Megan Morris
Biology Senior Seminar
Dr. Stan Grove
November 7, 2004
There are many people in the world today that decide to use fertility treatments to help them conceive a child, and this often leads to the birth of twins, triplets, or even higher order multiples. There are many risk factors that are involved in this type of pregnancy, and these issues have created a cloud of debate around this subject.
I. Introduction
II. Fertility Treatment Options
III. Multiple Pregnancies: possible problems for the mother and babies
IV. The alternatives and their controversy
V. Conclusion
It is assumed by most that we will all be able to grow up, fall in love, get married, and then have children of our own. This is not the lifestyle that all people choose, but it is still the view accepted by the majority of society. What happens when the unthinkable occurs and a happily married couple is unable to get pregnant? This is a reality for 7.1%, or 2.8 million, of the married couples in the United States (Lenox, 1999). Today, there are many people all over the world that decide to use fertility treatments to help them conceive a child, and this often leads to the birth of twins, triplets, or even higher order multiples. There are many risk factors that are involved in this type of pregnancy, and these issues have created a cloud of debate around this subject.
The use of fertility treatments in recent years has been accompanied by an increase in the number of multiple births seen annually. The twin birth rate has increased by 59% since 1980, and the triplet and higher order multiples birth rate is up 423% (Children’s Hospital of the King’s Daughter’s, 2004). There are two main forms of assisted reproductive therapy (ART) that are used currently. These are ovulation induction using fertility drugs alone and In vitro fertilization (IVF).
II. Fertility Treatment Options
Ovulation induction through the use of different forms of fertility drugs is the most common type of assisted reproductive therapy. The drug known as clomiphene, delivered in the form of an oral tablet, is commonly used for ovulation induction. It is taken over a restricted period of time during the menstrual cycle (Jacobs, 2004). This can vary between patients and physicians. The drug functions by allowing more than one egg to mature during the cycle. Clomiphene is just one example of the many different similar oral medications that could also be used.
Another commonly used method of induction is the injection of follicle stimulating hormones, or FSH. For this treatment, the patient is given FSH injections while being monitored by a physician. The physician uses ultrasound to keep count of the number of mature eggs in the woman’s ovaries. When the physician decides that there are enough eggs, a second hormone injection is then given that causes the release of the eggs from the ovaries. The final step is fertilization through sexual intercourse or artificial insemination (ACOG, 2004).
There are risks associated with these types of ART. The use of any ovulation induction therapy can cause a woman’s ovary to swell up to 10 times its normal size (Cowley and Springen, 1997). It is also possible for up to 40 eggs, as opposed to the normal one, to be released in one cycle (Cowley and Springen, 1997). This results in a much higher risk for the conception of a multiple fetus pregnancy. There is a 5%-10% chance of a multiple pregnancy with the use of clomiphene (Jacobs, 2004). This is significantly higher than the 1% rate of occurrence of twins in unassisted pregnancies (Dr. Joseph F. Smith Medical Library, 2003). In about 1 out of 5 pregnancies achieved using FSH injection therapy the result is a multiple birth (Brown, 2001). In an attempt to avoid the conception of these multiple fetus pregnancies, it is suggested that the physicians monitor the number of eggs maturing in the woman’s ovary. If the woman has a very high number of eggs, the physician should advise against intercourse or insemination during that cycle. The ideal solution would be to wait for the next cycle and try again in hopes that there will be fewer mature eggs, which would result in a safer attempt to conceive.
The second major form of assisted reproductive technology that is used today is In vitro fertilization, or IVF. The first step in this treatment is the use of fertility drugs to stimulate the ovaries to produce multiple eggs. These are the same types of drugs used in the previously discussed ovulation induction therapy. The doctor removes the eggs from the woman’s ovaries when they are mature. The eggs are then combined with sperm in a dish while in the laboratory, and fertilization of some of the eggs occurs. The eggs that are fertilized and develop into embryos are transferred back into the uterus of the woman on the second or third day after fertilization. The physician and the patient make the decision as to the number of embryos transplanted into the uterus. It is better to place only one or two in order to avoid the risk of multiple births, but there is no way to be sure that all or any of the embryos will implant in the uterus and develop. Because of this fact, higher numbers of embryos are commonly transplanted into the woman to increase the chances that one or more will take and a pregnancy will develop. While the risk of multiples is not as high with IVF as it is with ovulation induction, the IVF procedure still produces an increased number of multiples. Out of the 15,000 babies born as a result of IVF in 1998, 62% were single births, 32% were twins, and 6 % were triplets or more (Brown, 2001). The technology for these procedures is improving, and researchers are hopeful that improved success rates will allow for a reduction in the number of embryos transplanted in any given procedure. This would help to reduce the rates of multiple births which will in turn reduce the health risks faced by mothers and infants involved in the multiple fetus pregnancies and multiple infant births.
III. Multiple Fetus Pregnancies: possible problems for mother and babies
There are many people who believe that a multiple fetus pregnancy is just an easy way to get more than one baby at a time. For families that have been struggling with fertility, they may be overwhelmed with joy when they discover that they are not only pregnant, but they will be having more than one baby. People’s minds wander to pictures of twins dressed in matching clothes, or maybe even triplets all holding hands, all perfectly healthy. But what about when there are more babies than that? What about when there are four, five, six, seven or even eight babies growing in one woman? And what about when these multiples, yes even twins, are born with serious health conditions? Our society is very quick to glorify the idea of multiple births. We do not address the very real health risks that are posed to both the mother and the babies during pregnancy and after birth. The day to day care of the children once they all leave the hospital, if they are fortunate enough to do so, is also simply overlooked. Finally, there are extreme financial burdens that develop as a result of the fertility treatments that help to conceive many of these pregnancies, the medical bills for the mother during pregnancy and birth, medical bills for the infants, and the cost of raising multiples. These are all complications creating controversy in the fertility drug/multiple birth debate, and are all issues that need to be addressed.
Pregnancy is seen as a natural condition for a woman. Her body was developed with certain anatomical parts that would accommodate a growing fetus for nine months, allow her to give birth, and then help to provide it with nutrition once it was in the outside world. For the most part this is true, but a pregnancy can still be very taxing on a woman’s body. Now imagine a woman carrying more than one fetus in her uterus that was designed for only one. While it is a stretch and a tight fit, the uterus can typically accommodate two babies, twins, reasonably well. However, we are seeing more and more higher order multiple fetus pregnancies with the increasing use of assisted reproductive technology. The uterus of the female is being asked to house not just two, but three, four, five, six, and even more fetuses. This poses a large number of health risks for both the mother and the infants involved.
During the pregnancy, the mother of multiples is commonly asked to endure a lot of physical suffering to give her infants the best chance at life. The size of the uterus, and in turn the woman’s abdomen, grows to extreme sizes. The actual size is dependent upon the mother, the number of babies, and the number of previous pregnancies. In most cases the mother will be forced to stay off of her feet and rest in bed. The amount of time she will spend on bed-rest varies from patient to patient, and is also dependent upon the number of fetuses she is carrying. There are many other possible health risks that a woman faces. These include anemia, hypertension, toxemia, diabetes, and vaginal/uterine hemorrhage. The mother is also faced with very high risks of premature labor and delivery. While this can pose some risks for her, this is the complication that also poses the largest risk to the developing fetuses.
There are many health risks that a fetus developing in a multiple pregnancy features. There is a higher risk that the entire pregnancy will be miscarried. The majority of the possible health complications come as a result of the very high risk for their extremely premature birth. The standard length of a pregnancy is 40 weeks of gestation. Any birth at or after 37 weeks is considered to be full term. Each additional fetus in a pregnancy shortens the gestation period by about 3.5 weeks (Cowley and Springen, 1997). On average, a baby born after 32-34 weeks of gestation will face fewer complications from premature birth, but they are still at a much greater risk for health complications. Infants born prematurely often have immature lungs which require breathing assistance. They also have low birth-weight which contributes to their inability to control their body temperature. They are also prone to face many digestive problems as a result of their underdeveloped organs. One final example is that premature infants have a higher risk for neurological disorders to develop.
These are just some of the many examples of health problems faced by infants and mothers of multiple pregnancies and births. These health problems often lead to extended hospital stays for both the mother and the infants following birth. Hospital bills can become astronomical very quickly, and that is just the beginning of the financial strain that multiple births can put on a family and in turn their community. The monetary problems associated with multiple pregnancies and births develop even before the pregnancy in some cases, and then continue to grow throughout the pregnancy, birth, hospitalization, and life of the new children.
For many families, they endure the struggles of infertility and the use of assisted reproductive technology to conceive their children. These procedures can be very expensive. The total cost for one cycle of In vitro fertilization can cost $10,000 or more, and there is no guarantee that a pregnancy will result (Morrow, 1999). It is common for a patient to pay for multiple IVF procedures to try to get pregnant. The ovulation induction medication costs about 25% as much as the IVF procedure per cycle (A. A. Malpani, 2004). While the ovulation induction therapy is much cheaper it is also less effective. It would be possible for a person to end up spending just as much money on this treatment, because they would have to use it more cycles. Most of the money for these procedures comes out of the pocket of the patient. There are some insurance companies that provide differing amounts of coverage for infertility treatments. Thirteen states in the U.S. now require insurers to provide some infertility coverage. However, for many people, just getting pregnant can put them into extreme financial debt. This can leave them with no money as they face the possibility of an even more expensive future.
A multiple pregnancy can lead to very large medical bills. The mother may be required to spend several months in the hospital on bed-rest before the birth of the infants. “The cost for the delivery of twins is estimated to be ten times more than the birth of a single baby. The routine birth of triplets can cost around $100,000,” (Lenox, 1999). This is an extremely large price tag, and it just continues to rise with each additional infant in the pregnancy and birth. Since most of these babies are born prematurely they need to spend extensive amounts of time in the hospital in the neonatal intensive care unit (NICU). This stay in the nursery will add very large bills to the already huge hospital total. It is estimated that it can cost as much as $250,000 for each surviving baby to be cared for in the NICU (Morrow, 1999). When you multiply this by the total number of babies, the price becomes even more incredible. Insurance will cover some of these bills, but who pays the rest? For the most part, there is no way for the families to pay back the entire tab for their hospital stays. In many cases the hospital itself or the community has to foot the bill, and this is just for delivering the infants and getting them healthy enough to go home. What happens then? These families that are already in debt from conceiving the children and getting through the hospital are now forced with the daunting task of raising multiple new babies. The financial struggle is one that becomes a never-ending battle. These families tend to rely heavily on the community for support in raising and caring for their children. Is this fair for the new lives brought into this situation or the community that has no option but to help? On the other hand, is it right to deny any person the chance to have their own children? These are tough questions that are being debated every day. In response, the medical community is working on developing new strategies that will allow some type of compromise, and help to reduce the increasing numbers of multiple births.
IV. The alternatives and their controversy
There are a lot of concerns about the growing number of multiple fetus pregnancies and the ensuing births in our world today. These types of pregnancies pose many problems for both the mother and babies if the new lives even survive. The medical community has begun to address this situation by researching possible solutions to prevent these pregnancies, or ways to deal with them once they have occurred. There is currently only one solution, aside from total pregnancy abortion, for solving the multiple fetus pregnancy problem after implantation has already taken place. The procedure is called selective reduction, and it involves killing one or more fetuses to reduce the total number in the pregnancy. This is done to increase the chance of survival for the remaining lives. The procedure is usually only considered when four or more babies are involved, and the pregnancy is usually reduced to just two babies. It is usually performed between the 9 th and 12 th weeks of the pregnancy. A lethal injection of KCl is given near the heart of the fetus. The injection is given through the abdomen or the vagina, and ultrasound is used to help guide the needle to the fetus. The fetus dies and is then reabsorbed into the uterus. There is a 4-5% chance that the entire pregnancy will be miscarried, and a 75% chance of premature labor when this procedure is used (Fertile Thoughts, 2002). There are no real statistics on the frequency of use for this procedure, but it has been estimated that about 1,000 reductions performed each year in the United States (Brown, 2001). This can be compared to the fact that there are about 7, 300 deliveries of triplets and higher order multiples each year (Brown, 2001). Selective abortion is very controversial because of its obvious similarities to abortion. Supporters of the procedure argue that it is very different than abortion, because it is being used to help save the lives of the other babies. Either way you look at it, this procedure is still a very last ditch effort, and should be avoided if it is at all possible. The best solution is to avoid the multiples pregnancies by preventing them before they ever happen.
There are many ways that more intelligent and restrictive use of assisted reproductive technology can help to greatly reduce the number of multiple births. One argument supports the government putting a limit on the number of embryos that can be transplanted back into the uterus during IVF. In the United States, this decision is currently left up to the doctor and the patients. The patients tend to elect to transplant more embryos because of the high cost of the procedure. They want to improve their chance for pregnancy. Others argue that the government has no right to make this decision. There is a new IVF technique that increases the success rate which allows for fewer embryos to be transferred into the uterus. In this technique the embryos are transferred at the 5 day, blastocyst, stage instead of the 2-3 day stage. If the embryos survive to this stage and are still growing and developing, then there is a greater possibility that they will implant in the uterus and grow (Shady Grove Fertility Centers, 2004). As this procedure becomes more widely used, there is hope that IVF will no longer carry the higher order multiple birth risk. While this could be the solution for IVF, the ovulation induction drugs still have the greatest risk for multiples.
The huge amounts of eggs that are allowed to mature and be ovulated every cycle with the use of ovulation induction drugs is the most highly controversial fertility issue. The higher order multiple births usually occur as a result of this form of treatment. The simplest solution is to monitor the woman’s ovaries closely, and avoid sexual intercourse or artificial insemination when there are a high number of eggs in a given cycle. The patient could try again the next cycle in hopes that there would be a more reasonable number of matured eggs. Unfortunately, this decision is left up to the patient, and these people are usually very desperate for a baby and are willing to risk anything. The idea of multiples may even be a bonus for them. As a result, many times patients elect to continue on as planned no matter what the cost. There is really no way for this to be regulated by the government. It is left to the judgment of the physician and eventually the patient.
There is an argument that the dosages of fertility drugs should be lowered to help limit the effects. The current dosages produce overly large numbers of eggs which in turn leads to higher incidence of multiple births. The idea is that a reduction in the strength of the medication would reduce the number of eggs that were allowed to mature. This would hopefully lower the rate of multiple pregnancies. It would also lower the chances of getting pregnant which is just not acceptable for some desperate people. There are still others who feel that fertility drugs should be banned all together, and infertile people can adopt children in need of a home. They argue that it does not make sense to help people get pregnant with a large number of babies that they will not be able to afford to care for when there are many children who need parents to love them. This brings us back to the question of who has the right to deny people their chance at having their own biological children? This is an ethical question that has no answer, and will never have a right or wrong answer. There is no easy solution to the multiple birth dilemmas.
Our world is full of people who are battling infertility in their struggle to have a child. Many of these people decide to use fertility treatments to help them conceive a pregnancy, and this often leads to the birth of twins, triplets, or even higher order multiples. There are many risk factors for the mothers and infants involved in these pregnancies. The health of both mother and babies can be threatened, and there is a good chance that the babies will not survive. Is the use of ovulation induction and In vitro fertilization worth the risk that it could pose? This is a question that has created a lot of debate within the medical field. There is no way to answer this question. The best solution for the current time is to try and develop the best alternatives possible, and help the children that are born as a result. There is hope that the future will find a good compromise between the extremes of the fertility drug argument.
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