As reported by The Hartford Courant, April 24, 2005.

Infertile Couples Resisting In Vitro Advances

By William Hathaway

Under the microscope, the 3-day-old embryo exhibits the telltale signs that make a fertilized egg a good candidate to become a baby.

Dr. John Nulsen, medical director of the Center for Advanced Reproductive Services at the University of Connecticut Health Center in Farmington, now will try to persuade an infertile couple to use only this embryo, the healthiest-looking one among several the couple has paid to produce through in vitro fertilization.

He knows it will be a hard sell.

At $12,000 or more per attempt at in vitro fertilization - in which an egg is fertilized outside the woman's body and then implanted in the womb - couples demand the best odds of getting pregnant. Often, that means pushing doctors to implant as many embryos as they can.

The health dangers - to both mothers and babies - of multiple births are well-documented. Yet the strongest resistance Nulsen faces in his crusade to reduce multiple births comes from infertile couples themselves.

"You tell [doctors] to bring out all their weapons," said Milford lawyer Anita Flannigan Steenson, who has spent $70,000 and lost tens of thousands in potential income in her pursuit of pregnancy.

As the nation debates the moral status of embryos and whether they should be used in research, fertility specialists have honed their ability to identify the most viable embryos for in vitro fertilization. Even so, every day in fertility clinics, where heartbreak or joy can hang on each decision, economics and desperation often trump ethical and health concerns.

"[Couples] tell me, `We can only afford one shot at this,'" Nulsen said. "They shove the multiple-birth issue far off to one side. I tell them they will have a greater risk of having twins or triplets, and they say, 'Good.'"

Problems With Pregnancy
Even as futurists warn of an impending era of designer babies, today's technology still cannot guarantee couples they can have their own genetic children, much less order up tall, intelligent or athletic ones.

Men's sperm still fails to impregnate, and the quality and quantity of women's eggs still decline with age.

"I must have been asleep in biology when they told us we run out of eggs," Steenson said. Now 42, she still has a baby sweater she bought when she was 21. "That's how long I have been thinking about this."

But when she was ready to have a baby in her 30s, she and her husband, Jim Steenson, found that they couldn't conceive. When she was 39, she finally sought treatment at Yale Reproductive Clinic.

Ten times she underwent intrauterine insemination, in which ovulation was induced medically and her husband's sperm was injected into her uterus. Her insurance covered six of these procedures, at a cost of about $3,000 each, and two produced pregnancies.

The first pregnancy ended in an early miscarriage. Tests taken on the second pregnancy revealed a boy with severe genetic abnormalities.

"They told me my son wouldn't survive long after birth," Steenson said.

The couple terminated the pregnancy.

Steenson then learned her health insurance would not cover in vitro fertilization - her final hope of having her own genetic child.

Steenson supports fertility clinics' efforts to persuade couples to limit the number of embryos they implant. But she understands why couples balk. The problem, she said, is that the high cost of the procedure forces would-be parents to take risks with their health.

Steenson said she knows one woman who, nearly broke after failing to get pregnant in several IVF attempts, insisted that doctors implant nine of her fertilized embryos. The woman had triplets, and all three of the children have health problems.

Now Steenson is trying to convince state lawmakers that fewer women will "go for broke" and implant multiple embryos if Connecticut mandates insurance coverage of fertility treatments.

Nine states - including New York, Massachusetts and Rhode Island - mandate coverage for fertility treatments, according to the Connecticut Office of Legislative Research. Connecticut requires insurers to offer coverage of fertility treatments, but in many cases companies don't include it in the plans they provide for their employees.

Sen. Christopher Murphy, D-Southington, co-chairman of the public health committee, said "the chances are great" that a bill mandating employer coverage of fertility treatments will be adopted by the General Assembly this session.

Just how generous those benefits will be - including the number of procedures, the lifetime dollar limits and so forth - remains unclear as lawmakers reconcile two bills approved in committees.

"I think every one recognizes the need to do this without bankrupting insurance companies," Murphy said.

How Many Embryos?
Success comes at a high cost when fertility treatments end in multiple births - and they often do. As recently as 1997, according to a 2004 study in the New England Journal of Medicine, among women under 35 who successfully underwent in vitro fertilization, 30 percent gave birth to twins, and 13.7 percent gave birth to three or more babies.

The cost of early hospitalization for a woman carrying triplets and subsequent care for babies born prematurely, as twins and triplets often are, can run into hundreds of thousands of dollars, Nulsen said. Anxiety and depression are common in new parents of twins and triplets, studies show.

Premature babies also are at higher risk than full-term babies of dying or developing a host of maladies early on and later in life, including neurological impairments, cognitive delay and behavior problems.

For Nulsen, the lesson was hammered home as he watched a couple in the UConn fertility clinic finally get pregnant with triplets, only to see all of the babies die.

"That was devastating," Nulsen recalled.

Fertility clinics are required to report their success rates, and so clinic staff sometimes feel pressure to improve the odds of a pregnancy by implanting a greater number of fertilized embryos. But in recent years, national statistics show they have reduced the number of embryos they implant per treatment cycle. While the rate of twins conceived in clinics has remained steady, the rate of triplets decreased to 8.5 percent in younger women by 2000, the New England Journal study showed.

At UConn, the rate of triplets now is below 5 percent.

Nulsen said the chief reason doctors at UConn have been able to deliver a better-than-average 35 percent live birth rate while at the same time cutting the number of triplets is through the subtle art of embryo selection. After years of observation, fertility doctors say that embryos that divide robustly, are symmetrical in appearance and exhibit the orderly arrangement of genetic material called nucleolar precursor bodies tend to be more viable. Nulsen and other doctors are quick to acknowledge that less visually pleasing embryos can also be brought to term, but on average these are less likely to become babies.

Nulsen now regularly advises women under 35 to implant only one, or at most two, embryos. As women age, more embryos are implanted because they are less viable. A woman under 35 has about a one-in-three chance of delivering a child after a monthly cycle of in vitro fertilization, but after age 40 the success rate plummets to about 7 percent.

Last year the American Society for Reproductive Medicine revised its in vitro fertilization guidelines, saying that no more than two embryos should be implanted in a woman under age 35 and "consideration should be given to transferring only a single embryo." Even for patients age 38 to 40 who have gone through previous failed in vitro attempts, the society urges that no more than four embryos be used.

Who Chooses?
The decision about how many embryos to implant sets off a chain reaction of ethical quandaries for couples to navigate: How many embryos should we create? How many should we implant? Should the embryos be screened for genetic defects before being implanted? If several embryos successfully implant, should we abort some? If so, how many?

The growing success of single-embryo implants prompts yet another question: What should we do if we have embryos left over - destroy them, donate them for stem cell research or give them to an "embryo adoption" program?

These wrenching questions show that society still needs to address fundamental ethical issues related to fertility treatments, said Gilbert Meilaender, a member of the President's Council on Bioethics and a professor of ethics at Valparaiso University.

"From one angle, it makes a certain amount of sense, that if you implant fewer embryos there is a better health outcome," Meilaender said. "But it is troubling in the sense that you are choosing against certain embryos. It is the beginning of a eugenics sort of mentality, and you are increasing the store of frozen embryos, which has already been allowed to get out of hand. Both are disturbing things to have happen."

The Catholic Church opposes not only the use of embryos in research, but also in vitro fertilization.

"If the church says to a couple `you should have children,' that is a very different thing from saying that a parent has a right to a child," said Richard Doerflinger, deputy director of the secretariat for pro-life activities at the U.S. Conference of Catholic Bishops. "A child is not a thing you have a right to. He or she is a person in his or her own right."

At UConn, Mary Casey Jacob, a professor of psychiatry and obstetrics and gynecology, counsels many Catholics seeking fertility clinic services. She said that Catholic couples who ask their priests for advice are told that the church does not sanction fertility treatments. But the priests also tell them that the church loves children.

"Hundreds of Catholics have sat here and told me, `God wants me to have children.'" she said.

Jacob said the UConn clinic's staff puts limits on what it will do for couples. It will not help select a baby's sex - although the technology makes it possible to do so. The clinic also will not help a couple create a baby solely to provide potential medical treatment to an ailing sibling.

Meilaender said those issues are so fundamental to society as a whole that government should have a say on judgments made in fertility clinics.

"Society has an interest in the next generation produced," he said. "I do not think that it is a purely private matter, that couples have a right to produce a child, by any means whatever."

For now, most of the decisions do rest with infertile couples. And viewed through the prism of a desire to create a child, they do not seem so difficult, they say.

Caroline, 42, is the proud Litchfield County mother of a 4-month-old daughter conceived by the laboratory union of her husband's sperm and a donor's egg. Because her parents do not know how her daughter was conceived, she asked that her real name not be used.

"I did not feel embroiled in a mass of difficult ethical decisions," Caroline said. "When you are going through it, your heart is the guide."

For Steenson, her heart tells her to keep trying to get pregnant, even though her mind tells her the odds are stacked against her and her husband.

The failure to produce a child has created a bitter void in her daily life, one she now tries to fill by lobbying for insurance coverage for fertility treatments.

"This has come close to ruining my life," Steenson said. "I don't want what happened to me to happen to anyone else."

How long will she keep trying?

"Until it happens."