Sarah Arrowsmith laughed like a drain when she heard she was expecting triplets. "I thought it was very funny. It's how it caught me when I had the scan," she says. "People react in different ways. I laughed and Mark couldn't speak."
She already had a little boy of two. The couple were facing what some would consider the horrifying prospect of sleeplessness, physical and mental exhaustion, logistical problems (how to get three babies and a toddler fed/dressed/out of the car/across a road ...) and financial hardship. And the odds on triplets born in perfect health are not good.
According to Nicholas Fisk, professor of obstetrics at Imperial College School of Medicine, the rate of perinatal mortality - death immediately before or after birth - rises from 3.7% with twins to 7.3% with triplets. The risk of cerebral palsy goes up from 1.3 to 4.5%. The problem is that triplets are born on average at 34 or 35 weeks and the earlier and tinier they are, the more at risk. "The big factor is prematurity. If they are born under 150gm, the risks of cerebral palsy are 30 to 60 times as high as if they are born at term," says Fisk.
But Arrowsmith is one of the increasing number of women in this country whose babies' lives and health as well as their own health and plans for the future are being put at risk by fertility clinics that persist in putting three embryos into the womb, some senior doctors claim. They say that the statistical evidence shows that women under 40 who have IVF (in vitro fertilisation) have as much chance of taking home a healthy baby with two embryos replaced as with three, but many private clinics obstinately defy the guidelines.
The number of multiple births - twins or triplets - resulting from IVF has risen inexorably as more and more couples have sought treatment, more than doubling in six years from 716 in the year to March 1993 to 1,730 in the 12 months to March 1999. Hospital neonatal units, which have to cope with these sometimes seriously ill babies, are under severe pressure. A study last year in the British Medical Journal found that most of the major centres in the UK "are regularly unable to meet in-house demand".
More than 1,500 babies a year are being transferred, it said, usually because of a shortage of beds or nurses or both. Mothers about to give birth are shipped off to hospitals far from home. Worse still, twins or triplets are sent away from the hospital where their mother is recovering from a caesarian section and sometimes split up, perhaps hundreds of miles apart.
It nearly happened to Arrowsmith. At 27 weeks, she went into premature labour. If the babies survived, they would need the highest level of intensive care and her hospital, Queen Charlotte's in Hammersmith, London, did not have three cots available in the unit. "I had to be blue-lighted to Barnet," she says. "It was the ninth or the 11th hospital they phoned. I was distraught. I felt very unwell because they had given me this drug to stop the labour and the ambulance kept having to stop because I felt so sick."
One in 10 babies, some 72,500 a year, need special care immediately after birth according to Bliss, the national charity for the newborn. There are only 2,881 cots in units equipped to look after them. One in 100 - 7,250 - needs intensive care, yet there are just 913 such cots available. These are extremely expensive facilities, which also require specialised nurses. Neonatal units rely heavily on charitable funding - in 1999, voluntary organisations contributed £10m for new equipment.
Multiple births are not the only reason for the increased strain on the units. "We have got the technology now for more babies who are born sick or premature to be considered viable for treatment," says Suzanne Dobson, chief executive of Bliss. The government is now reviewing the units, to establish whether the facilities are grouped in the best placed hospitals to try to minimise the number of transfers that take place, but the nursing shortage will be harder to tackle. "It's a very high stress job," says Dobson. "Sick children are difficult to deal with. There is a high death rate and lots of distress for the parents."
Sarah was lucky. Her labour stopped again and the triplets were eventually born at 32 weeks. They were tiny and fragile. Charlie was the smallest at 2lbs 3oz, and he had a collapsed lung, Grace weighed 3lbs 3oz and Henry was a relatively robust 4lbs 4oz. There was no guarantee that they would all survive.
"We had it take it day by day," she says. "They got septicaemia and Grace nearly had a cardiac arrest. The doctors were very, very good. They never said, 'They'll be fine, don't worry.' They told it as it was."
Arrowsmith feels she owes the hospital the lives of the triplets, who are now healthy, lively two-year-olds. She says she was told at the fertility clinic that there was a risk of triplets if they transferred three embryos into her womb. "I knew two would have given me as good a chance but I said I'd have three," she says. She felt, against reason, that she must be improving the odds. But, previously, she had suffered a miscarriage after IVF which doctors thought might have been a multiple pregnancy. "One of the consultants at Queen Charlotte's said that with my history she would never have put three embryos back," she says.
During the pregnancy, doctors pointed out the dangers both to her and the babies of carrying three and she was offered what is called "selective reduction". "It's a potassium injection into the heart of the foetus. I was horrified, but some people who can't even contemplate three do it. It was mentioned every time I went to the hospital. I found it quite offensive, but I understand that they have to offer it. I had gone to so much trouble to have children that I could never think of doing it."
Professor Fisk frequently encounters that reaction. "The women I see are often in their first pregnancy and can't cope with the idea of terminating one baby," he says. Most have no idea that there are dangers inherent in carrying triplets. "They are often shocked at the risk. I think it is unethical to put three embryos back. Infertility clinics are motivated by seeming success rates."
Those success rates are at the heart of the dispute. For women under 40, the human fertilisation and embryology authority, which monitors all the UK fertility clinics, says the chance of a baby is the same with two or three embryos. But many older women go to the private clinics and their chances of pregnancy at all are low. Fertility doctors such as Ian Craft at the London Fertility Centre and Mohammed Taranissi at the Assisted Reproduction and Gynaecology Centre insist they should have the freedom to maximise the chances of those women by putting back three embryos - the maximum allowed by the HFEA - or even more.
Taranissi, who has the highest rate of three-embryo transfer in the UK, took the HFEA to a judicial review last month, to contest its right to limit the number of embryos he can transfer. However, he lost.
The HFEA is making nobody happy. On the one side is Mr Taranissi, demanding greater freedom. On the other side are the Royal College of Obstetricians and the British Fertility Society, both of which would like it to take a tougher line. The two bodies have published guidelines to all clinics stating that two embryos should normally be the maximum but the HFEA still allows a maximum of three. The guidelines, published last year, seem to have been ignored.
"There is no sign of the number of triplets in England decreasing as yet, which is disappointing," says Alan Templeton of the Royal College. While many NHS units had adopted two-embryo policies, private clinics were not falling into line. Yet in his view, there is no reason to risk triplets. "Scandinavian success rates are continuing to rise and they almost never put back three," he says. In fact, they are moving towards just one. In Scotland also, the policy is to transfer no more than two. "It is an English problem," he says. "Several of the big London private clinics are contributing more triplets than the whole of Scotland."
Apart from the dangers of death, damage and long-term ill-health to the babies, multiple births cost the NHS a fortune. "The savings from stopping triplet births would pay for the entire IVF programme in the UK," he says. "The cost to the NHS of the average triplet birth may run to five or six figures."
Richard Kennedy, secretary of the British Fertility Society and a consultant gynaecologist at the University Hospital of Coventry and Warwickshire, says tougher action is required: "The HFEA needs to sort out clinics that are disregarding the guidelines. But they are not prepared to do what we and the college have asked them to do and come down off the fence," he says.
At the very least, he says, there should be a code of practice to stop three-embryo transfer to women under 40 (Fisk says most of the women carrying triplets he sees are under 40). Then, there should be a properly conducted, randomised, controlled trial to establish whether or not it improves the chances of women over 40 producing a healthy baby and their risk of triplets. "Let's prove it once and for all," says Kennedy.
IVF is not the only problem. Many multiple births are the result of drugs which stimulate the ovaries. The drugs are prescribed by gynaecologists for women with ovulation problems, probably 20% of those who have difficulty conceiving. The Royal College thinks the treatment should only be given in specialist fertility centres, where women can be monitored to avoid multiple births.
With the number of women who want fertility treatment rising exponentially - more than 27,000 patients were treated in 1998-99, up from under 15,000 in six years - the problems for the NHS are going to increase unless multiple births are limited.
Arrowsmith will never regret having triplets, but it is not easy. She is lucky enough to have been able to afford help when the triplets were babies, and now they go to nursery three days a week, giving everyone breathing space. But she knows of other triplet mothers who have had no support. "It is extremely hard," she says. The Multiple Birth Foundation points out that there is no statutory entitlement to money or assistance. "We have identified that a great deal could be done and made available to these families which is not too complex, such as advice about routine care and sleeping and feeding," says Jane Denton, its director.
Families with IVF triplets and twins get little help and less sympathy. They chose to have the treatment. They wanted babies and their dream has come true. Sadly, it can sometimes seem more like a nightmare. For their sakes, for the children's sakes and in the interests of the hard-pressed NHS neonatal units, many believe the UK must take a tougher line on multiple births.
