Twin births: Double the joy, double the woes U. of U. tries to lower twin rate, offers incentive for single births

Heather May

Jul. 28, 2008 (McClatchy-Tribune Regional News delivered by Newstex) -- After 2 1/2 years of trying to have children, Kara and Troy Egan decided to try in vitro fertilization.

The Salt Lake County couple hoped fertilizing Kara's eggs in a lab and implanting them in her uterus would bypass problems caused by her endometriosis and give them one baby. But considering the emotional, physical and financial toll, there was no way they were going to transfer just one embryo and risk it not surviving.

The doctor implanted two, and today the Egans have 3-year-old twins.

Utah was recently highlighted in a CDC study of how many IVF pregnancies result in multiple births -- while the national average in 2005 was 49 percent, Utah and three other states tied for the highest percentage, at 56 percent.

There are a couple of reasons why: Utah's busiest infertility clinic, at the University of Utah, has a high twin rate. It implants an average of two embryos and both are more likely to survive because it does a good job, according to an unaffiliated expert.

Plus, most Utah insurance companies don't cover IVF, so it makes more financial sense to parents to have twins than have two pregnancies. And twins may be exactly what a couple struggling to start or complete a family wants.

"That was our payday for everything we had been through. I can't imagine not having one of them. They're just best friends," Kara Egan said of her spunky Kassidy and shy Kalli, who have an older brother and an unexpected younger sister.

But the U. is about to enter an international debate about whether having twins is a good idea.

Already skilled at reducing the number of more risky triplet and quadruplet births by implanting fewer embryos, the Utah Center for Reproductive Medicine is now trying to drop its twin rate by crafting incentives to encourage single births -- because those are healthiest for mothers and babies.

"We don't like multiple pregnancies," said C. Matthew Peterson, chairman of the U.'s department of obstetrics and gynecology and an infertility doctor at the clinic. "We have a program that will encourage couples to choose one [embryo]."

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Weighing the costs: The proposed incentives have not yet been approved by the U.'s Institutional Review Board, which must examine research involving humans, so the details are not yet available.

But today there is a clear financial incentive to implant more than one embryo at a time. Including the consultation, medications and egg retrieval, it costs $10,570 for IVF at the U., regardless of the number of embryos transferred.

If a couple transfer one and it doesn't survive, or if they want another child later, they spend at least another $4,300 to implant a frozen embryo.

Janie Wilson, operations director over women and newborn programs at Intermountain Healthcare's hospitals, said a group of Intermountain and U. doctors have tried, and failed, to persuade insurance companies to cover IVF, mainly out of concern for the health and financial cost of higher-order multiple births like triplets. She said if the state's biggest insurer, SelectHealth, would cover it, others would follow.

The insurer, a subsidiary of Intermountain Healthcare, covers diagnostic testing, infertility counseling and some treatments, but not IVF. "It is an industry standard that IVF is not typically covered," said Jason Burgess, SelectHealth's spokesman.

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The trouble with twins: Twins are at a higher risk of being born too early, too small and have a five-times greater risk than single babies of dying within a month of life, according to the CDC. Utah hospitals have had to add newborn intensive care units as multiple births increase: The twin rate has nearly doubled since 1989 because of IVF, ovulation-induction drugs like Clomid and aging mothers.

According to IHC data, about 15 percent of twins delivered in its system arrive at least seven weeks early. The most premature will cost $277,000 per child in hospitalization costs. Even when twins are born on time, they're more expensive: $3,000 per baby compared with $2,300 for a single delivery.

"These kids are usually a little bit smaller," Wilson said. "When you have a kid that's a little bit smaller, they don't have as strong a suck. They're more at risk for low blood sugar that would require intervention. They don't feed as well, which leads to developing jaundice."

But Keith Blauer, an infertility doctor at the Reproductive Care Center in Sandy, said most of his patients want twins. "They don't understand the complications or increased risk of C-sections or need oftentimes for bed rest. They just think it would be cute and fun to have twins."

J. Ross Milley, chief of the neonatology division at the U., Intermountain Medical Center and Primary Children's Medical Center, said infertility treatments are "job security" for doctors like him who specialize in ill newborns. "It's a medical burden we all share," he said.

Amy Kermath conceived twins, who are now 1, using Clomid. The Salt Lake County mother wasn't prepared to deal with the smaller one's medical problems. Weighing a little less than 5 pounds when he was born, Parker had trouble breathing and with his kidneys, and spent time at Primary Children's.

Today, Parker is still smaller than his twin, Connor, but he dominates his larger brother, stealing his bottle and patting him on the back when Connor takes a tumble.

Even after cleaning up double the diarrhea when her twins got rotavirus, Kermath said they have saved her health in other ways. She no longer stresses about her fertility. "If this is where I stop, I feel like I've got a family."

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A twin debate: Unlike Parker, most twins are born healthy. That's helped spur a debate about whether twins are a bad outcome. Some European countries that pay for IVF have mandated single embryo transfers. In the U.S., there are no legal mandates, but professional organizations have established voluntary guidelines that have driven down the triplet birth rate.

The guidelines suggest healthy women under 35 should consider using one embryo.

Infertility doctors at the New York Center for Human Reproduction have argued the guidelines shouldn't be mandatory or expanded. In a journal article, they noted the risk of a twin pregnancy is "relatively minor." And some women, particularly older ones, will not get pregnant if only one is implanted, the center notes.

Mark Hornstein, clinical director of the infertility clinic at Brigham and Women's Hospital in Massachusetts and president of the Society for Assisted Reproductive Technology, said his goal is to have "one healthy baby at a time."

After they receive counseling and a letter outlining the dangers of multiples, about 20 percent of his clients who are under 35 implant one embryo.

"We push them pretty hard," Hornstein said, noting that Massachusetts mandates insurance coverage of IVF.

Appropriate U. and Sandy patients are also advised to use one embryo, but only about 1 percent do. Ultimately, the decision is up to the couple, since they own the fertilized eggs.

"You just really want it to work. Anything you can do to [increase] your odds of it working, you want to do," said Jennifer Smith-Hardy, who conceived twins through IVF at the U. She now lives in North Carolina, along with her second set of twins, who were conceived naturally.

She's now glad the U. talked her out of transferring three embryos. "Having anything more than twins is almost unbearable."

hmay@sltrib.com

Newstex ID: KRTB-0192-26965407