Daily Iowan

Issue date: 5/12/08 Section: Metro

Media Credit: Ben Roberts/The Daily Iowan [Click to enlarge]

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Looking out at the hundreds of families crowded around the makeshift stage outside Kinnick Stadium on May 10, Dr. Craig Syrop addressed the group.

"I often get asked, 'Why do we do this?' But when that 18-year-old pops up, well, it means a lot," he said to the parents. "You are not alone. You know what it means to be infertile in a society that values children."

Syrop began the in vitro fertilization program at UI Hospitals and Clinics 20 years ago. As the anniversary was celebrated over Mother's Day weekend, past and present leaders in the field looked to the future while celebrating past successes with the families they've helped to create.

UIHC boasts success rates in the top 5 percent in the nation, and it has celebrated 4,700 live births; Amy Sparks, the director of the In Vitro Fertilization Reproductive Testing Laboratories, estimates the clinic will reach 4,800 by mid-summer.


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One couple attended the event with their 11-month-old son, Alex. Meredith Rich-Chappell, 34, and husband Andy Chappell, 36, met while in law school, and they will celebrate their 10th wedding anniversary in August. On May 10, they had other reasons to celebrate - Rich-Chappell's first Mother's Day, following the birth of Alex in June 2007 after two cycles of in vitro fertilization at the UIHC.

"It's nice to be with other couples who have gone through the same thing," Rich-Chappell said.

In vitro fertilization is a surgical procedure that fertilizes eggs outside a woman's womb and then transfers the fertilized eggs for implantation. This is often a last resort for couples who experience infertility, a diagnosis that affects 7.3 million couples - around12 percent of the reproductive-age population in the United States, according to the National Survey of Family Growth. The success rate for in vitro fertilization has improved greatly since the first test-tube baby was born in the United States in 1981. The number of live births is roughly 40,000 a year, which accounts for 1 percent of all pregnancies, according to the American Society for Reproductive Microsurgery.


Redefining success, but not without a cost

Alex Chappell embodies UIHC's definition of in vitro fertilization success: a healthy baby boy.

This definition of success has changed slightly from 20 years ago: Now, the stated goal for most practitioners is to produce one baby at a time, said Anne Adams, the executive director of the American Fertility Association, located in New York City, rather than simply any pregnancy, which often produced high numbers of multi-fetal babies.

"We were overjoyed. We just thought, 'Wow,' " said Michael Garvin, the father of twin 11-year-old daughters born via in vitro fertilization at UIHC. "It was a double answer to our prayers. We didn't want just one child."

The UIHC infertility lab instituted a single-embryo policy in June 2004, one of the first of the roughly 300 such clinics in the United States to do so. Sparks said this was done to minimize the harmful effects of multi-fetal pregnancies, which can lead to problems for the mother and fetuses, which have a high likelihood to be born prematurely.

Even with this single-embryo policy, 75 percent of patients transfer more than one egg; usually two, but never more than four. However, the costs for freezing embryos and trying again are much less than the original cost and result in a cumulative 82 percent success rate for those who qualify for single-embryo transfer.

"For 20 to 30 percent of couples, twins are the most preferred outcome," said Dr. Bradley Van Voorhis, who heads the in vitro clinic at UIHC. "But this is prior to being educated about the risks to multiples."

Britain and Belgium have passed federal laws imposing restrictions to the number of fertilized embryos that can transferred, and it is difficult to find quality in vitro fertilization labs in Italy (mostly because of the power of the Vatican), which is causing many couples to cross the border into France or Spain to seek treatment, said Dr. J. Clark Bundren, an infertility specialist in Tulsa, Okla.

"Belgium only wants single embryos transferred, but the government will pay for six cycles to guarantee that," Bundren said. "In the U.S., without mandatory insurance, we're still trying to increase success rates. It's probably a fair tradeoff both ways."

Bundren's clinic also aims to avoid multiple embryos, but this is difficult when couples don't have insurance that covers the treatments - which run as high as $19,000 a cycle at UIHC. According to the society for reproductive microsurgery, the average cost is $12,400 in the United States. Fourteen states currently require health-insurance for in vitro fertilization; Illinois is the closest state to Iowa with this type of coverage, which leads many couples to come to UIHC for treatment.

When the first in vitro cycle failed to produce viable eggs, the Chappells knew they wanted to try again. But if this didn't work - well, they weren't sure what they were going to do.

"Cost was certainly a factor. It's not the only factor we took into consideration, but we had maxed out on what our insurance would cover," Rich-Chappell said, adding that the couple could have done another procedure on their "own dime." "But it's an emotional roller coaster. I know that's cliché, but it is."

While mandatory insurance seems ideal for couples faced with multiple cycles, it often takes a toll on the programs in the respective states.

"The problem here is they are restricting the amount of money they pay so the people running the systems can't spend as much on drugs and such needed to keep the pregnancy rates high," Bundren said. "Like most things in life, you get what you pay for."

Sparks said she can't imagine there will ever be a federal restriction on the number of embryos transferred without mandated insurance coverage for in vitro fertilization.

"I'm in favor of regulation, but it's hard for a government regulation without providing coverage for it," she said. "I can't imagine that happening, no matter what the administration."


Controversial medicine goes mainstream

As a boy growing up in Oklahoma, Bundren was always interested in biology. His father was a research chemist, and Bundren worked at a science-center lab in high school, where he was allowed to grow cancer cells. He jokes about showing his medical students a picture of him at 16: horn-rimmed glasses, looking through a microscope at cell-culture systems. While in medical school at the University of Oklahoma, he was recruited by doctors at the Eastern Virginia Medical School to join the Vital Initiation of Pregnancy Project, where in 1981, he delivered Elizabeth Carr, the first "test tube" baby in the United States.

"When we proposed starting this in 1979 in Norfolk, Va., the church next door to where I attended church marched in front of the health department with signs about how we were blasphemous devils for messing with reproduction," Bundren said. "They condemned our technology, much like other religious and controversial areas of medicine."

This type of "controversial medicine" concerned many people at the onset, said Diana Cates, a UI religious-studies associate professor.

"There was a concern that the entities created this way are, themselves, unnatural. The entity is artificial or robotic," she said. "This was a production, not a human being with human dignity. There was this initial, emotional reaction to things people couldn't understand. Of course, once the world saw Louise Brown [the first 'test tube' baby, born in England in 1978], the emotional reaction shifted because these fears were disproved."

The increased acceptance is due, in part, to the increased number of couples successfully seeking treatment for infertility.

"It's no longer the 'Whoa, I can't believe you're having a test-tube baby.' People were hiding it. They thought it was awful, shameful," said Adams of the American Fertility Association. "Now, it's cocktail-party chatter."

Syrop said the parents of the early test-tube babies were worried what they would tell their children. He uses a comment a child said to him earlier in the day to illustrate how acceptance of in vitro has grown over the past two decades. Syrop laughs, retelling how the boy came up to him and "proudly proclaimed, I was in the freezer for four years!"

While the Chappells chose to keep the in vitro fertilization a secret from many while they were going through the process, they're very open about it now, and they plan to tell Alex all about his unconventional conception.

"I've already told him about it, at 1-week-old," Chappell said and then laughed, showing off the left-over needles and used shots from his wife's pregnancy, now stored in the hall closet. "Maybe he'll remember?"

"We'll probably tell him everything," Rich-Chappell said. "It's just a question of when."

The Garvin family told their daughters everything as well. When asked what being a "test tube" baby means, Elizabeth replied, "We're unique," but twin sister Katherine was quick modify that statement.

"But we're not different from the other kids."


Destruction for creation

But despite the families created through in vitro fertilization, religious and ethical concerns still persist 20 years later.

Kim Laube, now a mother of four from Altoona, Iowa, struggled with infertility for seven years. Before turning to adoption, she visited doctors in Des Moines to discuss in vitro fertilization - and most importantly, her desire to create life without destroying any fertilized embryos.

The doctors told her this was impossible. Numerous embryos needed to be fertilized in order to have a successful outcome, even if they only chose one to be implanted.

"They told me there was no way in vitro fertilization could be used without the destruction of life. That answer was unacceptable to me," the 39-year-old said. "The destruction of life overrides the creation of life."

Laube, who has a stepson, one biological child, and two adopted children, now serves as the executive director for Iowans for Life, a non-religiously affiliated organization that advocates for "total protection" of life, despite the circumstances surrounding conception.

"In regards to in vitro fertilization, the major part that is considered immoral or wrong is creating a life to then destroy life," she said, of the process that fertilizes a dozen or so eggs, and ultimately chooses only the healthiest few for transfer. "I'm not talking about one life that is created and put into a mother, but talking about many lives being created and then destroyed or frozen, potentially to be growing later or to be used for scientific study. Life is not being valued. You can't shrug your shoulders and put them in the freezer and say, 'That's all the life there is for that child.' 'Children' created through in vitro fertilization are children too easily forgotten."

Many religious conservatives agree.

"The Catholic Church was worried," Cates said. "It was worried society would become complacent and scientists would continue to do more. It's the slippery-slope argument."

Sparks of the UIHC said that religion can often play a role for couples who do not want to disclose that they're seeking in vitro fertilization treatment.

"For any Catholic coming through our office - they're going against their religion," she said. "But yet they want a family."


Making medical miracles

The UIHC is doing research to improve the method that the lab cultures embryos so the ones chosen for implantation are healthy and have the best chance to produce a pregnancy. This additional screening could eventually allow the lab to fertilize fewer embryos, Van Voorhis said.

The clinic is also working on long-term research - following babies born via in vitro fertilization to trace their health. Often, for multi-fetal pregnancies, the babies face known complications because a premature birth, but other conditions may need to be traced over many years.

"We need to look at the outcomes to make sure what we're doing is safe," Van Voohris said, citing a possibility that these children may be predisposed to infertility problems because of their parents' struggles. "Little is known about these individuals."

While in vitro fertilization has become increasingly mainstream and accepted in the last two decades, the demand for the procedure may not continue to rise. With the end of the baby-boom generation, there are simply fewer couples wanting to have children, Van Voorhis said. Also, economic factors, such as the current recession, often take a toll on the number of couples able to complete the expensive cycles.

"When the economy is good, people have the ability to do things that they otherwise couldn't," he said.

The benefits, however, often greatly overwhelm the cost. When asked if they will go through in vitro again to have another child, the Chappells paused and looked at each other, and then glanced over at Alex, sound asleep in his baby swing.

"Well," Rich-Chappell paused. "We haven't had this conversation yet."

Her husband jumped in: "There's no reason, based on our previous experience, why we wouldn't do it again. But you wonder - how many miracles should you expect to get? Some people never get the end result like we did."

E-mail DI Arts and Culture Editor Susan Elgin at:
susan-elgin@uiowa.edu

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