Double trouble: Gen-X couples risk multiple IVF births

Tim and Katie Lenzi faced emotional and financial hurdles in the four years in which Katie struggled to get pregnant.

Miscarriage, failed in vitro fertilization cycles and the cost of treatment took a toll on the couple.

"The biggest thing is you feel alone when it happens to you," Tim Lenzi said. "You want to be a parent, you want to have a family and you feel, well, why did we get singled out?"

So in 2001, when their doctor consulted them about how many embryos they wanted to use in their next IVF treatment, they said they would use all four that were available.

Katie was 32 at the time and she ultimately gave birth to twins.

As IVF technology and treatments have improved over the years, doctors are advising women to transfer fewer embryos during each cycle.

An IVF cycle costs about $15,000 and is not always covered by insurance, said Dr. John Rinehart, director of reproductive endocrinology and infertility at Evanston Northwestern Healthcare.
Subsequent cycles using frozen embryos can cost about $5,000 to $6,000, he said.

Guidelines published by the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine advise most women under the age of 35 to have a maximum of two embryos transferred.

As the procedure has become more successful, the risk of multiple births when using multiple embryos has risen.

But when patients like the Lenzis, who live in Libertyville, weigh their chance of having quadruplets against the chance of not getting pregnant at all, they often opt to use more embryos.

"Katie and I looked at each other and just said almost in unison 'We'll go for it." Tim Lenzi said. "Let's go for the home run, swing for the fence and put all four in there."

IVF past and present

For each cycle, a doctor collects eggs from a woman's ovaries. Those eggs are fertilized outside the womb and allowed to develop for a few days. Some or all of the resulting embryos are transferred to the uterus.

When doctors first began using IVF in the late '70s and early '80s, the first and last steps were done surgically, Rinehart said. He has been performing IVF for 25 years.

"All the procedures had to be done in the operating room," he said. "It was a huge task."

Thanks to new technological developments including the vaginal ultrasound, women now are able to complete the entire procedure without going under the knife. As drugs and techniques evolved, success rates have risen.

"In the early days," Rinehart said, "if you had one in 20 people get pregnant from IVF that was a great program."

In 2005 about seven in 20 IVF patients became pregnant in the U.S., according to a report published last year by the Centers for Disease Control. About 80 percent of those pregnancies resulted in a live birth.

The percentage of embryo transfers that resulted in live births rose for women of all ages between 1996 and 2005, according to the CDC.

Improvements to the fluid in which embryos are grown have allowed doctors to let them develop longer, usually five days. With more developed embryos, doctors can better identify the ones most likely to survive. Embryos with a greater number of cells are more likely to result in a pregnancy.

Doctors can also remove a cell from a developing embryo to test its genetic makeup, which can reveal potential abnormalities.

But that procedure is "not really ready for prime time," Rinehart said. "For the most part, everybody's relying still on morphology," the study of the physical attributes of the embryo.

Some worry the procedure of removing one cell from the embryo could damage it. Others argue the test has not led to improved delivery rates.

More embryos, more risk

The selection of embryos has improved to the point that more than 40 percent of assisted reproductive cycles conducted in 2005 involved the transfer of just two embryos.

Sue Bonk of Prospect Heights had eight embryos transferred in a single cycle after she started treatment in 1996.

"Back then they transferred anything - even things that shouldn't have been," such as poorly developed embryos, said Bonk. She leads a support group associated with RESOLVE, a national fertility association.

Bonk and her husband went through four IVF cycles before the fifth one, in which two embryos were transferred, resulted in a pregnancy. She now has a 6-year-old son named Keegan.

Transferring multiple embryos raises the possibility of a high risk, multiple-birth pregnancy. Risks include higher rates of caesarean sections, premature births, low birth weight and infant disability or death.

The Lenzis experienced firsthand some of the trauma that can accompany these pregnancies.

"At about 11 weeks pregnant we were with the high risk OB/GYN group," Tim Lenzi said. "[Katie] experienced heavy bleeding and discharge, and after having gone through a miscarriage we said, 'Oh my God, here we go again.'"

Katie had lost two of the embryos, but an ultrasound in the emergency room picked up two heartbeats.

The Lenzis eventually had twins, Megan and Dan, who will be seven in December.

Some countries regulate the number of embryos a couple can transfer, but the U.S. has no such rules. Standards vary at clinics and many considerations are taken into account, said Dr. Brian Kaplan of the Fertility Centers of Illinois [1].

"If the embryo looks beautiful and she's 29, you might put in just one embryo," he said. "If she has a history or the embryos don't look good, you might want to put in a third."

Generally, the older the patient, the more embryos are transferred.

A CDC study showed the average age of women using assisted reproductive services in 2005 was 36. About 40 percent of patients were under 35 and about 20 percent were older than 40.

Guidelines state the goal of assisted reproduction should be "the birth of a single, healthy child." Nevertheless, they state that many couples view multiple birth pregnancies as "desirable" and are "unaware of the risks they pose to both mother and babies."

"It's a hard sell [to implant fewer embryos], to be honest with you," said Rinehart. "They want to be pregnant. That's their focus."

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Embryos on ice:

Once a woman says yes to in vitro fertilization, a new set of questions emerges.

One especially troubling question is: What do you do with unused embryos created in the process?

That decision affected 400,000 cryopreserved - or frozen - embryos in the United States in 2002, according to a study by the Society for Artificial Reproductive Technology.

Lisa Peterson of Chicago said in the end she could not decide. She underwent eight IVF cycles over a period of about five years.

"We ended up choosing [that] the clinic could decide the best way to use them," said Peterson, a member of RESOLVE, a national fertility association.

For patients like Sue Bonk of Prospect Heights, freezing embryos has offered another chance at IVF if the first cycle is not successful.

Bonk, now 48, underwent four cycles before using two frozen embryos in the fifth, which succeeded.

She now has a six-year-old son, Keegan. His embryo had been frozen for about four weeks before being transferred.

Bonk said she used all of her frozen embryos, but that if she had had any more, she would have tried to become pregnant again.

"I wanted more than one child," Bonk said. "I'm blessed to have one, but I wouldn't have even thought about it. It would have just been, 'OK, let's go.'"

Most of the frozen embryos tabulated in the 2002 study - 340,762 of them - were being held for patient treatment.

Just over 2 percent were waiting to be destroyed per patient request and the same amount were waiting to be donated to another patient.

Of the embryos in the 2002 study, about 11,000 - 3 percent - were set aside for research.

But the questionable quality of the preserved embryos and the losses common in the freeze-thaw process mean that many of them will be unusable.

Researchers estimated that in the unlikely event they were all used for stem cell research, those 11,000 embryos could create at most 275 stem cell lines.

Many couples are uncertain what to do with frozen embryos, according to another study released in 2004. It focused on 31 women and seven couples from the reproductive endocrinology clinics at Duke and Johns Hopkins Universities.

Most of the respondents said that donating embryos to research was important, but only 14 of them planned to donate their own.

The same number said they were unsure what they would do.

According to the study, some participants said they felt none of the options available to them were ideal.

Tim Lenzi of Libertyville said he and his wife, Katie, chose to use all four viable embryos created when Katie underwent IVF in 2001.

"In one sense it was because of our reluctance to get into freezing embryos," Lenzi said. "It was an issue that made it easy to go for the home run and put all four in for the transfer."

As IVF practices have improved, so have techniques in freezing unused embryos, said Dr. John Rinehart, director of reproductive endocrinology and infertility at Evanston Northwestern Healthcare.

"Embryos we're freezing now have much higher viability," Rinehart said. "I've seen calculations that have said they'll last 2,000 years."