Twins and fertility treatments

The inability to have children has been around since the beginning of time. Kingdoms have been won and lost because queens have or have not produced an heir. Now despite advances in fertility options, the number of couples struggling to have a baby is on the rise.  Paradoxically, so is the number of twins. There were 8,081 twin births in Canada in 1993 and 11,559 in 2007.

And there's a twin wave sweeping Hollywood. Julia Roberts is credited with starting it back in 2004 when she was 37 years old and had Hazel and Phinnaeus (Finn). While Roberts has never said if her twins were born with any assistance from a lab, it has been widely reported that she and her husband had trouble starting a family.    

Twins conceived naturally happen 1 to 2 per cent of the time, as they always have.  But if a couple uses assisted reproductive technology, twins will be born more than 40 per cent of the time.

This is an issue for the health system because multiple pregnancies and births carry more risks to the mother and to the babies. Almost 70 per cent of all twins are born prematurely and/or with low birth weight. 

"Most twins are fine," says Dr. Keith Barrington,  chief of the neonatal unit at Sainte Justine University Health Center in Montreal. "But the risks for something going wrong are definitely higher."

Nevertheless, Dr. Clifford Librach, director of the Create Fertility Centre in Toronto says, "most parents see twins as a wow!"

Cathy, mother of twins Henry and Peter who turn one in May, 2011, says "I felt so lucky, I get two of something so great.  It was pretty special." 

At a lower end of the fertility intervention scale, a woman can use hormone enhancement drugs and conceive naturally. Any multiple pregnancies using this method cannot always be controlled. The highest level of intervention is in vitro fertilization or IVF whereby male sperm and female eggs are fertilized in the lab and then implanted in the woman. Doctors can decide how many embryos are implanted during IVF and there's a move afoot to reduce that number and thus the number of multiple births.

Canada and the U.S. have the highest rate of twin births from IVF in the world, Barrington says. Only Quebec has any regulation on the number of embryos implanted; that came into effect in 2010. Governments are being lobbied to pay for IVF treatments on the basis that infertility is a health problem. Experts advise them to do so if only a single embryo at a time is implanted in the mom like in Quebec. For their part, governments see potential savings in long-term health care when singletons are born versus multiples. 

A new study from Quebec, prepared before the IVF regulation and led by Barrington, demonstrates that if one embryo were transferred in clinics across Canada "there would be as many as 840 fewer babies admitted to the neonatal intensive care units, 40 deaths avoided, 46 fewer brain injuries and 42,400 fewer days of NICU hospitalization."

The study, released in April, found that 17 per cent of the babies admitted to the neonatal intensive care unit at the Royal Victoria hospital in Montreal resulted from some form of assisted reproductive technology. Seventy-five of the babies were twins or triplets whose mothers used IVF.

Barrington noted, "Among these 75 babies, there were six deaths, five babies who developed a brain bleed, and four babies who developed a potentially blinding eye condition." 

These are not statistics that parents want to hear. Nor do doctors. "We offer counseling on the risks with multiple births but we find no difference in their decisions," says Librach.

The data for the Quebec study was gathered July 2005 to July 2007. Barrington says that not even a year since Quebec began paying for IVF — single embryos with multiple cycles —  "we have suddenly become very efficient with the lowest twin pregnancy rate for any place in the world." 

Ontario received a report from an expert panel in 2009 that advocated much the same as Quebec has implemented. One recommendation says: "To maintain their accreditation, fertility clinics and centres must reduce their annual multiple birth rate to less than 15 per cent within five years and to less than 10 per cent within 10 years."  The report is still being reviewed. 

At the moment Ontario covers three cycles of IVF only in cases of two blocked Fallopian tubes. 

Governments making decisions about how many embryos should be implanted has the taint of a government crossing the threshold into the bedrooms of the nation.  Barrington says there are already all kinds of restrictions put on people's behaviour by governments and this is not any different.  "In many other walks of life, we force people to wear seat belts or to wear bike helmets.  With IVF, it's the mother's health, and another human being, or two.  We do have a right to try to control the situation."

The decision to try for twins is a very complex one.

Hollywood represents the very public face of the twin trend. Some of the stars delayed having children. Celine Dion, 42, has long been open about conceiving her first son with fertility treatments and wanting more children. She has said that twins Nelson and Eddy born in October, 2010, were conceived after six attempts using the frozen sperm of her husband.

Perhaps some Hollywood stars are so successful having twins because they can afford several cycles of IVF. The average cost of one cycle or an embryo implantation in Canada is about $15,000. This figure includes about $6,000 for hormone drugs that may be covered by some workplace insurance plans. 

The optimum time for women to have children is when they are under 35 years old. "It is very difficult for woman over the age of 42 to get pregnant," say Librach.

In fact most studies recommend that women over 35 be permitted to have two embryos implanted because their success rates for pregnancy even with IVF are so low. The average rate of live births after IVF is 31 per cent, but it is reduced as women get older. 

It is this daunting failure rate that puts families on an emotional roller coaster and often leads to the decision to implant more than one embryo implant and, when successful, leads to multiple babies.

The vast majority of couples have tried several other reproductive technologies before they end up at an IVF clinic. They were prodded and probed and had their sex habits thoroughly investigated and monitored. The woman had probably taken hormone enhancement drugs to encourage her body to release multiple eggs. They went for cycle monitoring which means numerous tests to determine "the right moment" and then were sent home to do what comes naturally. 

IVF is not easy.  "I had to stick myself with about 70 needles leading up to the egg extraction," says Cathy who had twins when she was 38, "and the egg extraction itself was very painful."

Most couples, given the choice, would rather have their dream family in one pregnancy, than go through the invasive fertility cycle multiple times. "It's such a long shot that even one embryo will take, we tried two to give us a better chance. It was a real bonus when we found out that both embryos were developing," says Cathy.

An ongoing issue is to improve the success rate so that parents can have one embryo implanted with more certainty of having a healthy baby. Some of the unknown lies in the quality of the woman's eggs. Older women, i.e. those over 40, often do not have good quality eggs.  It is suspected that in Hollywood many of the stars use donor eggs. 

A lot of research is focusing on ensuring the best quality egg is implanted and high-level tests are being developed in this area. Doctors have improved techniques to select the best eggs to fertilize in the lab. Many women opt for genetic tests as an additional check. As science gets closer to being able to choose "a good quality embryo," more challenges lie ahead for couples as they deal with the ethics of their choice.