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5 June 2006
IVF: Double Trouble
by Angie Rankman

Sam has taken a turn for the worse and we need to sign a release for a blood transfusion. Sam is in bad shape; his system has shut down. His oxygen levels are low. The head night nurse-practitioner (NP) steps out of the unit and steers us toward the nursing station. She sits down on a desk and says, "Sam is very sick. He is not responding to our treatments. Of the forty-eight babies in the NICU (neonatal intensive care unit) tonight, I'm afraid Sam is in the worst shape. We are going to try him on an oscillator. It may be our last resort." But is the head night NP's knowledge of sick babies and last resorts even helpful? Is she employing a time-honored technique that gently forces parents to contemplate death as a possibility? If Sam dies I will be left reaching out for a baby I never held.

This is just one of the many harrowing and moving extracts from The Early Birds: A Mother's Story For Our Times, written by former book editor Jenny Minton, who lives in Hartford, Connecticut. Jenny's book is a timely reminder that while celebrating the incredible advances in assisted reproductive technologies such as IVF (in vitro fertilization), we often lose sight of the fact that nature is still the final arbiter.

After 9 months of trying to conceive with her husband, Jenny was 30 when they finally decided upon IVF treatment. Jenny gave birth to twin boys, Sam and Gus, in the winter of 2002; she was thirty-one weeks pregnant. The boys had arrived over 2 months early. Weighing only 3.5 pounds each, Sam and Gus were immediately taken to a NICU and placed on life support. After describing the distressing circumstances of the birth in her book, Jenny relives every grim and anxious moment of the 64 days that her two boys spent on the critically ill list fighting for their lives.

While infertility treatment has been available to women for 30 years, Jenny's book is a very raw and personal example that shows how medical science currently stands at a crossroads. Medical practitioners have come to realize that while IVF is an increasingly popular treatment for infertility, only one in five treatment cycles results in pregnancy and live birth. In order to combat one inexact science another is adopted, and many IVF practitioners try to increase the chances of pregnancy rates in women by implanting multiple embryos for each cycle. But a study in the British Medical Journal by researchers at the Centre for Research in Primary and Community Care at the University of Hertfordshire states: "the chance of a multiple birth after in vitro fertilization involving multiple embryos is around 45 percent... multiple birth is largely thought to be responsible for the higher risk of perinatal and infant mortality in babies born as a result of the technique."

Sure, you could argue that IVF is entirely voluntary, but if more women knew of the potential trauma involved with IVF, would there be so many couples rushing into treatment? There are moments in The Early Birds where Jenny thinks back to how little she knew of her treatment, and the limited amount of information that doctors imparted about the IVF program. Aside from not knowing the risks involved, there may also be another cost associated with a lack of communication between health professionals and the IVF recipient. With a great deal of guilt, Jenny discusses in her book what she perceives to be her own shortfalls in not being able to carry her sons to full term. Of course, the fault does not lie with the mothers of IVF babies, and neither does it completely lie with IVF practitioners. It seems that IVF (which is largely unregulated in the U.S.) is far from a complete science, but nobody is telling this to the recipients of IVF.

Now equipped with a better understanding of the dangers of twin IVF births, the authors of the UK study consider this situation unacceptable, and that the public health risks posed by the multiple embryo technique as unnecessary. "The much increased risk of multiple birth in babies conceived following infertility treatment continues to constitute a public health burden, which is largely preventable," say the researchers. Their study, and others like it, have placed enormous pressure on practitioners to adopt better techniques for fertility treatments, and prompted calls to immediately dispense with the unstable technique. But with the demand for fertility treatments increasing, there needs to be a viable replacement option that is not only safer, but one that can deliver the same birth rates. The obvious step would be to use single embryo transfer; but critics maintain that birth rates would drop. The authors of the UK study dismiss this claim, pointing out IVF successes in Sweden. "Sweden was one of the first countries to systematically move towards single embryo transfer. And their experience indicates that [it] does not necessarily compromise the 'take home baby' rate but does dramatically reduce the multiple birth rate." This is a rather odd conclusion, as the initial reason for the multiple embryo technique was to increase IVF "take home" birth rates. Have doctors been wrong all this time?

Well, it now turns out that there are other factors that determine whether a mother who has undergone IVF treatment will have twins or not: folic acid. Folic acid was used to fortify flour in the U.S. in 1998, after studies showed that if taken up to 12 weeks into a pregnancy, it could prevent neural-tube abnormalities such as spina bifida. However, too much folic acid was associated with an 11-13 percent increase in the incidence of multiple births after fertility treatment, and an increase in the unfortunate consequences that can often follow. Was Jenny's twin birth the result of too much folic acid? In the medical journal The Lancet, a Dr Haggarty commented that: "the high incidence of twin births associated with treatment for infertility could be reduced, while maintaining live birth rates, by encouraging women not to exceed recommended doses of folic acid." The researchers did indeed find that their results were consistent with developments in the U.S. Exactly what the right dose of folic acid is - for a healthy, non-twin birth - is something that each woman considering IVF will have to discuss with her doctor.

There have been numerous encouraging developments on infertility techniques since researchers have begun to get acquainted with the pros and cons of folic acid. Professor Nava Dekel, of the Weizmann Institute's Biological Regulation Department, discovered a remarkable way to condition the womb of women about to embark on IVF treatment that would double success rates. Of the 12 women who participated in Professor Dekel's trials, 11 became pregnant during their following round of IVF. This would mean, one would think, that along with significantly increased chances of pregnancy, the days of multiple embryo techniques are numbered.

Although Jenny's boys survived, and she even went on to have another boy with the IVF program, Jenny's story reads like a nightmare in parts. Her story highlights the fact that nature is complex and often unforgiving, and no matter how much we might like to think that we have control over life and death, we actually have very little. It is because of this that doctors, working with an incomplete science, have to communicate the dangers and risks associated with IVF, and not give the impression that infertility treatments are smoothly running baby-making factories.

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