Worried by an explosion of multiple births that now includes the world's first set of surviving octuplets, physicians are calling for more careful use of fertility drugs.
Doctors at the American Society for Reproductive Medicine, the country's leading group of fertility specialists, are working on guidelines to improve the monitoring of women on fertility drugs, provide more education for doctors and patients, and possibly regulate physicians to ensure they have the appropriate training.
The guidelines would urge doctors to routinely take measures that would limit multiple pregnancies to triplets.
The steps include avoiding pregnancy if too many eggs are produced, or switching to in-vitro fertilization, a method that enables doctors to control the number of embryos.
These practices are not being used widely enough, said Dr. Marian Damewood, who serves on the society's board of directors.
The octuplets are the most recent and extreme example of a disturbing trend, she said.
"We do not consider this a success," said Damewood, a fertility specialist at the Greater Baltimore Medical Center.
The concern arises from the risk: The more fetuses a mother carries, the higher the risk to all.
The infants are virtually always born prematurely, with underdeveloped organs. They face numerous health problems, including lung disease, brain damage and vision impairment. They often die.
Members of the American Society for Reproductive Medicine are likely to vote on the guidelines when they meet next month in Washington. The guidelines essentially would become national standards -- intended to advise doctors, although they would not have the force of law.
The octuplets remained in critical condition yesterday, seven of them breathing with the assistance of mechanical ventilators. All were being kept under plastic blankets and on warming beds, and were being given a substance called surfactant to prevent ** potentially fatal lung disease.
The largest infant, a boy, weighed 26 ounces. The smallest, a girl, weighed 10.3 ounces and measured just under 10 inches. "She is approximately the size of a Beanie Baby toy and can fit in a woman's hand," said a hospital spokeswoman.
The mother, Nkem Chukwu, was improving after surgery to stem internal bleeding, said her chief obstetrician, Dr. Brian Kirshon of St. Luke's Hospital, and she could be home for Christmas.
The rate of multiple births consisting of triplets or larger combinations has doubled over the past decade and increased fourfold during the past two decades.
In 1996, there were 560 quadruplet births and 81 higher-order multiples in the United States, according to the National Center for Health Statistics.
In large part, experts blamed the increase on the growing popularity of fertility procedures: drug therapy as well as in-vitro fertilization. Both techniques increase the risk of multiple pregnancies.
Doctors performing in-vitro fertilization combine a mother's eggs and a father's sperm in a dish, then implant several embryos in the womb in the hope that at least one develops into a fetus.
Drug therapy involves the use of two hormones: one to stimulate the production of eggs and another to trigger the release of eggs into the uterus.
Both techniques present a higher risk of a multiple pregnancy, but the risk is lower with in-vitro fertilization because doctors can control the number of embryos they implant.
Under existing guidelines of the American Society for Reproductive Medicine, doctors are encouraged to implant no more than three in women 35 and under, and four in women 35 to 40.
But with drug therapy, the risk is higher because physicians have only incomplete control over how many eggs are produced and then released.
The guidelines would lay out steps doctors should take to prevent too many embryos from developing. Damewood says doctors can withhold the second medicine, thus ending the treatment for that month.
They can also shift to in-vitro fertilization -- the physician would remove all the eggs, fertilize them, and then implant only three in the uterus.
These guidelines could prove controversial because they would
call for more frequent use of in-vitro fertilization. That procedure costs an average of $8,000, compared with about $2,000 for drug therapy alone.
Damewood said the guidelines should help fertility specialists resist pressure from patients so desperate to have a child that they are willing to accept the high risk of multiple births. When insurance companies cover only one round of fertility drugs or in-vitro fertilization, patients often push for everything in their one chance.
Fertility clinics share the blame, critics say. Eager to demonstrate high pregnancy success rates, they often are too aggressive, said Lori Knowles, a bioethicist at the Hastings Center, a think tank in Garrison, N.Y.
Dr. Sidney Wolfe, director of the Public Citizen Health Research Group, said clinics are not encouraging younger couples to try natural methods such as timing intercourse for the most fertile time of the month.
"These are drug-induced adverse reactions," Wolfe said of the multiple pregnancies. "There is little doubt in my mind that a number of women who go to these clinics have not had an adequate trial of nonpharmacologic ways of conceiving a child."
In the Texas case, the woman and her husband, Iyke Paul Lewis, have been trying to have children for some time. Earlier this year, she miscarried triplets after 21 weeks. Then, she became pregnant for a second time -- again after taking fertility drugs.
Texas Children's Hospital, where the infants are, declined to say who had treated the patient with fertility drugs and how closely she was monitored.
Officials did say the mother had refused the option of selective reduction -- aborting some fetuses to improve the survival chances of others -- for religious reasons.
Pub Date: 12/23/98