For more than a year, Cristy Hefner and her husband tried unsuccessfully to conceive on their own. The year after that was filled with tests, infertility treatments and tears for the Minooka couple.
They wanted a baby so badly that they stored the sperm of Hefner’s husband, allowing her to undergo a third attempt at in vitro fertilization and finally get pregnant while he was deployed in Iraq.
He was serving overseas during most of Hefner’s pregnancy, making it home just 10 days before she delivered their healthy twins.
“Because of the fact that I was trying so hard, two were just a blessing,” she said. “Each day is an adventure. It’s exhausting but so much fun. It’s worth it.”
Like the Hefners, more and more couples have been seeking the help of infertility treatments regardless of the increased odds of birthing more than one baby at a time. This phenomenon – and the fact that women are bearing their children later in life – has led to what’s been called “an epidemic of multiple pregnancies,” according to a Centers for Disease Control and Prevention report released last month.
From 1980 to 2009, the twin birth rate in the United States rose 76 percent, from almost 1.9 percent to about 3.3 percent of all births, according to CDC data. The birth rate of triplets and other higher-order multiples increased more than 400 percent during the 1980s and 1990s but has been fluctuating since hitting a 1998 high.
The increase in multiple births is concerning because it means more babies face elevated health risks, such as preterm birth and low birth weight, experts said. When babies aren’t carried full term, their organs are less likely to be fully developed.
“It was a big rise, and we needed to understand what caused it and respond,” said Dr. Ralph Kazer, chief of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine. “The clear focus is on the well-being of the babies. If you have twins, you’re more likely to deliver early.
“When you look at it as a public health issue, you’re talking about a lot of sick babies.”
Because of the rise in the twin birth rate, about 865,000 additional twins were born in the United States during the 30-year study period, according to the CDC. More than half of these babies had a low birth weight, and one in 10 were born at a very low weight.
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The decreased gestational age and smaller size of infants born as multiples makes them eight times more likely to die within their first month, according to CDC data.
“We just really need to decrease the rate of multiples as much as we can,” said Dr. Meike Uhler, reproductive endocrinologist with Fertility Centers of Illinois. “Every time there is an additional baby in the uterus, there is an increased risk.”
Tina Sharma, who delivered premature fraternal twin girls in June, said her babies still are struggling with problems that stemmed from being born before their gastrointestinal and neurological systems were fully developed.
Although there have been some improvements with time, they still don’t eat or sleep like most babies their age, the Warrenville mother said. For instance, they can’t take a bottle while being held. Each has to be laid down on her side on a fixed surface and have the bottle held a special way. Even then they can only handle a small amount at a time with breaks in between gulps, she said.
One baby has difficulty with sensory input and is easily overwhelmed by her environment, she said. Both girls have difficulty falling asleep and sleeping uninterrupted. At about 8 months old, they each still wake up three times a night.
“I love my two girls ferociously, but if I had my choice, I would choose for them to have been born one at a time from two separate pregnancies,” Sharma wrote in an email. It’s “not just because it would have been easier on me and my husband and our extended family, but mostly because it just seems more fair to the babies.”
Approximately 10 to 15 percent of all couples of reproductive age who try to have children will run into difficulty conceiving, Kazer said. As age increases so does the likelihood of difficulty.
Fortunately, the availability, awareness and insurance coverage of infertility treatment has increased dramatically during the past three decades, he said.
Expanded use of infertility treatments likely accounts for about two-thirds of the increase in the twin birth rate from 1980 to 2009, according to the CDC’s January report.
Both popular types of infertility treatment increase the risk of multiple births, experts said.
The first is the use of fertility drugs to stimulate the ovaries to release eggs, Kazer said. This can help women who don’t ovulate on their own or couples attempting artificial insemination after trying unsuccessfully to conceive. In either case, the drugs can cause the release of more than one egg, increasing the chances of a multiples pregnancy.
In an attempt to reduce the number of multiple births, there has been a shift away from using injectable medicines to stimulate ovaries, Kazer said. Injections can cause significantly more eggs to be released than medicines in pill form do.
The other type of infertility treatment is in vitro fertilization, where the eggs and sperm are combined outside the body and at least one embryo is then placed in the uterus. The more embryos transplanted, the more likely a successful pregnancy, but also the more likely the woman is to get pregnant with multiples.
“We are recognizing the importance of minimizing the number of twin pregnancies that we generate,” Kazer said. “Certainly during the last five to 10 years there’s been a major focus on appropriately limiting the number of embryos transferred.”
Guidelines from the American Society for Reproductive Medicine first published in 1998 suggest how many embryos should be transferred based on age of the woman and quality of the embryos.
Because Faith Babbitt’s embryos were “not outstanding quality,” doctors transplanted two, she said. The day of her 6-week sonogram she and her husband learned that one of the embryos had split; Babbitt was pregnant with three babies.
Warning the Evanston couple that a triplet pregnancy could be very dangerous for the babies, the doctor immediately suggested selective reduction, or aborting one of the embryos, Babbitt said. But the couple found that option “unacceptable.”
After a rocky pregnancy of only 26 weeks, Babbitt delivered three baby girls weighing just over 1.5 pounds each, she said. One needed eye surgery and was diagnosed with pulmonary hypertension and chronic lung disease. Another had to have heart surgery. All three were put on ventilators and treated for jaundice.
One of the triplets spent three months in the hospital; the other two made it home after four. They just celebrated their second birthday.
“It was a lot, and it was a miracle getting them here,” Babbitt said. “At the end of the day, they are at or exceeding where they should be developmentally. They’re amazing, strong girls. No matter how hard it was, I would do it three times again to have them here.”
In response to pregnancies like Babbitt’s, single-embryo transfers are becoming more and more the norm, experts said.
Since 2007, Fertility Centers of Illinois, which has clinics all over Chicagoland, has performed 605 single-embryo transfers, Uhler said. At the two-week mark, 70 percent of the women in those cases had positive pregnancy tests. At six weeks, when the heartbeat is present, 62 percent had maintained the pregnancy.
“We all have been trying to go to single-embryo transfers, especially when the patient is young,” Uhler said.
Efforts to reduce multiple births associated with infertility treatment may be working, experts said. Since 1998, the birth rate of triplets and other higher order multiples has generally trended downward, according to the CDC. In 2009, the birth rate of higher order multiples was about 20 percent lower than the 1998 high.
The twin birth rate continues to increase, but the pace of increase has slowed, according the CDC. From 1980 to 2004, increases in the twin birth rate averaged more than 2 percent a year. From 2005 to 2009, the rate rose by less than 1 percent a year.
Still, there is an element to the equation that is completely out of the hands of the fertility doctors.
About one-third of the total rise in the twin birth rate the past three decades is attributed to a general shift of women having their children later in life, according to the CDC report. In 1980, only about 20 percent of all births were to women aged 30 and older. That age group accounted for more than 35 percent of births from 2000 to 2009.
The older maternal age at childbirth is significant because historically women in their 30s have higher spontaneous (unaided by infertility treatment) twinning rates, according to the CDC.
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“No one knows exactly why women over 35 are more likely to have twins,” Kazer said. “It’s probably related to some kind of change in the way their ovaries respond to hormonal stimulation as they age.”
One theory is that the amount of follicle-stimulating hormone a woman’s body produces increases with age in preparation for menopause, Uhler said. While some women are in their later reproductive years, the increased level of that hormone may cause more than one egg to be released at a time.
At age 35, Lisa Katzenberger conceived her twins without the aid of any fertility therapy. However, she wasn’t at all surprised by the multiple pregnancy, she said.
Born completely healthy at 38 weeks, her little boy and girl were the fourth set of twins to enter her family in two generations.
Although the Chicago mother has been around twins her entire life, she said nothing could have fully prepared her for the work it takes to parent a pair. Her children are about 17 months old, and there are still days she finds herself crying from the stress.
“However, I’ve never felt more satisfaction in my life than I experience now on a daily basis,” she said. “It’s fascinating, and at the end of the day even though I’m tired physically and emotionally, I feel like I witnessed something special and accomplished something important.”