Multiple births: a joy, but a risk

Over the low drone of machines in the neonatal intensive-care unit, Ashley Mata hiccups as she learns to breathe.

Nothing to worry about, a doctor at San Jose's Good Samaritan Hospital later assures the parents of the month-old girl, whose very survival has been clouded with doubt before her life began.

Ashley and her three brothers, Juan Carlos, Anthony and Eduardo, were born nine weeks premature, weighing no more than 3 1/2 pounds each. All were born with respiratory distress syndrome, which left their lungs too rigid and small to breathe properly.

With quality care and a bit of luck, the Mata quadruplets will be OK and develop normally. But the deaths of four Minnesota sextuplets last month has forced the Matas and a San Jose couple now expecting sextuplets to face the riskier, sometimes tragic side of what is often considered a magical curiosity.

Griselda and Juan Manuel Mata, as well as Gracie and Brian Soldani, are among the thousands of American couples each year who once yearned to be parents and then, with the help of fertility treatments, hit the baby jackpot. But now they are confronted by ethical dilemmas and emotional strains before they encounter the day-to-day tasks of raising multiple children. The most wrenching question: Should they undergo "selective reduction" - eliminating one or more fetuses to help the others survive?
Their quandaries reflect a national surge in births of "high-order multiples" -triplets or more - caused by assisted reproductive technologies such as in-vitro fertil ization and ovulation shots. Thousands of women each year now endure months of fertility treatments and the emotional and physical highs and lows, before they are left with the choice between selective reduction - often strongly advised by doctors - or braving a multiple pregnancy, hoping the fetuses will have time to mature.

"These are women who have been often trying desperately to have a child," said David Magnus, an ethicist at Stanford University School of Medicine. "Now they're told that the object of their desires needs to be terminated."

For 30-year-old Griselda Mata, the harrowing choice followed nine frustrating years in which she couldn't get pregnant. Then, with fertility aids, she was suddenly carrying quads. The medical, financial and moral questions hung in the air as she and her husband debated if they had the heart to reduce. The couple knew that if they waited past the 13th week of pregnancy, the procedure would be too risky.

In the end, they decided, it just didn't feel right.

"I couldn't do it," Mata said.

Others solemnly choose reduction - for a bevy of health, financial and practical reasons - only to find themselves hesitating when the day comes to reduce.

One 40-year-old San Jose woman, who asked to remain anonymous, said she had researched multiple births extensively, reading books and Web sites, and talking to doctors.

"I wanted a baby or two," she said. "I did not want three."

But around the sixth week of her pregnancy, she learned that triplets were likely. Week by week, she watched the sonograms develop.

When doctors found three fetuses, she and her husband swiftly chose to reduce. But on the day of the operation, she said, it was "hard to be sure that we'd made the right decision. I think we did. But on that day, immediately following the procedure, there were questions, uncertainty."

Mixed feelings
Taxing physical,

emotional journey

Ethicists say the media and society in general routinely coo over multiple births as miraculous, random events, blinding many people to the true impacts and risks.

"There's a lightheartedness that tends to accompany these things," said Art Caplan, a bioethicist at the University of Pennsylvania Medical School.

On the day she came home, just three days after her delivery, Griselda Mata felt a mixture of sadness and elation.

Nine years had passed since the birth of her first daughter, Michelle Perez. Griselda and Juan Manuel, also 30, had never managed to conceive naturally. Now, with four children struggling to survive in the neonatal unit, she was apart from them again, grudgingly resting her own tired body.

It was the climax of a journey that had been emotionally and physically taxing. Over the years, Mata, who has four sisters and a brother, had watched as her siblings gave her 10 nephews and nieces, still dreaming of another child of her own.

"Maybe God didn't want me to have any more kids," she recalled thinking.

She had all but given up. Then, in November, she went to a fertility clinic in Los Gatos and asked the specialists what they could do. They recommended a two-step process: a shot to force ovulation, followed by artificial insemination. To her surprise, it took only one try to get pregnant.

Two weeks later, when Mata discovered she had four babies on the way, she was in shock.

Warning signs

`Lots of pain'

during pregnancy

The pregnancy was difficult from the start.

Like a fidgety passenger on a long flight, she spent long nights shifting around on the couch. "Lots of pain - you can't even sleep at night," Mata said.

Dr. Alan Fishman, who delivered the quads at Good Samaritan, said that by 23 to 24 weeks of gestation a quadruplet pregnancy already equals the size of a full-term single pregnancy. Since there's no room left, the body must make room.

Despite her resolve and decade-long wait, even Mata began to show signs of surrender. "I can't stand this any longer," she told her doctor, a month before her delivery.

Doctors convinced her to hold out.

Now, as Mata cradles tiny Ashley in a rocking chair, the pain has faded. She visits her month-old babies twice a day in the neonatal unit, a brightly lit room lined with the miniature plexiglass houses that shield them from the world. The babies probably will leave the hospital one by one, as doctors see fit.

At the Mata home on San Jose's East Side, the couple is figuring out the details: how many cribs and bottles they'll need, who will care for them and when, and how to pay for it all. Mata expects her husband, daughter and two nieces will help care for the quads, but Juan Manuel's fumigation job may not bring in enough income for the whole family. And while Medi-Cal covered much of Mata's pregnancy costs, Juan Manuel remains uninsured, leaving the family vulnerable to high medical costs down the road.

"I think it's going to be OK," she said. "I hope."

Survival chances
Doctor says fetuses

need 24 weeks

Gracie Soldani hasn't had to grapple with most of those questions yet. Twenty-one weeks into her sextuplet pregnancy, some days are fairly painless - and other days hurt a lot. Labor could come at any moment in the next two months for the 28-year-old San Jose expectant mom. Doctors tell her she needs to keep the fetuses inside her for at least 24 weeks for them to have any chance.

Soldani declined an interview with the Mercury News, in part because her doctors were concerned about publicity following the tragic deaths of the four Minnesota sextuplets whose parents refused reduction on religious grounds. But Soldani and her husband, Brian, 33, offer insight into their experience through a blog.

Following a miscarriage last fall, Gracie Soldani redoubled her efforts to have a baby in the first months of 2007. She endured a blitz of fertility drugs, artificial inseminations, ovulation shots and in-vitro attempts, at one point taking a stomach shot seven days in a row.

A week after her last insemination visit, Soldani had a positive pregnancy test. Within four days, she gained 30 pounds. Then she found out she was pregnant with six.

"At first we thought about reduction," Soldani's blog says. "We just feel in our hearts that after seeing the ultrasound with all the beating hearts as strong as a Vegas strip that we couldn't go through with it."

Reducing number

A small risk

of miscarriage

If a couple does choose reduction, doctors inject a saline fluid into the selected fetuses' hearts 11 or 12 weeks into the pregnancy. There is a small risk that the mother will miscarry all the fetuses during the procedure.

Fishman, who specializes in high-risk births at Good Samaritan, said his patients have usually considered reduction before meeting him and just want to know more about the procedure.

"They're a pretty sophisticated consumer base," he said. "It tends to be a rarer choice that you see people continuing with these long-odds, high-risk pregnancies."

Those odds can be daunting. Twenty-four-week-old fetuses have a 35 percent chance of surviving without major neurological handicaps such as blindness, deafness or mental retardation. By 28 weeks, their chances leap to 75 percent. By 30 weeks, rates climb to about 85 percent.

Once the multiple babies are born, families find themselves grappling with the high cost of keeping them healthy. Many will end up in the hospital for months, Stanford's Magnus said, and some won't survive. And, he said, families may crumble under the pressure of raising so many kids at once.

The solution, Magnus said, is for couples to use more precise fertility technology and to know the risks before jumping on board. If a couple strongly opposes abortion, he said, they should think about whether they can stomach the choice between reduction and six children.

Aimee and Brad, a couple from southern Santa Clara County who asked that their last name not be published, never had to solve this quandary. But even before fertility treatment, they struggled with the knowledge that if they were to conceive multiple babies, they would have to reduce.

Brad had read eye-popping numbers for the costs of conceiving, delivering and raising triplets. He knew the reduction surgery could cause miscarriage, and that multiple babies were likely to be less healthy. And he feared the emotional stress a multiple pregnancy would bring to his marriage. His wife questioned whether they could envision sharing their attention three, four or five ways.

So the couple chose not to tempt fate: They implanted just two embryos, in vitro. Now they have 1 1/2-year-old twin boys.

"If four or five took, we would have definitely reduced it down to two," Brad said. "We couldn't have handled it. I know that."

source : www.mercurynews.com