One and the Same (14 page)

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Ricki and Steve were like so many couples trying to get pregnant: anxious and ill-informed. Though this couple, in their early thirties, went to one of the most reputable fertility clinics in New York City, they heard few specifics about what they might be in for. “No one informed me of the risks of multiples,” says Ricki, a genial woman with shoulder-length black hair, who works part-time in her suburban library. “I just thought that with twins, you got more uncomfortable at the end of the pregnancy and were more likely to have a cesarean birth. I didn't realize how common premature birth was with twins.”

Ricki's husband, a furniture maker who is dressed in his company work shirt when I meet him, recalls trying to obtain some hard data. “I really felt that I had to fight tooth and nail for every number, every statistical fact, every probability,” says Steve, whose baby face contradicts his graying hair. “I'm well versed in calculus and statistics and things, but whenever I wanted to see real solid IVF numbers and probabilities,
I felt that, at best, the doctors were extremely evasive and not forthcoming. They would say something like ‘I don't have those figures, and even if I did, they wouldn't be meaningful to you.' I don't think it's a nefarious conspiracy on their part. But I do think that perhaps on some unconscious level, their impetus is numbers: They want to be able to point to statistics and say, ‘We have a certain percentage higher success rate than the next clinic.' To a large extent they were more motivated to push you through the process than to make you aware of what can go wrong. If you were going to go out and buy a car and the dealer said, ‘You have a two percent chance of this car killing you as soon as you leave the parking lot,' you would never buy the car. It would be considered statistically absurd to take that kind of risk. If they told you the real numbers for prematurity and birth problems, a lot of people might be dissuaded.”

“But what if it meant no car at all?” Ricki calls from the kitchen, where she's making tea.

There's the hitch: no risk, no baby—or that's what Ricki and Steve were led to believe. They don't regret their sweet twins for a moment; they just wish they'd had a more realistic sense of what might lie ahead.

They ended up having premature fraternal twins, born at twenty-four weeks (full term is from thirty-seven to forty-one weeks), each weighing a precarious one pound, twelve ounces. Both babies were immediately intubated, hooked to respirators, and rushed to the Neonatal Intensive Care Unit (NICU). Sammy fought for his life in his early weeks; part of his intestine became infected and failed, so doctors inserted a drain in his side. When his condition worsened, they performed surgery for seven hours to remove a third of his small intestine, and later confessed they were surprised he pulled through. “One doctor told me, ‘I'm not supposed to say this, but it must have been the hand of God,'” Steve recalls, “‘because we didn't think it would make it. Not one in ten children would have even survived that surgery at his size.'”

Today, at three years old, Sammy has mild cerebral palsy—he has
worn leg braces, and until recently, his speech was unclear. But he holds his own in a regular nursery school class with his brother, Ste-vie. When I meet the boys at their noon pickup on a sunny fall day, they appear chipper and healthy. During the short drive home, they sing along in their car seats to “Here Come the ABCs” by They Might Be Giants, and ask Mom what's for lunch. Sammy takes my hand to walk up the steps to his house, and when he passes his father in the doorway, he blurts out matter-of-factly, “I missed you today, Daddy.”

Both parents say they feel lucky, but it's evident they were traumatized by the roller-coaster events of the boys' earliest months. “There's a lot of shock,” Ricki admits over mugs of tea at her blondwood kitchen table, “a feeling of free fall and dread. I remember thinking I would have given everything I owned just to give them another week of gestation. Because it makes such a difference.” She adjusts her titanium glasses. “I remember feeling so much guilt that we did infertility treatments and caused them to be born; that maybe I hadn't taken it easy enough during the pregnancy and I caused them to be born early; that they'll have to deal with this prematurity and low birth weight the rest of their lives. During the first six months when they came home, there were times when I felt like I shouldn't have done this.”

Most people are aware of our national twin boom: According to the Centers for Disease Control and Prevention, twin births in the United States have increased 70 percent since 1980. Between 1980 and 1995, the number of triplets (or “high-order multiples”) born to white mothers ballooned by an astounding
500
percent. Today, one in thirty-one births is a twin. (In 1970, it was one in sixty births.)

Credit goes chiefly to reproductive technologies like IVF (in vitro fertilization), and to delayed maternity—women conceiving between the ages of thirty-five and forty—when there's a greater chance of releasing two eggs in one cycle. From 25 to 35 percent of IVF pregnancies produce multiple fetuses, and there are an estimated three million–plus IVF children in the world today. (Natural twins will
happen only one or two times in a hundred births.) Which means the vast majority of these twins are fraternal (dyzygotic), the result of two separate sperm fertilizing two separate eggs, and, as with any other two siblings, roughly half their DNA is shared. Identical twins (monozygotic)—which occur when one fertilized egg splits—share 100 percent of their genes. Identicals are always a gestational fluke, although studies show the accident is more likely with reproductive technology. Fraternal twins can run in families when the mother has a genetic predisposition to hyperovulate, meaning she releases more than one egg during her monthly cycle; identical twins are not hereditary. And there's no proof that twins skip a generation: “An old wives' tale,” says Dr. Louis Keith.

Obviously, reproductive technology has answered the prayers of countless couples, and the high success rate of IVF is a potent justification for the craze. However, I was struck during my research by the intensity of some doctors' concerns that the hazards are not always highlighted, and even when they are, couples pay no heed.

The fact is that multiple births are high-risk. Neonatal death is five times higher for twins than for singletons. For triplets, the chance of infant death is eleven times higher than for single babies. Twins and triplets are often born too early and underweight (50 percent of all twins are premature, 90 percent of triplets), which can cause developmental problems in utero, at birth, or later on. Twins who are small for their gestational age suffer motor deficiencies, mental retardation, visual abnormalities, behavioral disturbances, and speech problems. A twin is four times more likely to be born with cerebral palsy.

“It is true that modern reproductive technologies and medications started an epidemic of multiple birth,” says Dr. Avner Hershlag, the venerable head of the fertility clinic at Long Island's North Shore Hospital, who happens to be Natalie Portman's father. “The reason why multiple pregnancy became such a problem is because the principle of fertility drugs is to make
multiple
eggs, which can result in multiple babies. … I know that your perspective is twins, but the main
concern is actually over supertwins—triplets and higher—because that really increases the risk to the babies and the mother.”

Hershlag, who speaks with the Israeli accent of his birthplace, rattles off the risks to the newborns: “severe respiratory problems, liver problems, blindness, and mental problems, with delayed developmental milestones. There's the need for long-term admissions to the NICU, huge costs incurred to the system and to the parents, and it goes on. There is also significant mortality. I'll give you a number I just read today: that in the UK each year, one hundred and twenty-six babies born after IVF die as a consequence of multiple birth.”

He turns immediately to the mother's risks: “Everything that can happen adversely in pregnancy happens more with high-multiple birth, including diabetes in pregnancy, premature separation of the placenta with abruption and bleeding, hypertension, increased discomfort in the pregnancy, increased bed rest—including loss of working days—and that's all before delivery. The most major impact is probably
after
delivery, and that is the social change in people's lives as a result of multiples. There are studies that specifically address the parenting anxiety index. An article from 2004 in
Fertility and Sterility
says the anxiety increases severalfold as you conceive with multiples and deliver them, and any additional baby increases your stress by that much more. We in our practice would not have to do any surveys; we know that reality; we live it.”

“The majority of twins do pretty well,” says Dr. James Grifo, of NYU's fertility center in Manhattan. “A singleton pregnancy is complicated; a twin pregnancy is
more
complicated; a triplet pregnancy is even
more
complicated. But the reality is that a twin pregnancy generally has a very good outcome.” In May 2009, six months after my interviews with Hershlag and Grifo, new research upped the ante on the risks of multiples: Europe's leading journal on reproductive medicine,
Human Reproduction
, published an international study that found that twins born
as a result of fertility treatment
—not just twins in general—have a higher risk of “adverse outcome, including preterm
birth, low birthweight and death, compared with spontaneously conceived twins.” In other words, it's not just that fertility treatments lead to a higher chance of a multiple birth—which is, in itself, always more high-risk—but twins born of fertility treatments were more likely than spontaneously conceived twins to end up in the NICU or to be admitted to a hospital during their first three years of life.

I tell Grifo that some doctors I've spoken to say that even though adverse outcomes are in the minority, they're a life sentence for parents.

“It definitely changes their life; there's no doubt about it,” Grifo replies.

I ask whether that possibility is communicated by fertility specialists to their patients.

“We do our best,” Grifo replies, “but it's shoot the messenger. No one wants to hear it; they just want to be pregnant.”

When infertile parents focus all their efforts and savings on producing a child, they may not factor in the perils of producing two, three, or more. On the contrary, a couple that hasn't been able to conceive and is about to spend tens of thousands—sometimes hundreds of thousands—on IVF usually wants to maximize the chances of getting a baby out of it; and understandably, many of them are thrilled at the notion of an instant family of four. The conventional wisdom is unquestionably that getting pregnant with twins through IVF is serendipitous. Two for the price of one looks pretty good when the price tag for each stab at pregnancy is exorbitant and the biological clock is ticking.

The crude summary of how IVF works is this: A woman is given drugs to stimulate her ovaries; she produces multiple eggs, which are extracted and joined in a dish with her mate's sperm; hopefully, embryos result and are transferred back into the woman, with fingers crossed that at least one will take and develop into a baby.

Maximizing the chances of success used to mean “putting back” more embryos. “Because the procedure was inefficient to begin with,” Hershlag explains, “and we could not tell which embryo was going to
make it, it was very common to place multiple embryos in a woman's uterus with the hope and prayer that one of them will take and become a baby. And in those years, people were putting tons of embryos—could be five, six, seven—in a woman who was in her mid-thirties. Since then, as IVF has become a more efficient, reliable, and reproducible method of treating infertile patients with almost predictable pregnancy rates, we doctors have started to relax. Patients have also started to relax; they're not demanding that as many embryos be transferred, and we are being much more cautious.”

Grifo has, like Hershlag, cut down on the number of embryos transferred regularly in his clinic, but he says parents are not always as “relaxed” about it as Hershlag describes. “I spend more time talking people
out of
transferring too many embryos, rather than the opposite. Patients say to me, ‘Look, I want four embryos,' and I'm sitting there saying, ‘No, no, no, this isn't what we should do.' The idea that
we're
actually driving this is totally false.”

He explains that they've been able to cut back on embryos because of new methods that discern the most promising ones in the lab: quality over quantity. “Now we can take our data and say to the patient, ‘Look, I'm happy to put two embryos back, but my recommendation is that we put
one
back, because if we put back a second embryo, we're not making more pregnancies; we're just making more twins, and that's not our goal. Are you willing to let us put one back, knowing that by putting one, I'm not hurting your pregnancy rate; I'm just giving you a lower chance of twins?' And the response from many patients is, ‘I want twins. Do it.'” He sighs. “The fact is, patients have a say in their care; that's the way we practice, and it's the right way to practice, even if the patient is asking for the wrong thing. It's our job to educate them, but at the end of the day, it's their cycle.”

Hershlag says, “I sit down with my patients and talk about triplets, the complication rates, prematurity, the lifestyle of having triplets. I say to my patients, ‘It consumes your life, and it's wonderful on the one hand, but on the other hand, it's probably not how God
meant for us to have babies.' And in many cases, after they hear my whole speech, they say, ‘Okay, Doctor, we really appreciate your concern. Now can you put in three?' They say, ‘It's my last IVF cycle. … My husband just lost his job, and this is the last time that his insurance will pay for it.'”