The Center For Reproductive Medicine

ALL FOUR CRM physicians recently were named to the distinguished Best Doctors in America list for 2006! Only 3 to 5 percent of specialists nationwide receive this honor, nominated by fellow physicians. As a result, the CRM physicians will be featured in the December 2006 edition of
Orlando Magazine.

New! CRM is WESH-TV’s infertility health expert. (This file requires Windows Media Player.)

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“It's extremely rare to put back two embryos and have someone conceive with four babies," said Dr. Sharon Jaffe.

They had Jaffe implant two embryos, which were grown in a lab at Orlando's Center for Reproductive Medicine. And instead of having one or two babies, they had two sets of identical twins.

"Our goal is one healthy baby. If we get two, that's great. We rarely get more than two and when we get more than two, we talk to the patient about the potential risk (of) complication and send them immediately to a high-risk obstetrician," Jaffe said.

That obstetrician gave the Ewings the option of removing one of the embryos, which is called selective reduction. They rejected that offer.

Jaffe said most parents make that choice because they don't want to risk losing something for which they've worked so hard.

Hundreds of embryos are stored at the center, and they're good for 15 to 20 years. But thanks to medical advances, there are far more options than just the costly in-vitro fertilization.
There are drugs and procedures that help patients become pregnant.
Jaffee is eager to help.

"I love it. Every time I get a pregnancy, every time I do an ultrasound, I just say, 'This is great. Isn't this exciting?' And when we show the heartbeat when we do the early ultrasound,
I get excited like I did for the first one," Jaffe said.

HOT SPRINGS, Va. – Women with large uteri or T-shaped cavities may be more prone to poor reproductive outcomes than those with smaller, more arcuate-shaped uteri, Dr. G. Ward Adcock III said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Uterine cavity shapes can vary dramatically, and there are almost no objective data describing "normal" uterine cavity shapes and sizes or what they indicate clinically.

"We do know that extreme sizes and shapes of uterine cavities, such as those of DES [diethylstilbestrol]-exposed patients, are very commonly associated with complicated pregnancies," commented Dr. Adcock, who is an ob.gyn. resident at Greenville (S.C.) Memorial Hospital .

In a study assessing the correlation between uterine size and shape, Dr. Adcock and his associates retrospectively analyzed 200 randomly selected hysterosalpingograms (HSGs).

They found that among women with a history of first-trimester pregnancy losses, 13 patients, or 31%, had an angle between their tubal ostia greater than 160 degrees, producing a markedly T-shaped uterus.

Among patients with a surgical diagnosis of endometriosis, "we found that 80% of patients had an angle between the tubal ostia of less than 90 degrees," giving the fundus of the uterus a Y-like or arcuate shape.

When the uterine areas were analyzed, 33% of the women who reported first-trimester pregnancy losses had uterine cavities that were larger than 11 [cm.sup.2]; these uterine cavities were significantly larger than those of women who did not experience pregnancy losses.

Each HSG was performed as part of an infertility evaluation. For inclusion in the study, the HSG had to meet criteria for being "normal," meaning there could be no abnormal uterine pathology, such as fibroids or polyps. Any cavities that had shaggy or irregular borders were excluded.

HSG films were placed in a light box, and the outline of their images was traced, allowing researchers to then calculate the area of the uteri. Lines were drawn from the center through each cornua and then down from the center through the internal os.

Using an electronic caliper, they measured each of the line segments and they measured the angle of the tubal ostia with a protractor.

The researchers calculated the average of the measurements to produce an image of a "normal" uterus.

The mean angle between the tubal ostia was 132 degrees and the mean area was 6.1 [cm.sup.2].

In addition, the right side of the uterus was found to be larger than the left side in 65% of the women.

In telephone interviews, 71 of the women were asked about their age, method of conception, history of first-trimester loss, preterm delivery, mode of delivery reason for cesarean section if she had one, and history of endometriosis or other gynecologic disease. The women were a mean age of 35 years, and none had tubal pathology.

There were no statistically significant differences in uterine dimensions between those women who were unable to become pregnant, compared with those who had more than one pregnancy.

It was surprising that "there was no difference in the uterine cavities of nulliparous women and multiparous patients," Dr. Gary DeVane, a formal discussant of the study noted at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

Soundings of uteri from multiparous patients are usually deeper than those of nulliparous women, he said. On the basis of this study, "I'm now beginning to think that this is [due to] cervical enlargement."

In addition, the finding that women with larger uteri had higher miscarriage rates is "not what I was expecting. ... I've always assumed that smaller cavities had higher miscarriage rates. This could be a selection bias problem," said Dr. DeVane of Orlando .

On that point, a physician from the audience noted that first-trimester pregnancy losses are generally thought to be due to chromosomal-mediating factors, rather than by uterine factors. Uterine factors are believed to be more relevant for losses later in pregnancy.

The finding that women with T-shaped uteri had higher miscarriage rates "fits with what we know about DES exposure," Dr. DeVane added.

Dr. Adcock cautioned that since his study findings were based on a population of women who were evaluated for infertility, they may not be applicable to a general female population.

Obtaining data on a healthy population would entail convincing such women to undergo an HSG for the sake of the study.

Minimal-stimulation in vitro fertilization may be a cost-effective option for young women who want to conceive, Dr. Gary DeVane said.

While conventional in vitro fertilization (IVF) procedures yield better pregnancy rates, minimal-stimulation IVF yields higher numbers of retrievable eggs when gonadotropins are used, according to a two-phase prospective study.

A relatively new assisted reproductive technique, minimal-stimulation IVF (MS-IVF) aims to induce ovulation with less hormonal stimulation than what is used in conventional IVF.

The problem is finding the right dose of medication that [R1]will ultimately yield acceptably high pregnancy rates while remaining cost effective, Dr. DeVane said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

The bulk of the savings from MS-IVF comes from the reduction in fertility drugs.

Although he's not sure that MS-IVF is the best method for everyone, the lower cost will make assisted reproductive technologies accessible to more women, according to Dr. DeVane of the Center for Reproductive Medicine in Orlando , Fla.

In the first, exploratory phase of the study, 106 patients underwent MS-IVF, receiving a dose of clomiphene citrate that was substantially less than that used in standard IVF, in addition to hCG.

The cancellation rate was 18%; of the remaining patients who went to retrieval, 85% had eggs recovered and went to embryo transfer.

There were 20 pregnancies after transfer, translating into a 17% pregnancy rate per retrieval. The implantation rate, defined as the number of gestational sacs divided by the total number of embryos transferred in a group of patients, was 9%.

Patients under age 35--who comprised 80% of the study group--had better results:

Twenty-five percent had five or more eggs retrieved, and this cohort accounted for more than one-half of the pregnancies, Dr. DeVane observed.

MS-IVF from phase I appeared to be cost beneficial, but "we weren't very happy with the pregnancy rate," Dr. DeVane said.

For phase II, the investigators upped the ovarian stimulation with an ultrashort GnRH-A flare, given for 4 days, and avoided clomiphene altogether. They observed less spontaneous ovulation with this protocol than with the clomiphene, Dr. DeVane reported.

Eggs were retrieved in 34 hours and transferred on day 3. Retrieval was canceled if patients didn't have at least two follicles.

In 110 patients, the cancellation rate was 25%. Of the remaining patients, 45 pregnancies resulted, translating into a clinical pregnancy rate of 37% per retrieval and an implantation rate of 23% per transfer, clearly better than the phase I outcomes.

Of the women who had successful egg retrievals, 50% had five or more oocytes harvested. The live birth rate was 33%, but more than half of those were part of multiple gestations.

As in phase 1, women under age 35--who comprised approximately 85% of the phase II study group--had better retrieval rates.

The improvement with protocol II is probably due to the higher number of eggs retrieved.

But egg retrieval and pregnancy rates for conventional IVF have improved in recent years as well. "Some of the successes that we had may be just a reflection of [generally] better IVF techniques," he said.

The study was not intended as a formal cost analysis but as a way to provide access to patients who would not otherwise consider IVF because of the cost, Dr. DeVane said.

Discussant Dr. Barry Verkauf, an ob/gyn. in private practice in Tampa, Fla., who was not involved in the study, calculated that a phase I cycle costs $3,200, while a phase II cycle costs around $4,700 because more medication, anesthesia, and monitoring are necessary.

However, the phase II procedure may ultimately prove more cost effective, with a cost per live birth of $14,461, compared with a cost per live birth of $22,222 for phase I.

One cycle of conventional IVF can cost twice as much as the phase II protocol, according to Dr. DeVane, although he said he is not entirely convinced that MS-IVF is a cost-effective approach for everybody because of the low egg yield and other factors.

Since the trend in assisted reproductive technology is toward less stimulation, MS-IVF would be a good alternative for certain women, including younger women who are financially strapped and patients who don't want to deal with the issue of cryopreserving extra eggs, Dr. DeVane said.

"Rather than higher pregnancy rates at all costs, clearly our new paradigm is to achieve acceptable rates at acceptable costs," Dr. Verkauf said.

”Become a mother at 50?” Orlando Sentinel
STUDY SAYS GO AHEAD; HOWEVER, AN ORLANDO EXPERT WARNED WOMEN TO CHECK OUT ALL THE RISKS BEFORE USING DONATED EGGS TO GET PREGNANT.

Healthy postmenopausal women in their 50s shouldn't be prevented from having babies with donated eggs, according to a study published today in the Journal of the American Medical Association.
Even so, one Orlando infertility expert has his doubts about the wisdom of fertility treatments for women of that age.

"I'm not sure it's always wise to do it just because we can do it," said Dr. Gary DeVane of the Center for Reproductive Medicine, who doesn't take patients older than 48.

The latest study involved 77 postmenopausal women who participated in the assisted reproduction program at the University of Southern California between 1991 and last year. There were no deaths of either an infant or mother, and 42 of the healthy postmenopausal women had babies.

The rates of pregnancy of 45 percent and multiple births of 30 percent were similar to those in younger women who get pregnant with donor eggs.

But preeclampsia, a potentially serious condition involving high blood pressure, occurred in 35 percent of the older women, and gestational diabetes occurred in about 20 percent -- rates at least double the rate of younger women.

Those conditions, researchers said, were temporary and not reason enough to exclude women from attempting pregnancy.

Along with increased health risks, about 78 percent of the women had Caesarean births, which DeVane called "pretty high."

Biologically, most women cannot become pregnant after menopause, which occurs around age 51.
In such cases, donated eggs and sperm create embryos through in-vitro fertilization, and patients take hormones to prepare the uterus for pregnancy.

DeVane said his center's ethics board decided eight years ago that it wouldn't treat women who had undergone menopause. DeVane said he doesn't remember the last time anyone older than 49 had inquired about fertility treatment.

Elsewhere in Orlando, at the Reproductive Health Institute at Arnold Palmer Hospital for Children & Women, the usual age cutoff is 47.

But Dr. Richard Paulson, the lead researcher of USC's program, said women past menopause should not be denied.

"Not only do I not have a problem in allowing them to become pregnant, I would have an ethical problem in denying them," he said.

“Cycle of pain, blame,” Orlando Sentinel
Polycystic ovary syndrome can derail women's bodies

Tina Robertson's health problems used to be boiled down to three words: fat, lazy, liar.
She was gaining weight despite eating less. She was tired because she was fat. She was a liar, doctors told her, because she had to be concealing her true eating habits.

After many years and increasingly poor health, Robertson discovered the three words that really were causing her troubles: polycystic ovary syndrome.

Most people have never heard of the disease, but PCOS affects an estimated 5 percent to 10 percent of all women of childbearing age. There is no simple way to define the disease, but at the basic level, it is caused by a hormonal imbalance.

Women with the condition produce too many male hormones, and they frequently have trouble with insulin - another hormone that regulates sugar in the body.

Symptoms vary among women. But often, the ovaries are permeated with tiny, fluid-filled sacs called cysts. The women have irregular periods or none at all. It commonly leads to obesity, excessive hair growth, acne and infertility.

There is no cure, but doctors say the ailment can be managed. Many PCOS patients can have babies, lose weight and improve their health -- if they know what they are dealing with. Unfortunately, the realization often comes after many years of misery.

"Once I got fat, everything that was ever wrong with me was blamed on my weight," said Robertson, 28, a business development coordinator in Orlando. "Eventually you start to accept that this is your life. You get up in the morning, go to work, come home dead tired and take a nap. You feel terrible, but it's the only existence you know. And you blame yourself, because everyone else is."

Doctors have struggled to define PCOS since the 1800s, when the disease was coined "diabetes of the bearded woman." It also goes by the name Stein-Levanthal Syndrome for the two doctors in the 1930s who connected the problem to ovarian cysts.

But PCOS remains tough to pin down. There is no single test for the problem, and some women do not even get those telltale cysts in the ovaries.

Doctors can diagnose the condition through a combination of medical history, laboratory tests and a sonogram to look at the ovaries.

Most notably, the hormone imbalance creates havoc for a woman's menstrual cycle. Women are supposed to menstruate every 21 to 35 days. But PCOS patients may get their periods rarely, or they stop altogether.

This is because the women no longer release eggs from their ovaries, which cannot function normally. When a woman does not ovulate, she cannot get pregnant, making PCOS a leading cause of infertility.
"It is the most common problem that I see as a reproductive endocrinologist," said Dr. Mark Trolice, director of the Reproductive Health Institute at the Arnold Palmer Hospital for Children & Women in Orlando. "I think there are a lot of women who have it, but don't know what's wrong with them. It's very, very frustrating for them."

The disease can cause obesity because many PCOS patients also become resistant to insulin, the hormone that orchestrates the body's storage of food as fat.

The woman's body reacts by cranking out high levels of the hormone. The insulin then begins storing more food as fat. The PCOS patient can gain weight very quickly, despite dieting. Many women try to lose weight by eating foods that stimulate more insulin production -- carbohydrates such as pasta, rice or fruit.

When Robertson started gaining weight as a teenager, she was an active kid who played volleyball, racquetball, soccer and other sports. She stopped eating breakfast and often skipped lunch but continued to get bigger.

"I would live on tuna and fat-free mayonnaise, pasta, rice and crackers," Robertson said. "But it didn't matter, and my doctors kept saying, there is no way this is how you're living. Even my parents started to doubt me. They thought I was hiding food."

Robertson got engaged at 18 and gained 50 pounds in the six months leading up to her wedding day. Her family blamed it on stress, then watched in befuddlement as she put on another 125 pounds in the next year and a half.

The extra weight creates a vicious cycle for the PCOS patient. As a woman gets heavier, she becomes less active. The lack of exercise spurs more insulin production. That's why doctors say a first step in treating the disease is weight loss and exercise.

It is not easy, but women with PCOS can lose weight, Trolice said. Sometimes, that's enough to get a woman's body back on track. She may even be able to get pregnant.

"If your insulin levels are too high, the insulin can bombard the ovary and make the ab-normal hormone production that will not allow you to ovulate," said Dr. Sharon Jaffe, a reproductive endocrinologist with Center for Infertility and Reproductive Medicine in Orlando."Once you get the insulin under control, a lot of these patients will start ovulating normally and they can get pregnant on their own."
Getting the menstrual cycle under control is pivotal for other reasons, as well. Women who do not get regular periods are more susceptible to uterine cancer later in life. The lining of the uterus must be shed regularly through menstruation to maintain health.

Yet it's not uncommon for women with irregular periods to be told by doctors that an erratic cycle is normal. Some doctors even tell them they are lucky to be avoiding the monthly inconvenience.
"Ever since I started my periods at 11, my cycle was really irregular," said Laura Perez of Kissimmee, who also has PCOS. "My first gynecologist said I would grow out of it, but when I didn't, another doctor told me it was normal. He said my cycle was just going to be this way."

There are several medications that can help PCOS patients. Women who are insulin resistant can take a drug called metformin, which is designed to increase the body's sensitivity to the hormone. They can also take birth control pills to trigger a monthly period.

The other symptoms of the disease must be addressed individually. Some women report a decrease in unwanted hair with weight loss and regular menstruation, but many still need to bleach, pluck, shave or undergo electrolysis.

Also, women who want to get pregnant may need help with fertility drugs. But doctors say many PCOS patients can become pregnant and deliver healthy babies, provided their overall health is good.
"If they're blood pressure and other things are under control, they can go on and have healthy pregnancies," Trolice said.

Perez is proof of that. Her twin sons were delivered in January after she conceived with the help of fertility medications. Perez and her husband used the drugs on and off for 10 years before they had success.

"I can't believe that they're mine sometimes," said Perez, who runs a support group for PCOS women. "I had so many doctors tell me that I'd never get pregnant. But there's a lot of treatment out there now, and a lot of support, which is good because there are a lot of women going through the same thing."
There may be some PCOS patients who go unrecognized because they do not fit the classic description, said Dr. Kenneth Gelman, a reproductive endocrinologist in Hollywood. Skinny women can have PCOS. Doctors need to be sensitive to the disease whenever a woman has menstrual irregularities.
"I think it's very much underdiagnosed," Gelman said. "It comes in all shapes and sizes, and I think it may not be suspected by gynecologists initially in a lot of women whose outward appearance doesn't immediately make you think of" PCOS.

If untreated, the condition can contribute to heart disease, diabetes or cancer. The ailment needs to be taken seriously, Robertson said, because its consequences can be dire.

"When you refer to a disease like cancer, everyone immediately gets scared, but you say polycystic ovary syndrome, and people think it's just some kind of woman problem," Robertson said. "But they need to understand this isn't just a reproductive problem, it throws your whole body out of whack."
Robyn Suriano can be reached at rsuriano@orlandosentinel.com or 407-420-5487.

“Read about one of Dr. Loy’s patents,” New York Times
Patents: Reversible sterilization for women

EVERY year, several hundred thousand women in the United States choose tubal ligation as a form of birth control. The procedure is a type of sterilization in which the fallopian tubes are blocked so a woman's eggs cannot pass from her ovaries to her uterus and sperm cannot reach the eggs. While the technique for men, vasectomy, can sometimes be reversed, tubal ligation is considered permanent.
Randall Loy believes that some of those women would prefer a reversible sterilization, something that would function like the intrauterine device, or IUD, but without the negative image of health problems associated with it. So Mr. Loy, who lives in Longwood, Fla., has patented a fallopian tube plug that can be inserted in an out-patient procedure and, he says, can be removed at any time.

Mr. Loy has designed the plug to be made of a rigid, rod-shaped material. In his patent, he suggests stainless steel or any material that can later be picked up by X-ray or ultrasound. That way, the plug could be monitored externally. The plug is also coated with what Mr. Loy calls a biocompatible material.
The shaft of the plug is about the size of a fallopian tube and has spikes or protrusions arrayed around one end. The protrusions are formed from the coating to "significantly lessen the chance of breaking off and remaining in the tube after removal of the plug," Mr. Loy said.

When the plug is inserted, the protrusions are flat against the surface. Once the plug is in place, the protrusions are extended outward from the shaft so that they grip the sides of the fallopian tube. There are two rows of protrusions, offset from each other. So when extended, the protrusions also form a solid barrier that blocks passage through the tube.

The plug has a knob on one end so that a scope with moveable jaws can be used to insert and then later remove it. Mr. Loy said both procedures could be performed without anesthesia. He holds patent 5,979,446.

They stumble about like miniature celebrants at a New Year’s Eve party, banging into this or that, toppling over on the carpet only to pick themselves up and teeter ever on-ward.

Today is a celebration of Mother’s Day at Central Florida’s biggest baby factory. Those at the Center for Reproductive Medicine are reveling in the successes of the past year.

Bhushan K. Gangrade enjoys the festivities in relative anonymity. Few of the parents seem to know him, although it is by his hand that their children exist. He was the one who joined the sperm and eggs and nurtured the embryos in the incubators.

It is an amazing thing to have seen them from the Petri dish to the stroller, he says.

The two doctors who run the clinic, Randall Loy and Gary DeVane, walk around with a much higher profile. Parents thank them with all their hearts and push babies into their arms for pictures. These doctors gave them something they value as much as their own lives.

The doctor says he may have to move the party to a different venue next year because his office can no longer accommodate the crowd. What was a miracle in 1978 the birth of the first test-tube baby in England is now commonplace.

But progress has not guaranteed success, despite the impression given by the crawling herd.
Most couples who go to clinics like this one leave empty-handed. They pay thousands of dollars to take their chances in a procedure in which the odds are 5-to-1 against them.

For every happy couple in this office today, there are many more out there still longing for a baby. They have gone through the grueling, expensive procedure sometimes several times to no avail.
Deborah is one of them. Like other women in this story, her name is being withheld for privacy reasons. A past attempt to bear children has failed, and she does not have $10,000 to give it another try. By the time she can save it up, she may be too old.

“I want a child so bad, and it is strange to realize that I can’t have one just because I’m not rich,” she says.

The treatment can be as harsh as the condition. Side effects include emotional distress, physical dangers and moral quandaries.

DeVane does not sugarcoat what he does: It is miserable. This is what you do if you have no other option.

Janet is lying on the table, awake but doped up on enough drugs to dull the pain she is about to endure.
She is undergoing her first attempt at in-vitro fertilization.

Her reproductive system seems to be in good working order, with the exception of blocked fallopian tubes, the result of a childhood infection. The tubes transport eggs from the ovaries into the uterus.
In-vitro fertilization is most effective in healthy young women whose only problem is their fallopian tubes.

The bridge was out, so we had to come up with another option, Janet’s husband explained
Janet’s legs are in the stirrups. A television screen shows an ultrasound image of her ovaries. It looks scrambled to an untrained observer, but it is a map for DeVane to follow as he inserts the large needle into her vagina.

The needle appears on the ultrasound picture. In a nearby room, Janet’s husband is watching on another monitor. It is better that he is not in the room.

Under normal in-vitro fertilization, Janet would be unconscious on a hospital operating table. But she is undergoing a discount procedure. It will cost $3,000, about a third of the normal cost. She is doing this because her health insurance does not cover this type of fertility treatment. This is not unusual. Most people who undergo in-vitro pay out of their own pockets.

Much of the savings in Janet’s treatment comes from the hormone drug DeVane has given her.

In a normal in-vitro procedure, the doctor takes complete control of the menstrual cycle. He first gives the woman a hormone that prevents her from ovulating. Then she receives daily injections of another hormone called Fertinex, which stimulates the ovaries to produce extra eggs.

When the eggs mature, the doctor gives her yet another drug, HCG, to induce ovulation. The eggs then are harvested right before they normally would be expelled into the fallopian tubes.

The more eggs the doctor collects, the better. More eggs allow for the creation of more embryos once they have been mixed with the husbands sperm.

The weaker drug given to Janet, called Clomid, will prompt her ovaries to produce only three to five eggs. She is gambling that her age she is in her late 20s will allow her to get pregnant with a minimum number of embryos.

Because DeVane will be removing only a few eggs, he can do the procedure in his clinic while Janet is under local anesthesia. Avoiding the hospital cuts another $1,300 from the bill.

Two nurses hover around the doctor. A door in the corner of the room that leads to the laboratory is open. Gangrade has his instruments and microscope ready.

DeVane directs the needle to an egg follicle in Janet’s right ovary. He injects a liquid into the follicle and then sucks it back out, hoping to withdraw an egg along with it. The fluid is captured in a container and handed off to Gangrade. DeVane goes back to work.

He repeats the procedure, flushing out another follicle. Gangrade examines each batch sent back to him, shouting out when he finds an egg.

DeVane retrieves three eggs from Janet’s right ovary before moving to the left. The ultrasound shows that the left side does not contain many, if any, mature eggs. This makes the hunt more painful.

“We’ve got four eggs,” DeVane tells his patient. “You want me to go for more?”

All the tubes and the needle are flushed and the resulting fluid examined on the slight chance that an undiscovered egg might have gotten stuck in the works. No such luck.

While Janet goes into a recovery room, her husband enters a small stall next to the laboratory. It is time for his contribution, a much easier process than what his wife has gone through. In a few minutes, he rings a bell. A nurse opens a small sliding door, and there is a small cup with semen in it.

The semen will be cleansed to form a sperm concentrate. Then it will be mixed with the eggs in Petri dishes. The dishes are placed into an incubator set at 98.6 degrees.

Gangrade will pull them out tomorrow. If there are two nuclei in any of the eggs, a new life has begun. The odds are that, with four eggs, three will be fertilized.

If all goes well, the resulting embryos will grow to eight cells within three days. Then some or all of them will be transferred to Janet’s uterus through a catheter a much gentler procedure than the one she has just endured.

If she does not get pregnant, youth has another advantage for Janet. She has plenty of time to try again, as long as she can come up with the $3,000.

It is a devastating diagnosis for men and women who have dreamed their whole lives of raising a family.
Everywhere there are reminders of the joy they are missing out on. Their friends have babies. There are babies on television, babies on commercials, babies on billboards, babies in shopping carts at the supermarket and babies pushed in strollers by beaming parents. There are babies everywhere but in their homes.

The joy of others often reinforces their own despair. Why should these other people have children and not us?

I always wondered, Why me? a Central Florida woman says. Why is what a teenager can do in the back of a car on a Saturday night taking all my time and all my resources?

The official diagnosis comes when a couple has failed to produce a pregnancy after a year of trying.
The problem can be traced to the man almost as often as to the woman. Either he does not have enough sperm, or it is not active or healthy enough to impregnate an egg. A doctor can make that diagnosis with a microscope.

Age is the biggest factor because it reduces the viability of a woman’s eggs. The de-cline actually starts after her teen years and escalates rapidly in her late 30s.

The baby-boom generation has produced thousands of fertility patients as aging couples who have concentrated on their careers now turn their focus to raising families.

There are myriad other problems. The woman may not be ovulating regularly, or at all. There may ovarian cysts or tumors in the uterus. The mucous in her cervix may be toxic to sperm. The fallopian tubes may be blocked or damaged by adhesions or endometriosis.

There are a wide variety of treatments. They include microsurgery to unclog fallopian tubes or repair an ovary or uterus. Hormones are used to induce ovulation.

For some, however, these do not work, and in-vitro fertilization is the last hope. It is a grueling procedure.

The heavy doses of hormones wreak havoc on a woman’s emotional state. She must go to the doctor’s office almost every day for ultrasound examinations and blood tests. The doctor must closely monitor egg development and also watch out for hyperstimulation of the ovaries.

Hyperstimulation causes a buildup of fluid in the body that can shut down the kidneys and cause cardiac arrest. Some research also indicates that the hormone treatment may slightly increase a woman’s risk of ovarian cancer.

It takes up your whole life, says one woman who has been through the process twice. It is like a full-time job. It is hard to think about or pay attention to anything else when you are in the middle of it.
Women sometimes go through in-vitro fertilization when they are perfectly normal but their husbands have poor-quality sperm. By manipulating the sperm and eggs in Petri dishes, lab specialists can create a union that could not take place under natural conditions.

The medical procedure was introduced in the United States in the early 1980s. Since then, improvements in the technique have led to gradual increases in success rates.

But still, the latest available numbers from the Society for Assisted Reproductive Technology show that, in 1994, there were 33,600 in-vitro fertilization attempts in the United States resulting in only 6,339 births.

Rebecca is 38 years old and, unlike Janet, does not have time to see if she can get pregnant on the cheap.

She already has a 3-year-old boy who was produced through artificial insemination using her husband’s sperm. Now she desperately wants another child.

She tried using artificial insemination again, but two attempts did not get her pregnant. She tried three times with in-vitro fertilization but had no luck.

She was among the lucky minority in Florida whose health insurance covered the cost of the procedure. But the coverage ran out after three attempts.

She was about to give up when a change in her insurance policy allowed her three more attempts.
“We figured it was a blessing and a sign from God that maybe we should do it again,” she says. “I don’t know if it is stupidity or courage, but we keep trying.”

Two more attempts failed. One produced a pregnancy, but she had a miscarriage, more common with in-vitro patients. The child would have been a boy.

“All those times and we didn’t get pregnant, and then we did and lost the baby,” she says. “I never had anything go wrong with the pregnancy. Then we went to the doctor, and he couldn’t find the heartbeat.”

And so she wallowed in guilt. Did she strain too much when she moved the kitchen table that day? Was she working too hard? Was her child lost through some fault of her own?

Rebecca is down to her last attempt. Her eggs have become less viable with age and her husband has a low sperm count, the result of a reversed vasectomy.

Her husband would prefer she give up. Time after time, he has seen her hopes dashed, has seen how each failed attempt devastates her.

“The disappointment gets worse,” he says. “I am numb to it, but it gets worse for her.”

The hormone drug Rebecca takes is giving her headaches and disrupting her sleep.

“It has been tough this time,” she says. “I feel whacked-out from the hormones. I get very emotional.

We’ve been emotionally wrung out. But you realize the chances are running out. You think, This could be it.”

The hormone has stimulated her ovaries into producing only one large egg and two smaller ones. Small eggs generally are not as fertile.

“This time I will stay in bed for two days (after the embryo transfer),” she says. “I want to know that I did absolutely everything I can.”

Rebecca has not told many of her friends and relatives what she is doing because she does not want to have to explain over and over again that the attempt failed.

“You get a lot of patients who don’t want to give up,” says Dr. Frank Riggall from the Arnold Palmer Hospital Fertility Center.

“There is a point where you have to say we have nothing to offer you. It’s a hard concept for them to grasp.”

In a natural ovulation cycle, a woman generally releases one egg. This results in one child if she becomes pregnant. Only seven in 1,000 pregnancies result in a multiple birth two or more children.
But with in-vitro fertilization, a doctor generally recovers several eggs from the woman because her ovaries have been artificially stimulated.

Ideally, the doctor would mimic nature and transplant only one embryo so the woman would carry a single child. But the odds are not good that a single embryo will implant in the uterus, particularly in a woman with fertility problems.

To increase the odds of a pregnancy, the doctor usually transfers multiple embryos between two and six into the woman.

But there also is a good chance that two or more of the embryos will implant, resulting in a multiple birth. Almost 35 percent of in-vitro pregnancies in 1994 resulted in multiple births. Of these, 28 percent were twins and the remainder triplets or more.

Multiple births increase the danger to both the mother and her offspring. There is a greater risk of miscarriage, premature delivery, Caesarean delivery, life-threatening complications for both mother and children, underweight infants and infant mortality.

A 1991 study reported the cost of a single birth was $9,845 compared to $37,947 for a birth involving twins. A report from 1994 listed the cost of bearing triplets at $121,000, which includes a long stay in the neonatal intensive care unit.

Mothers who carry three or four babies also can face a wrenching decision whether to abort one or more of the babies to increase the odds that the others will survive. The procedure is called a reduction and is done near the end of the first trimester.

The doctor inserts a large needle through the woman’s abdomen and then injects a lethal dose of potassium chloride into the heart of the most easily accessible fetus. The fetal remains are absorbed by the woman’s body.

Loy says that about a third of the women from his clinic who become pregnant with three or more children choose the procedure based on good medical reasoning.

“There is no way a 90-pound woman with triplets can carry them to near term,” he says.
Ten percent of reductions result in the loss of all the children.

Loy and DeVane say they talk at length with patients about the procedure, particularly when they talk about the number of embryos they will transplant into the woman.

The way to reduce multiple births is to cut down on the number of transferred embryos. But in doing this, a clinic also risks seeing its success rate drop.

The biggest clinic in Florida the Northwest Fertility Center in Broward County reported an excellent 38 percent success rate in 1994. But the clinic also reported that more than half of its deliveries were multiples.

Northwest has been trying to cut that number by reducing the number of transplanted embryos, he says. But the multiple-birth rate still is at 38 percent. He says reductions are recommended to about 10 percent of the clinics patients.

Hoffman says this is not because of excessive embryo transfers. He says it has more to do with the clinics improving techniques. Northwest doesn’t transfer more embryos than other clinics, he says, but a higher percentage of them survive.

DeVane says he is running into a similar problem. Recently, seven of his patients be-came pregnant with triplets. He attributes this to a new fluid the clinic uses to nourish developing embryos. It seems to have greatly enhanced the survivability of the embryos once transplanted to the womb.

“We’d put three embryos back and get three-out-of-three takes,” he says. “We don’t know what to expect.”

DeVane says that clinics are trying to adjust the number of embryos they transfer to bring them in line with improvements in technology.

“We are looking at limiting embryo transfers in women under 35 to only two,” DeVane says.
Sometimes, however, patients will object to such limitations. This is because of the high cost of the procedure. Because most insurance companies in Florida do not cover the procedure, about 70 percent of patients at DeVane’s clinic pay their own bills.

This puts pressure on the patients and the doctors to ensure a pregnancy because the patients might be able to afford only one attempt. Doctors talk of patients who have taken out second mortgages on their homes to pay for the procedure.

Randall Loy says one couple who had saved for years wanted him to transfer four embryos to ensure a pregnancy. Loy wanted to transfer only two.

She said, “I realize the consequences, but this is our one and only shot,” Loy says.

They compromised and put in three. All the embryos implanted, and now she is carrying triplets.

One alternative for patients is to use a smaller number of embryos and freeze the rest in liquid nitrogen. If the initial transfer of two embryos does not produce a pregnancy, then there would be more embryos to try again at minimal cost.

But the preservation of embryos has sparked both moral and legal debates. Is an embryo a human life? Should embryos that have been abandoned by the parents be given to an infertile couple rather than be destroyed? Could a woman have an embryo implanted against the wishes of an ex-husband?

Once frozen, an embryo loses some of its viability. The survival rate in the womb is not as good for frozen as for fresh embryos.

“No one knows how long an embryo is good for,” Loy says. “But we’ve had a pregnancy seven years later.”

And so she had a child, now 8 years old. She decided to have a second child. That one took five attempts.

A veteran of the procedure, she knew what she was doing when she told the doctor she wanted him to transplant five embryos into her womb. She knew the risks of multiple birth. But she was in her late 30s and wanted to increase the odds of a pregnancy.

She also decided in advance there would be no reduction if three or four of the embryos took hold in her uterus.

“I had to work so hard to have the children, there was no way I could say to selectively eliminate one,” she says. “For me it was not an option.”

Susan ended up carrying twins. She went into labor 512 weeks early and required a C-section. Her placenta erupted, and she hemorrhaged.

“Just the medical bills from the fertility treatments cost more than $100,000,” she says. “It came out of the family bank account because insurance did not cover the costs.”

“I am seeing a lady who is 44 tomorrow,” DeVane says. “There is very little I can do for her. It doesn’t matter how healthy she is, even if she does aerobics. Her eggs are 44 years old.”

There is a solution, but DeVane and Loy still are not ready to embrace it. That solution is to use donor eggs from anonymous younger women.

As female baby boomers get into their 40s, there is a growing demand for young eggs.

The procedure is very effective. Doctors, in fact, achieve better pregnancy rates using donor eggs than a woman’s own eggs. DeVane says the body’s rejection process, which makes organ transplants so difficult, actually works to an advantage when putting a foreign embryo in a woman’s uterus. The uterus is designed to accept foreign material.

A 40-year-old woman who has about a 5 percent chance of becoming pregnant with her own eggs can have up to a 50 percent chance using eggs from a younger donor.

“You can make a lot of money doing donor eggs,” DeVane says. “These generally are the most desperate people.”

DeVane had a patient who wanted to use a donor egg from her own daughter. This meant that the donor’s new sibling also would be her biological child. DeVane did the procedure after sending the women to counseling.

But he and Loy will not yet use eggs from anonymous donors who are paid to provide them.

“We never considered what amount would be coercion for a 19-year-old Rollins College student,” Loy says. “Would $2,000 make them do something they otherwise wouldn’t do?”

He says his clinic is not ruling out using anonymous donors but wants to do more re-search first.
The Arnold Palmer Hospital Fertility Center does use anonymous donors. The clinics director, Riggall, says he tries to get women who want to donate eggs for the altruistic purpose of helping another woman. But the donor also is paid $1,500 for her time and trouble.

Riggall says the amount is not enough for a woman to undergo the procedure for the money alone. In fact, the clinic has not had many women sign up.

“There are a lot easier ways to get $1,500,” he says. “We have a list of people who need egg donors.”

Deborah once ran an infertility support group. She was not a professional counselor, just an infertile woman trying to help others like herself.

“You’d be surprised how many infertile couples there are living in these parts,” she says.
Deborah is just as desperate as any of the women who have come to her for help. It was that desperation two years ago that caused her to barter the eggs from her ovaries for a chance to get pregnant.

Deborah did not have the money to pay for in-vitro fertilization. But she learned that the Northwest Center for Infertility and Reproductive Endocrinology in Broward County was using an innovative approach for some women.

Generally, one of them cannot produce fertile eggs, usually because of advanced age. But this woman has good financial resources. She is the recipient.

The other woman, usually younger, generally has a problem such as blocked fallopian tubes but can produce good eggs. She cannot afford in-vitro fertilization. She is the do-nor.

The deal is that the donor will give half the eggs she produces after the hormone stimulation to the recipient. The recipient then subsidizes the treatment costs for the do-nor.

Almost every day, they had to drive more than three hours from Osceola County to Broward County for blood tests and ultrasound examinations.

Deborah was a good producer. Her ovaries churned out an amazing 43 eggs in one month.
“They called me their little chicken,” she says.

This was a relief because the clinic had told her she would be dropped from the pro-gram if she did not produce enough eggs.

“I was an emotional hostage,” she says. “The general consensus among the women was this probably was not going to work, but what choice did we have?”
None of the women got pregnant.

“When we look back, we think, ‘This was pathetic,’ ” she says. “They’d herd us here, and they’d herd us there. We were only the donors. We did not pay the big money.”

Hoffman from Northwest says it is not unusual for women who have not become pregnant to be angry.
“That is human nature,” he says. “If they get a baby, they are happy. If they don’t, it’s normal to be angry.”

And though some in the industry frown on this method of egg donation, calling it egg selling, Hoffman defends it as a mutually beneficial relationship between two women.
Both are treated equally, he says.

But he does admit that the donor is told her treatment can be canceled if she does not produce enough eggs.

“We are honest,” he says. “We have to look out for two groups of people (donors and recipients). If we do the stimulation and it does not look promising, the recipient can cancel the cycle and the donor can finish at her own expense.”

“We do the best we can,” he says. “We can’t guarantee a pregnancy. We are not gods.”

Despite all she has been through, including what she believes are medical complications from hormone treatments, the only reason Deborah is not attempting another in-vitro attempt is money.

“God only knows what is in that stuff,” she says of the hormone. “I’m waiting to start glowing. But that’s the price you pay. It sounds really strange, but if they gave me a chance, Id do it again.”

B.K. Gangrade is cleaning up an egg that is too small to see with the naked eye but is visible on the microscope screen. Manipulating a miniature tool, he scrapes away extraneous tissue from the surface of the egg, which looks like a fragile bubble. This will allow the sperm easier access.
Does he ever damage the eggs?

With a delicate touch and the right equipment, a laboratory expert can do amazing things with sperm and eggs.

Using a tiny suction device he operates with small breath inhalations, Gangrade can hold an egg in place with a tiny hollow tube. Then he chases around a bunch of sperm with a microscopic needle that he makes himself, finally sucking up one inside it.

With the egg held securely in place, he punctures it with the needle and injects the sperm.
This procedure has been the biggest in-vitro breakthrough in the past decade. Now men who don’t have enough good-quality sperm to impregnate their wives even with artificial insemination can still sire children.

Even men who have had vasectomies that cannot be reversed successfully can have children. Doctors simply remove sperm directly from the testes. If there is not enough sperm, they can remove small samples of testicular tissue and extract sperm from them.

Microsurgery is now possible on embryos. Lab experts can cut into an egg, creating a pathway for a sperm to enter. They also can weaken the outer shell of an embryo with a well-placed slice, making it easier for the embryo to implant in the woman.

“Even now, it is theoretically possible to break up an embryo into eight cells and create eight identical twins,” says Gangrade.

Gangrade knows that such possibilities are why critics accuse those in his field of playing God.
“I am not creating life,” he says. “I am helping people.”

In fact, religious opposition to in-vitro fertilization has been pretty muted, says Arthur Caplan, director of the University of Pennsylvania’s Center for Bioethics. He has been observing and writing on the issue for years.

Caplan says though Catholics, Greek Orthodox and some Orthodox Jews oppose the procedure, their opposition is not vehement, nothing like the type of religious opposition there is to abortion.

“But the issue promises to undergo much more scrutiny in the next century,” he says, “as scientists learn more about manipulating genetics. Scientists already have the ability to remove a single cell from an embryo and test it for a variety of genetic traits before the embryo is transferred into the woman’s uterus.”

Right now, the procedure can be used to screen out embryos that carry cystic fibrosis and other genetic diseases. As scientists learn more about human genetics, they could screen embryos for a wide variety of not only diseases but also traits.

“I don’t think cloning is the issue, but using this in tandem with genetic knowledge to select types of children,” Caplan says. “When they get good enough, even fertile couples could use this to make babies. Give me a child that is tall, one that is smart.”

Adds Loy: “In 20 years, it probably will be possible to place an order for a 6-foot-2-inch, blond-hair-and-blue-eyed football player.”

For now, the embryos that Gangrade nurtures in his incubators are only as perfect as nature allows. As he talks in his laboratory, a nurse who is examining a blood test passes the news that yet another patient is pregnant. There is a brief cheer.

One of the door frames in the office is lined with dozens of pieces of colored tape, each with a name. The status of a patient whether or not she is pregnant is revealed by which side of the door frame the tape is located on. Right is pregnant, left is not.

Gangrade searches through the strips until he finds the one he wants. He moves the strip to the right side. It has plenty of company. From the looks of things, the clinic is having a good year.
The Center for Reproductive Medicine is now the second biggest clinic in the state.
Mother’s Day should be a very crowded event next year.

There are no government guidelines mandating educational or experience requirements for fertility specialists.

The most highly trained specialists are board-certified reproductive endocrinologists.

These are doctors who have completed training as an OB-GYN and then have under-gone an additional two or three years of training in fertility. They then have passed extensive written and oral examination.
There are only three such certified specialists in Central Florida Drs. Randall Loy, Gary DeVane and Sharon Jaffe.

Such a certification is not necessary, however. Many good reproductive specialists have gone through the training but simply never took the examination.

And doctors such as urologists and OB-GYNs also are qualified to treat many fertility problems.
A national information and lobbying group based in Massachusetts, called RESOLVE (617) 623-0744, keeps a list of qualified doctors. The organization also has dozens of informational pamphlets and papers on infertility.

As a general rule, women who are in their mid-30s and have fertility problems are advised to seek expert help as quickly as possible because time is working against them.

The success rate of a fertility clinic can be checked through a report published annually by the Society for Assisted Reproductive Technologies, an affiliate of the American Society for Reproductive Medicine (205) 978-5000. This rate is the number of patients who come in for in-vitro treatment vs. the percentage who actually take home a baby.

The numbers reported by the organization generally are dated. The most current figures are from 1994. Technology changes so rapidly that 3-year-old information may no longer reflect the current state of the industry or of a particular clinic.

Also, a clinic that takes on difficult cases such as women over the age of 40 will not have numbers as good as a clinic that handles younger women.

There are two main clinics with laboratories in Central Florida the Center for Reproductive Medicine and the Arnold Palmer Hospital Fertility Center.

A typical in-vitro procedure costs about $10,000, although this can vary according to the needs of individual patients. Most private insurance companies do not cover the procedure.

Only 13 states have statutes that deal with infertility coverage. They range from Massachusetts and Illinois, which mandate full coverage, to California and Texas, which man-date only that insurance companies offer coverage. This usually leaves it up to an employer whether to provide that type of coverage.

“We think it is an anti-family bias,” says Andy Homer, director of government affairs for RESOLVE. “This (in-vitro) is an accepted procedure. For someone who has the ability to have children, it is hard to understand how heart-breaking it can be when things don’t work out.”

Even without insurance, thousands of couples undergo the procedure. Many are aging baby boomers, professionals who can put together enough money for a last shot at having children.

“If there are more desperate patients than the infertile couple, I haven’t met them,” says Arthur Caplan, director of the University of Pennsylvania’s Center for Bioethics. “And I’m including cancer patients.”

“A big investment,” Orlando Sentinel
Coping with the high cost of infertility treatment

Imagine that you're a happily married couple with only one wish in the world: to have a baby.
But you can't seem to do it the usual way.

Then you find out what many infertile couples find out: Having a bundle of joy can cost a bundle-especially if you live in an area where infertility treatment is not covered by insurance.

For example, LeAnne and Michael Sullivan of Orlando forked over about $30,000 be-fore producing twins Darby and Kelsey, born May 18.

Kathi and Bryan Coughenour of St. Cloud, Fla., spent about $10,000 on various treatments-money they either borrowed or earned by selling possessions-before deciding that group fundraising, such as garage and bake sales, was the way to go.

Kathi Coughenour formed a support group designed to offer emotional support and something else: one in vitro fertilization procedure for each couple in the group who wants it and for whom it's medically appropriate.

In IVF, a doctor retrieves or "harvests" a woman's eggs from the ovaries. Then the egg is fertilized in a lab dish with sperm-either the husband's or a donor's-and inserted into the uterus.

When the woman is 39 or younger and the man's sperm is normal, the typical take-home-baby rate (that's what doctors call it) for minimally stimulated IVF, which relies on a little help from standard fertility drugs, is 8 to 12 percent, says Dr. Randall Loy, an Orlando reproductive endocrinologist.
For traditional IVF, which uses expensive fertility drugs that significantly increase egg production, the rate is 25 to 30 percent, Loy says.

Minimally stimulated IVF costs about $2,500, with traditional IVF costing as much as $10,000.

"I didn't need that much to put down on a house," Kathi Coughenour says. "Infertility is a very discriminatory problem. Unless you have about $10,000 lying around in your checking account, it's kind of hard."

Indeed, some couples resort to extreme measures, such as taking out second mortgages on their homes, selling their cars-or even selling their homes.

"I found out a couple was doing that (selling their house) one time and I canceled their treatment," says Dr. Mark Jutras, a reproductive endocrinologist in Orlando. "I felt it was a risk they shouldn't be taking. If they got pregnant, they needed a house to raise the child in."

Only 10 states have addressed the problem of infertility. Seven of those 10-Illinois, Arkansas, Hawaii, Maryland, Massachusetts, New York and Rhode Island-require employ-ers to carry infertility coverage; the other three-California, Connecticut and Texas-require only that insurers offer the coverage to employers.

Illinois law requires employers with 25 or more insured workers to include coverage of IVF and other assisted reproduction treatments, though there's a limit of four completed procedures. If treatment results in a live birth, two treatments for a second child are covered.

According to RESOLVE, a national information and lobbying group based in Somerville, Mass., infertility affects 4.9 million Americans, or 8.5 percent of couples in their childbearing years, ages 15 to 44.

(RESOLVE's Illinois chapter-312-743-1623 or 800-395-5522-can be contacted for in-formation on treatments and facilities available in the Chicago area.)

Lobbying organizations such as RESOLVE are pushing to have infertility coverage included in any national health-care reform plan that finally emerges from Congress.

"Infertility services are included in all the plans floating in Congress but with the specific exclusion of IVF," says Diane Aronson, executive director of RESOLVE. "We're concerned about that because that's where the field is opening up and where the opportunities are" for infertile couples.

"There's a tendency among some people to think anything can be added to the benefits package of a health insurance policy and it won't affect price," says Richard Coorsh of the Health Insurance Association of America. "It doesn't work that way.

"There have been studies indicating that, cumulatively, the cost of state-mandated benefits such as IVF could raise health insurance premiums by up to 20 percent."

Not so, says Lynne Lawrence, director of government relations at the American Fertility Society (205-978-5000).

In Massachusetts, which has required employers to provide infertility coverage since 1987, the coverage accounts for "four-tenths of 1 percent of the total monthly family premium," she says.

Cheryl Koerner's mother, Phyllis, could tell just by looking: Cheryl was going to have twins.

The first sonogram confirmed her mother's lay medical analysis: two little heads were present. A subsequent X-ray showed only one baby, leaving Cheryl and husband Richard to wait in limbo right up until the hour Theresa and Phillip - healthy fraternal twins - entered the world.

Three years later Cheryl and Richard Koerner's Orlando household was again expecting a new baby. This time the doctors thought the sonograms were conclusive. It's only one baby, they said.

Shaun and Shane Koerner - fraternal twin boys - are now 8 years old. Their sister Marcia, 13, just wishes she had been a twin too.

The Koerners - Cheryl is a homemaker; Richard manages an Orlando microfilm
lab - are part of a nationwide boom in twins and other multiple births.

In the past 10 years the number of multiple births in the United States has more than doubled. There are now 22 twin births per 1,000 births - or about 2 percent, according to the National Center for Health Statistics, a division of the U.S. Public Health Service.

The number of triplets also has jumped significantly - to one triplet birth for each 8,000 babies born. Twenty years ago triplet births were even more of a rarity than they are now.

In the United States an estimated 50,000 women had twins in 1989 - more than 4,000 in Florida alone. In the state, according to the Florida Department of Health and Rehabilitative Services, there were an estimated 84 triplet and other multiple births. Nationwide, triplets and other multiples were born to
about 2,300 mothers last year.

Experts cite these reasons for the increase in multiple births:

"We have steadily charted an increase in multiple births," said Stephanie Ventura, a demographer with the national health center. "A big part of the twin boom is first-time mothers who are aged 33 to 39. These women are having multiple births at unprecedented rates. Not just twins, but triplets - even
quadruplets."

As women pass 30, their bodies produce more follicle-stimulating hormone, which is central to ovulation. The hormone stimulates the follicles, allowing eggs to be released.

Production of the hormone also increases when a woman, who has taken the birth control pill for many years, quits taking the pill to have a baby - an occurrence common to many women over 30.

Doctors usually recommend that women who have been on the pill use an alternative form of birth control for three to six months before trying to become pregnant. Doing so makes a prospective mother healthier and can decrease the chance that an older mother will have twins.

But there are those mothers who know they have a high chance of giving birth to twins because they take fertility drugs to help them conceive.

"Clomid (the most popular fertility pill) gives couples a 5 to 10 percent greater chance of conceiving twins and a greater risk of other multiple births," said Dr. Gary W. Devane, a Winter Park infertility specialist.

"There are even more powerful fertility drugs but a common side effect of all certainly includes the risk of multiple births."

Devane estimates that 25 percent of all women over 30 might need a fertility drug to assist in conception because many don't ovulate properly as they get older. Because so many women are over 30 when they first consider pregnancy - and because so many use fertility drugs - it would follow that the
drugs are a particular culprit in the multiple-birth rise.

Still, Ventura of the health center, said twin and triplet births will continue to increase, with or without drugs. "The number of births last year was the highest it's been since 1954 - more than 4 million babies were born in 1989. The number of babies born has been increasing about 3 percent each year
since 1986. "The numbers are slowly increasing so twin births are going to increase as well," she said.

Cheryl Kroener said she won't chance another pregnancy.

"At my age, and with my genes," she said. "More twins would be almost inevitable."