Twice as Nice?

There’s nothing more glamorous than multiples. Signs of society’s fascination with them emerged as early as 1934 when the Dionne quintuplets — the world’s first known quintuplets that survived past infancy, and the only recorded all-female quints — were born in Callander, Ontario. Our current obsession with Jon & Kate Plus 8, the Octomom and the Jolie-Pitt twins are modern evidence of our fascination with multiple births.

While most parents admit that six to eight kids at a time would be impossible to handle, many still believe that having twins would be a charming experience.

“It’s very heart wrenching to see two beautiful children walking down the street with their mother,” says Dr. Albert Yuzpe, co-founder and co-director of Genesis Fertility Centre in Vancouver. That, according to Yuzpe, can present a problem when it comes to patients seeking In Vitro Fertilization (IVF).
Women who cannot naturally conceive with their partner undergo IVF for a variety of reasons, including blocked fallopian tubes, endometriosis (a condition in which cells meant to be inside the uterus develop outside of it) or low sperm count. The IVF process retrieves eggs from the body and fertilizes them by sperm in a dish. Ideally, a few days later, a number of good quality embryos will have formed. The number of embryos that are then placed back into the patient is determined by the woman’s age, and often, patient preference. Hopefully, this results in pregnancy, and often, because of multiple-egg replacement, IVF can cause twins or triplets.

In order to reduce the number of unwanted multiple pregnancies, Yuzpe hopes to pioneer the replacement of just a single embryo at a time, as it almost totally eliminates the risk of twins. The ideal candidates for elective single embryo replacement are what he calls “good prognosis patients,” women under 37 who have a good chance of becoming pregnant.

“We want to reduce the health risks associated with multiple pregnancy and we’re also thinking of the health-care costs that are saved as a result,” says Yuzpe. He believes that by reducing the number of multiples — and thereby reducing the costs associated with the many complications that can arise — the IVF community would have an argument to convince the B.C. government to provide IVF funding.

“In Quebec they are now, I think, prepared to undertake funding for IVF and Ontario has a commission that they put together, and [the government] is looking favourably at it. If the two largest provinces in the country are prepared to do it, why shouldn’t everybody else?” says Yuzpe.

While IVF continues to go unfunded, making it very expensive for the patient, couples generally hesitate to implant just a single embryo. “When people pay, they want the absolute best outcome — they want that extra one or two or three per cent chance that they’re going to be pregnant,” says Yuzpe. “They want the best bang for their buck, but we want this to be the best bang for the baby’s health, because our job is not to get patients pregnant; our job is to get patients to have healthy babies and that doesn’t always go together.”

Healthy twins are born all the time, but the risk of complication is extremely high when compared to single babies. Multiple pregnancies often result in smaller babies, prematurity, and, says Yuzpe, six times the risk of cerebral palsy for at least one of the babies in a twin pregnancy (this increases to 16 times the risk in a triplet pregnancy). “We have many patients that walk in and say, ‘We want to have twins,’” says Yuzpe. “And that’s because I don’t think the public really understands what twins represent medically and socially and emotionally.”

Though she’s convinced now that single embryo replacement is preferable, a few years ago, Laura Nightingale wouldn’t have agreed. It was her and her husband Ken’s third and final attempt at IVF; the first two tries didn’t take and she didn’t have any extra eggs on reserve. “Throughout the whole thing I would have definitely implanted four because you don’t know any better and you’re desperate,” she says.

Nightingale’s fallopian tubes were blocked, so in 2007 under Yuzpe’s care, she underwent IVF. Because she was less than 35 years old, the maximum number of embryos Yuzpe would implant was two. On their third attempt, Nightingale became pregnant with triplets, but within a week of finding a third heartbeat, she lost the third baby. She ended up carrying twins. “People think, the more you implant the better chance and they probably think, ‘If I have twins, great, because I don’t want to go through this again and that would be like killing two birds with one stone.’”

But having twins, says Nightingale, is extremely difficult, and not nearly as attractive as the media makes it seem. “I was the first one who thought, ‘As long as I have a kid, no problem,’” says Nightingale. “But it’s harder than people think: double the work, double the feeding, double the strollers, double the high chairs, double everything.”

It’s especially difficult if you can’t afford assistance or if you don’t have any close relatives living nearby and willing to help. “Having twins could be the beginning of the end of a lot of things, including sanity,” she says, only partially joking. “Every movie star under the moon has the money to manipulate multiple births but they can afford ten nannies for each child. When you can’t afford that, it’s not glamorous.”

In addition to the financial and emotional strain came the physical toll Nightingale’s pregnancy took on both her and her babies. During her pregnancy, Nightingale suffered from pre-eclampsia (hypertension) and placenta previa — a condition in which the placenta hangs very low, causing bleeding and other complications. “In my case, there wasn’t enough blood flowing to their umbilical cords,” says Nightingale. As a result, one of her babies, Jalen, had difficulty growing and at birth weighed only one pound, 15 ounces. Jalen’s twin sister, Kayla, was two pounds, six ounces. They were born at 30 weeks and were incubator babies, spending the first four months of their lives in the hospital. Nightingale herself was on strict bed rest for 10 weeks.

At two weeks old, Kayla developed necrotizing enterocolitis (NEC), a gastrointestinal disease that resulted in an operation and three-week coma, from which she recovered. Jalen has chronic lung disease as a result of being on a respirator for so long.

Now, Nightingale’s health is good, and at 19 months, so is the twins’, relatively speaking. She and Ken take great joy in their children, but Nightingale cautions prospective parents about hoping for multiples. “Let nature take its course and inseminate one egg,” she says. “You know you can repeat the process later, and you don’t need two at once.”

Yuzpe agrees. And he says he’s shown that single-embryo replacement is successful in good prognosis patients. “In our clinic we showed that it gave us a pregnancy rate in the range of 60% in that select group of patients and no multiples,” he says. “I’m not saying that more than one embryo is bad; I’m saying that in the select group, one embryo is better.” •

Genesis Fertility Centre, 1367 West Broadway Ave., Vancouver, 604-879-3032, genesis-fertility.com