Multiple births stir call for controls on fertility

Seven tiny babies cling to life in a Houston hospital, remaining members of what had been the world's first surviving octuplets. They have the strong faith of their mother, the support of their father and the local community, which has donated everything from groceries to baby wipes, and the prayers of many around the world.

But the multiple birth is also raising deep ethical questions about reproduction and concerns about the lack of government regulation. Many doctors, in fact, now argue that there should be restrictions on reproductive technologies and changes in a health-care system that often results in women taking bigger medical risks to bear children.

If something isn't done, some experts say, the Houston births - and last year's McCaughey septuplets - will lead to false confidence in a medical technology that comes with no guarantees.

Already, the use of drugs and other reproductive technologies has led to a boom in the delivery of triplets, quadruplets, and other higher-order multiple births in the US.

"We're pleased this couple is going to have good children," says Benjamin Younger of the American Society for Reproductive Medicine in Birmingham, Ala. But "we don't look at this as a good thing.... The focus should be on trying to have single pregnancies."

"It's a wake-up call that regulation, guidelines, limits on reproductive technology are way overdue," adds Arthur Caplan of the Center for Bioethics at the University of Pennsylvania in Philadelphia.

Few specialists believe such changes will take place anytime soon. Social dynamics are partly to blame. Although the rate of infertility has not gone up, a larger share of US women is putting off child-rearing until later years, when doctors say pregnancy becomes more difficult.

To aid the process of getting pregnant, an increasing number are turning to a fast-growing branch of medical science called assisted reproductive technology, or ART.

Arithmetic of reproduction

Fifteen percent of the 60 million American women of reproductive age in 1995 used some kind of infertility service compared with 12 percent in 1988. Childless women aged 35 to 44 were the most likely to use such services, typically medical advice, tests, and drugs. Couples who go that route often find that ART can be expensive.

For example, patients at the Partners in OB/Gyn in Providence, R.I., usually go through routine screening for infertility. If doctors find no problem, they chart options. About one-fifth go on to use fertility drugs, typically low-level drugs costing $400 to $500 a month. If that treatment doesn't work, couples often move to much stronger fertility drugs, requiring daily injections and extensive monitoring.

"It's easy to spend $1,000 to $1,500 a month on drugs," Dr. Younger says. That' still less than half as expensive as surgical techniques, such as in vitro fertilization, where fertility drugs are also used. And often, insurance covers none or only part of such costs.

So financially as well as emotionally, the pressure mounts to have a child quickly and, at times, forgo some of the monitoring, he adds. Typically, one-quarter of women who become pregnant with the drugs can expect to have more than one baby at a time. The challenge is that there is no way to predict how many more children the drugs will produce.

That is why multiple births are skyrocketing in the US. The rate of twin births grew 37 percent from 1980 to 1996, according to the latest data from the US Department of Health and Human Services. The number of live births in triplet, quadruplet, quintuplet, and other multiple deliveries rose 344 percent during the same period. In 1980, there were slightly more than 1,300 such births; in 1996, there were 5,939 - an all-time high.

That would not be bad necessarily, except that the babies often don't survive. At press time, seven of the eight babies born to Nkem Chukwu in Houston were still alive. But several other women in the US and abroad, who have carried that many children, have lost some or all of their babies.

To save some of the children, doctors routinely suggest aborting some of the fetuses - a difficult choice for any parent. "We try not to impose our religious views on patients," says Tawfik Hawwa, a doctor at Partners in OB/Gyn in Providence. "Whatever decision they make, they're not completely at peace. But they realize they're decisions that need to be made.... We stress to them that we will treat them no matter what."

Call for more controls

But is it enough to educate parents on the risks of multiple births and, when that slim possibility occurs, leave them the agonizing choice of risky delivery or selective abortion?

Some doctors say it is. "As far as technology ... I don't think it needs any limitations," says Dr. Hawwa. "It's just another treatment in infertility. [Otherwise] where do you draw the line?"

"Overall many couples benefit from this" technology, adds Younger. But he criticizes the insurance industry for not covering ART as a mainstream medical practice and the federal government for its hands-off policy toward reproductive and contraceptive research. "Invariably it gets linked politically to abortion," he says.

Mr. Caplan of the Bioethics Center goes several steps further. He wants restrictions on who receives fertility drugs and how many embryos can be planted in women. He suggests a licensing body that would accredit ART specialists. (Currently, any doctor can become one.) And he urges the industry to set up rules for handling disputes over frozen embryos and ART procedures.

"The field needs some oversight from top and bottom," he says. "Reproductive technology is the closest thing we have right now to the Wild West."

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