Infertility and the Science of Making Babies 

Carolyn, 28, paced nervously in her kitchen, awaiting a phone call. She and her husband, parents to a 4-year-old daughter, had completed their first attempt at in vitro fertilization (IVF) after two heartbreaking years of failed, more conservative infertility treatments.

Today they’d learn the results. Theirs had been a case of unexplained, secondary infertility; doctors could find no reason why the couple couldn’t conceive again. When the phone rang and Carolyn was told the cycle had been unsuccessful, she mechanically said thank you.

Then she burst into tears. She had produced six embryos from the treatment cycle. The doctor recommended she transfer two  embryos and freeze the others for future attempts. Two hadn’t seemed enough at the time, but she took his advice. Now she regretted not insisting on more. She wiped away her tears and strengthened her resolve. Next time she’d make the doctor transfer all her remaining embryos. That would surely yield positive results, wouldn’t it?

What is infertility?
Infertility is defined as the inability to conceive after one year (six months for women over 35) of unprotected intercourse, or the inability to carry a pregnancy to live birth. It affects 7.3 million people in the U.S.; of those, more than three million are affected by secondary infertility. Secondary infertility is a woman’s inability to become pregnant or carry a baby to term following the birth of one or more biological children. Pursuing treatment for infertility requires serious consideration of the potential risks and benefits. There are financial, physical, ethical, and moral considerations to weigh.

For one thing, treatment can be expensive. The average IVF cycle in the United States costs around $12,400. (IVF involves fertilizing eggs with sperm outside a woman’s body, then transferring embryos into her womb.) There’s no mandate that insurance cover the costs, so rules vary by insurance company and state. Call your carrier to ensure that the services you’ll need and the provider you select will be covered. And verify that there’s no lifetime maximum for infertility services which would cap payments as long as you hold a particular policy.

If there is a lifetime maximum, know what it is. You can hit it quickly, and you must guarantee that you’re willing and able to pay what’s not covered. Other services, such as intrauterine insemination (IUI; when eggs are fertilized inside a woman’s body by semen that is introduced to the uterus via a catheter), are less invasive and less costly. But for repeated attempts, costs multiply. And medications are a separate charge; they can run several thousand dollars, and count toward your lifetime maximum.

Risks and rewards
Fertility treatments are not benign. Successful ones make for happy patients. But the road to success is bumpy. Ovarian hyperstimulation syndrome (OHSS), where the medication that stimulates egg production results in too many eggs, can be dangerous. It can lead to weight gain, abdominal pain, leaking of fluid from the released eggs into the abdomen, and shortness of breath. It can also lead to “mega multiples” during the process of intrauterine insemination.

IUI is less invasive than IVF. Usually, unless there’s a known reason why it wouldn’t work, a doctor would suggest trying this treatment for infertility first. Ideally with IUI, a few good-sized eggs develop; one or two will fertilize. A reputable doctor will cancel an IUI cycle if a large number of intermediate-sized eggs develop to a mature, or usable, size. With OHSS, many eggs develop; after insemination, there’s no knowing how many will fertilize.

Less is more
Multiple gestation may not seem like a complication, but it’s not the desired outcome. Twins and triplets are cute, and the multiples on TV reality shows have adorable adventures. Their lives look like fun.

And they may have fun on TV—but it’s not reality. Rather, there’s increased probability of maternal complications such as preterm labor, high blood pressure, the need for prolonged bed rest or hospitalization, excessive bleeding at delivery, and, often, preterm emergency delivery. Rarely are twins delivered vaginally, and never in my 18 years as a nurse have I seen triplets or more delivered except by cesarean section. A cesarean adds the potential for post-operative complications for the mother, like infection, pneumonia, and wound separation.

There are also potential complications for preemies. These fragile beings aren’t dolls, but real, live humans. They risk low birth weight; vision, respiratory, or feeding problems; lower immunity to illness; difficulty with body temperature control; and increased chance of bleeding into the brain.

The more babies a woman carries, the more likely she’ll deliver early. The earlier she delivers, the more pronounced these problems may be. Some linger after the volunteer help has gone and the fanfare has faded.

Multiplication and subtraction
Selective reduction helps control how many fetuses a woman will try to carry to term. If a patient is pregnant with multiples (usually three or more) and wants to carry fewer, a specialist can do the reduction, usually in the first trimester. A medication is injected into the sac around the fetus to stop cardiac activity, giving the remaining fetuses a better chance to survive. It also decreases their—and their mother’s—risk for complications.

For religious and emotional reasons, reduction isn’t for everyone. If it’s not for you, consider whether to pursue infertility treatments at all, since outcomes can be unpredictable. Unwillingness to reduce could result in loss of all fetuses, and jeopardy to the health of mother and babies.

A good doctor will explain all procedures and all the possible outcomes of infertility treatment. Choose a doctor based on schooling, recommendations, and success rate, not because you’ve heard he does what patients want. You’re paying for his expertise; if he gives advice, take it. Emotionally, it may not be the advice you want, but logically, remember he’s taking your health, and that of your potential children, into account.

Linda Cassar is a registered nurse who works with high-risk new moms and infants in a major medical center in northern New Jersey.

June 2009