyl, founder of the Triplet Connection, a support organization for parents of multiples in Stockton.

Melcher, the Gahanna, Ohio, woman who had quadruplets, was one such mother. Several doctors recommended selective reduction. She chose the one obstetrician who didn’t. But the pregnancy was not a happy one.

“I was terrified the whole time [about the chance of having medically compromised babies] because the doctors all made me feel it would be my fault if that happened,” said Melcher, whose babies were healthy.

There are few statistics on selective reduction. The procedure, in which potassium chloride is injected into a fetus causing it to succumb immediately, is usually performed to reduce four or more children to twins or triplets. It sometimes causes the mother to miscarry all the fetuses.

“Selective reduction has a place, but only if it’s [medically indicated] and the patient is counseled,” Salem said. “To me, it’s a gross type of solution.”

One support group for parents of multiples--Mothers of Supertwins--is lobbying for improvements in preconceptual counseling in infertility clinics. Financial pressures often lead couples into high-risk treatments without regard to the risk of multiples, says Maureen Boyle of the Brentwood, N.Y.-based organization.

In such cases, “we routinely hear of eight to 11 embryos transferred,” she said. “Hawaii, for example, will pay for one cycle [under the state’s universal health care plan]. So families go for broke. When they are pregnant with multiples, though, they often can’t find a doctor in that state who will do selective reduction. So they have to fly to San Francisco for selective reduction.”

But even if the risks of having multiples are explained thoroughly, many patients--so desperate to become parents--simply cannot envision them, experts say.

“Families who are in heavy-duty infertility treatment have been down such a long road that it’s quite understandable if they brush off the implications,” Malmstrom said. “So often we hear, ‘Oh, we’d be so blessed, so delighted, after all these years of no children.’ They are sort of in a romance about being parents and don’t understand the implication for themselves or the babies.”

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Baby Boom

Contributing to the rise in multiple births in the United States are the growing numbers of births to women over 35--who are more likely than younger women to have twins--and wider use of fertility drugs and in vitro fertilization.

* Rate of sets of twins or larger multiples per 1,000 births

* Rate of sets of triplets or larger multiples per 100,000 births

* Cost Explosion

Hospital costs from birth until discharge grow by leaps and bounds with each infant in multiple-gestation pregnancies. For example, while three healthy babies born separately to three mothers might cost $4,500, healthy triplets typically cost at least $30,000.

Estimated cost range:

One baby: $1,500-$10,000

Twins: $10,000-$100,000

Triplets: $30,000-$150,000

Quadruplets: $70,000-$200,000

Quintuplets: $100,000-$300,000

Sources: Center for Health Statistics, Long Beach Memorial Medical Center