Iowa Alumni Magazine | April 2009 | Features

Life Science

By Kathryn Howe
As the nation's latest multiple birth raises eyebrows about in vitro fertilization, UI specialists address the technology's promises—and misconceptions.
A gentle breeze rocks the red swing dangling from a tree in the front yard. Abandoned until spring, it sways especially bright above a fresh blanket of white snow. The swing gives up a secret about who lives inside this charming home with the green shutters: a child—a family.

The swing belongs to Alexander Brandt, all wild blond hair and goofy half-grins, born in June 2007 to Andy and Meredith Chappell. "He has changed our lives forever," Andy, 97JD, says of his almost two-year-old son. "And every day, we thank both God and science for his arrival."

Alexander is the Chappells' miracle baby, conceived through in vitro fertilization (IVF) at the University of Iowa's Center for Advanced Reproductive Care. A procedure that's realized dreams for countless hopeful parents like the Chappells, IVF is also a fertility solution vulnerable to intense scrutiny, as became evident this past January in the aftermath of the birth in California of 33-year-old Nadya Suleman's octuplets.

News that these babies were born to a single, unemployed mother with six other young children at home whipped the nation into a furor over the perils and ethics of the field—not to mention the taxpayer costs involved in the neonatal care of the premature infants. Public opinion vilified Suleman's doctor, who she claimed implanted the remaining six embryos left over from her previous IVF treatments. Even as fertility specialists pointed out that such an act represented a gross breach of medical guidelines, the debacle delivered a serious blow to the entire reputation of reproductive medicine.

One out of 100 babies born in the United States is the result of IVF. Using this procedure, women take drugs that mimic female hormones and stimulate the production of multiple eggs, which specialists then retrieve from the ovaries and inseminate in a culture dish. If fertilization occurs, the embryos incubate for an additional few days before the best—the most likely to grow—are placed inside a patient's uterus. Many people incorrectly assume that high-profile families like Iowa's McCaughey septuplets or the Gosselin brood on Jon & Kate Plus 8 are the products of IVF; in truth, these particular cases resulted from the combination of fertility drugs and intrauterine insemination, or IUI, a treatment that gives specialists less control over the number of babies. In IVF, many doctors take strict measures to reduce the possibility of multiple children—and perhaps no program in the country can surpass Iowa for making such efforts while also maintaining an exceptional pregnancy rate.

Established in 1987 as the state's first IVF program, Iowa's Center for Advanced Reproductive Care boasts a nationally recognized reputation for culturing and selecting embryos most likely to end in pregnancy. Like other U.S. fertility clinics, Iowa receives direction and oversight from the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology. While those organizations offer guidelines regarding the implantation of embryos—no more than two (in select cases three) in a woman like Suleman in her early 30s—the UI follows even stricter rules to ensure positive outcomes for mothers and babies. If a prospective mother meets certain criteria, UI doctors will only implant one embryo.

PHOTO: Reggie Morrow/ADPRO Design Little Alexander has brought joy, light, and love to the lives of Andy and Meredith Chappell, who turned to UI experts for help in dealing with fertility problems.

"Our goal is always one healthy baby, one at a time," says UI reproductive endocrinologist Brad Van Voorhis, 84MD, director of the center, which has helped facilitate more than 3,000 deliveries. "Multiples are a complication to be avoided. When I hear about octuplets, I wonder how careful that practitioner was in monitoring the mother."

Although mega-births grab headlines, most stories emerging from fertility clinics parallel the Chappells' journey. Says Meredith: "Most people just desperately want to be parents and can't for whatever reasons. They just want to be a family."

Inside the house with the red swing, smiling blue eyes peer over the arm of the living room couch, engaging Mom and Dad in the umpteenth game of peekaboo. Alex runs around with a sippy cup of milk in hand, bouncing a purple ball and chirping "hi."

That he's even here still amazes the Chappells, who first walked into the UI's Reproductive Endocrinology and Infertility Clinic four winters ago, shaken and uncertain about their chances of conceiving a child. They'd tried for a year on their own with zero luck. Meredith, 97BA, 97BS, 00JD, knew something was wrong and she blamed herself. However, a physical evaluation revealed problems for both Meredith and Andy. She had a partially blocked fallopian tube, and his semen analysis showed sluggish sperm motility and a below average count. "Slow and low," he jokes.

Such problems are far from rare. Infertility affects ten to 15 percent of all couples. In addition to blocked tubes and sperm issues, obstacles include absence of ovulation, endometriosis, uterine abnormalities—and even people starting families later in life. Sometimes, doctors simply can't explain why a couple fails to conceive. Whatever the diagnosis, the stress, grief, and heartbreak remain the same.

In their case, the Chappells began treatment slowly, one step at a time. After several failed attempts at IUI, doctors told them that they were excellent candidates for IVF. By this time, though, the Chappells had learned to greet optimism with skepticism. By this time, they needed laughter in the midst of despair—even dubbing their e-mail progress reports to close friends and family as "Operation Turkey Baster." Still, they began the laborious process: close monitoring of Meredith's menstrual cycle, shots of "super ovulation" drugs, ultrasound tests, probing, and waiting. Andy gave Meredith the shots of fertility meds in her hip and felt her every cringe.

On their first round of IVF, the Chappells stopped just short of the retrieval procedure after Meredith did not produce enough eggs. They tried again with a different drug protocol. This time, UI specialists retrieved ten eggs. Seven fertilized, but five later degenerated. The Chappells had two chances left.

The human uterus is designed to shelter one fetus at a time. Carrying many babies creates great physiologic stress on the female body, including high blood pressure and diabetes. Multiple babies typically arrive early and face a myriad of immediate health dangers, as well as long-range obstacles such as cerebral palsy, vision loss, and developmental and learning disabilities. In a bid to avoid such complications, the UI's IVF program follows a mandatory single blastocyst transfer policy—believed to be the only one in the country. A blastocyst is a five-day-old embryo comprised of 70 to 100 cells. Doctors will only implant one blastocyst in women aged 37 and under, as long as the embryo quality is considered "good" or "excellent" and the patient has not previously failed an IVF cycle.

The transfer of a single embryo can be a tough sell to patients who've tried so long to have a baby and who can't afford several rounds of a procedure that costs up to $15,000. Fortunately, this UI protocol boasts a stunning 70 percent delivery rate. Patients can also freeze their remaining embryos. Should the first "fresh" round fail, they can try again with a frozen embryo without the full-blown costs associated with starting completely over (fertility medications and egg retrieval comprise the lion's share of the price tag).

For women age 38 and older—or for younger women who don't have at least one "good" embryo—UI specialists may transfer up to two blastocysts. Never more than that.

Van Voorhis says he's hesitant to condemn any doctor whose patient ends up carrying several babies. Sometimes, despite doctors' attempts to control the situation, nature takes the steering wheel. Embryos can split inside a woman's body—or other unexpected events can occur. Van Voorhis once stared in astonishment at an ultrasound screen, counting six babies inside a uterus where he'd only implanted one embryo. He learned that his patients had sexual intercourse during the IVF process and some of the woman's eggs had fertilized naturally. The couple agreed to reduce the pregnancy to triplets—an agonizing decision for a couple eagerly anticipating children—and the event led to a new guideline suggesting patients abstain from unprotected intercourse for several days before egg retrieval.

Nonetheless, the story of the California octuplets exposed weaknesses in what many people consider a poorly regulated field—one not subject to the force of law. (According to the U.S. Centers for Disease Control, only 20 percent of fertility clinics actually follow the suggested professional guidelines.) Across the country, anger and judgment boiled over the ethics of how a doctor could treat a woman with a big family already; someone who lived in her mother's cramped house with no source of income. As one expert pointed out on in the days following the Suleman birth: "If you leave it up to the marketplace, there will be abuses."

Fertility doctors feel reluctant to call for laws, though, maintaining that legislation can interfere with the physician-patient relationship and their ability to provide individualized care. "I'm concerned any time federal or state laws become involved in medical decision-making," says Ginny Ryan, 03R, 06F, a UI reproductive endocrinologist with a research interest in bioethics. "Too many nuances, too many special circumstances arise from patient to patient." Instead, Ryan says professional organizations should exhibit more oversight and take tougher action against clinics that violate their standards.

To those who believe Suleman never should have received additional fertility treatment, Ryan replies: "[Doctors] aren't social engineers. We have to be comfortable medically with what we're doing, but it's not for us to determine who makes a capable parent or if someone is a better parent because she has more money. We can't say that a certain family size is enough. Plenty of typical nuclear families fall apart, struggle."

However, patients at the UI do undergo a comprehensive evaluation, which includes questions about emotional and mental health. Anyone showing signs of substance abuse or severe psychiatric disturbance must complete corrective treatment before admittance into the IVF program. Likewise, couples who exhibit a severely dysfunctional, unstable, or abusive relationship must receive therapy prior to treatment. Patients accepted for the IVF program include same-sex partners and single mothers, in addition to heterosexual couples.

The Chappells arrived at UIHC on September 10, 2006, for their embryo transfer. With the quality of the two remaining embryos in doubt, doctors decided to implant both. At her appointment ten days later, Meredith gave a urine sample for a pregnancy test and prepared for more bad news. Instead, clinic nurse Jan Gerard, 76BSN, pointed to a faint purple dot on the test stick and said, "Well, you're kinda pregnant."

"We probably still didn't believe it until we finally saw the baby's heartbeat at about seven weeks," Meredith says.

Her pregnancy proved uneventful and Alexander entered the world at 3:34 a.m. on June 2, 2007, his umbilical cord wrapped twice around his neck and a look of surprise on his face.

Every day, the Chappells laugh at Alex's antics, a new word or a funny gesture. They marvel at how excited he gets to see them at the end of the work day; one smile from him and the worries of their professional lives as attorneys just melt away. They have no plans yet for giving Alex a sibling. They still take days one at a time.

"We feel so lucky to have had Alex," says Andy. "How many miracles should one couple expect to get?"