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20090223
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Fresh Air
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Liza Mundy: Multiple Births 'Changing Our World'

TERRY GROSS, host:

This is Fresh Air. I'm Terry Gross. It used to be considered pretty remarkable when a woman gave birth to twins, triplets or quadruplets, and it was most certainly a remarkable story when Nadia Suleman gave birth to octuplets after already conceiving six children through in vitro vertilization. But perhaps what is most remarkable now is how relatively commonplace multiple births have become because they're so often the result of fertility treatments.

In the U.S., more than a third of children conceived through in vitro fertilization are born in sort of a set. My guest, Liza Mundy, writes that perhaps no change wrought by fertility medicine has been as profound and far-reaching as the explosion in multiple births. Mundy is the author of "Everything Conceivable: How Assisted Reproduction Is Changing Our World." She describes the book as an analysis of the impact reproductive science is having on our ideas about human life and the changes that reproductive science is imposing on families, medicine, culture, schools, the women's movement and the human race itself. Mundy is a staff writer for the Washington Post. Liza Mundy, welcome to Fresh Air.

Now, I've thought about how challenging it must be for a mother to suddenly have two, three, four, five or eight babies, but your book raises so many other questions about how multiple births are affecting both parents and society. One of the many issues you bring up regarding multiple births that I certainly hadn't thought about is that multiple births often means multiple deaths. Could you give us a sense of why the mortality rate for twins, triplets, quads, octuplets is so high?

Ms. LIZA MUNDY (Staff Writer, The Washington Post; Author, "Everything Conceivable: How Assisted Reproduction Is Changing Our World"): Well, there are any number of reasons, but often because these children are more likely to be born premature and they're more likely to be born low birth weight, so 15 to 20 percent of triplets are lost before viability. The mortality rate for triplets and also for twins is much higher than it is for singletons.

You know, basically, our uteruses are single-occupancy dwellings, and we're not really set up to nurture and give birth to more than one child at a time, and so any number of serious problems can arise with multiple births - things like twin-to-twin transfusion syndrome, where one twin is sort of taking the nutrients from the other and one gets much larger than the other does. Rates of cerebral palsy are much higher with multiple births. There are all sorts of medical problems, including, you know, miscarriage and infant death that occur in multiple births that nobody is really prepared for because we hear about it so seldom.

GROSS: Well, you say that, you know, in multiple births there's often not enough room for brain growth.

Ms. MUNDY: That's right. I mean, growth in the womb can be stunted, and if both of the two fetuses are attached to the same placenta, then they're sort of competing for nutrients. So really, all sorts of things can go wrong. And also, it's important to remember that all sorts of health problems with the mother are more likely - you know, although maternal mortality is rare now in pregnancies, the chances of it are higher in multiple births.

GROSS: But why is that?

Ms. MUNDY: Well, again, it's because we're not really set up to give birth to three children at a time. And so, you know, the mother's body is working much harder to nurture and provide nutrients to more than one child. Preeclampsia, which is one of the most serious complications of pregnancy, involves high blood pressure and swelling due to fluid retention and kidney malfunction. And the only cure, so-called cure for preeclampsia is delivery of the babies. And so again, mothers are more likely to develop preeclampsia with multiple births, and that forces the doctor to induce labor.

We've got all these special wards now in hospitals, these special wings for high-risk pregnancies, and typically these beds are full of mothers on, you know, extended bed rest as a result of being pregnant with multiples.

GROSS: And you say that there's been a lot of growth in neonatal intensive care units because there are so many premature babies being born as part of what some doctors describe as an epidemic of multiple births.

Ms. MUNDY: Yes, exactly. I mean, one of the reason that doctors have gotten really pretty good at delivering high-order multiples is because they're getting so much practice. But again, we typically hear about the really high-profile, extreme cases, and in fact, this is something that's going on all the time, and it's not always so successful. I've come to think of it sort of as extreme childbirth, you know, like an extreme sport that women are on these, you know, tables giving birth to any number of children, and sort of as in wartime medicine, doctors are getting better and better at handling these extraordinarily high-pressure deliveries.

GROSS: You know, in terms of what issues multiple pregnancies poses for society, is the expense of multiple infants in ICUs something that we are shouldering as a society?

Ms. MUNDY: We are shouldering it as a society. I mean, even if people have medical insurance to pay for the care of infants born as a result of multiple births, of course, that could be affecting insurance rates. And I talked to the parent of triplets, and she's always in the doctor's office, in part because her children were born with various, you know, developmental delays, but also more susceptible to illness and more likely to sort of give each other whatever they've got. And so she just described the really months of having triplets as being constant trips to the doctor's office.

GROSS: Let's look at some of the reasons why infertility treatments often lead to multiple births. Why do some fertility drugs lead to multiples?

Ms. GRUNDY: Well, typically, fertility drugs sort of goose a woman's reproductive cycle and cause her to ovulate often more than one egg a month. Typically, we ovulate one egg a month. It's really sort of an extraordinary process by which all these hormones wash through our bodies and awaken some egg cells but ensure that just one comes to maturity. It's one of the many ways that our bodies are designed to make sure that that we typically bear one child at a time.

And what happens when a woman takes fertility drugs is she will ovulate any number eggs in a single cycle, and so as a result of either having sex or being artificially inseminated, which is a pretty common low-level fertility treatment, she could become pregnant with any number of fetuses. And typically, the really high-order multiples that we hear about are the result of just fertility drugs which are - it's just very hard to control the number of conceptions that occur.

The other reason is in the more high-level procedure of in vitro fertilization, where the eggs are actually removed from the woman's body and fertilized with sperm in the laboratory, once they become embryos, either at three days or sometimes at five days, they're then transferred back into the woman's uterus. And again, any number of embryos can be transferred. In the old days, 10 or 15 or 20 years ago, doctors might transfer eight or 10 or 12. Certainly, they're getting much more conservative about this. But even with two embryos or three embryos - and of course, patients want to assure that the procedure succeeds, so they often want a number of embryos transferred - so you could end up, therefore, with twins or with triplets.

And the other thing about IVF embryos, for reasons nobody quite understands, they're more likely to twin, so they're more likely to split in the uterus and result in identical twins. So even if you transfer one or two embryos, you might end up with two or three fetuses.

GROSS: And as far as I know, I think a lot of women encourage the transplantation of multiple embryos because it costs, what, $12,000 per cycle for in vitro fertilization. So how many times do you want to spend for $12,000?

Ms. MUNDY: That's exactly right.

GROSS: You want it to work the first time around if possible.

Ms. MUNDY: That's exactly right, that the patients really want this to work. They have the idea often that two would be a bargain. It's not just that you want it to work, but if you could get both the children that you want with one treatment, you know, so much the better. So doctors repeatedly tell me that they have patients urging them to transfer at least two embryos and often more - the sort of idea, you know, the more the merrier, and it's almost like buying in bulk. Because so often in this country patients are paying for this procedure, financial considerations are enormously influential when deciding how many embryos to transfer.

GROSS: When a woman finds out that she's actually carrying multiple fetuses, that several of the embryos have become fetuses, there is a procedure to eliminate some of the fetuses, and some women opt to do that. What is the procedure and what are some of the larger issues that it raises?

Ms. MUNDY: Yes, the issue is called selective reduction, and there are a number of doctors who perform this procedure. Most of them don't like to really have their names published because it could be seen as a form of abortion, I think. That's arguable. I had one doctor argue that, you know, abortion completely eliminates all fetuses in the uterus and selective reduction doesn't.

But this is a procedure whereby a doctor would inject potassium chloride into the heart of a fetus in order to take pregnancy down to a more manageable number. And again, in the older days, when a woman might be more likely to be pregnant with extreme multiples as a result of IVF, it was a pretty clear cut - I think it was a more clear-cut situation if you're pregnant with six fetuses, you know, to take it down to two. It was a pretty clear-cut decision for the health of the babies and the health of the mother.

But what you see, I think, increasingly, is a woman pregnant with triplets who is really torn between carrying three of them to term and sort of braving whatever risks are involved, or being more conservative and eliminating one of the fetuses in order to better ensure the health of the two than remain. And in some cases now, patients are making the decision to reduce twins to a singleton, and this is something that is more controversial because twins are at a higher risk, but some would argue that the risk is not great enough to really sort of justify that procedure. It's a very undefined ethical terrain, and it's very difficult for the patients who have often worked so hard just to achieve a pregnancy, you know, and then are forced make this very difficult choice.

And you know, in some cases, the doctor will say to them, I find two girls and a boy here, and so would you like to make the decision based on gender? One of the interesting things to me about reproductive technology and assisted reproduction is all of the choices that it imposes on patients that unfold as the pregnancy develops, and they're often choices that people are just completely unprepared for.

GROSS: Are there choices you can make during the fertility treatments that you're having to prevent or at least seriously limit the possibility that you'll be carrying multiple fetuses?

Ms. MUNDY: Well, I think one of the first choices would be how many embryos to transfer back, and this is one of the first choices that patients face. And it's again, a little bit of a tug-of-war between the patient and the doctor. Typically, it's a choice that does reside with the patient, although I think doctors increasingly are willing to say, you know what, I'm just not going to do three. You're young, and you have a good chance of conceiving, and so we're going to do two or we're going to do one. But that's, I think, the first opportunity that patients have to limit multiples.

I suppose before that you could say that patients, if they can afford it, might have the choice to just forego fertility drugs and that sort of first level of treatment and go straight to IVF. But in order to make that choice, of course, you have to either have insurance coverage for IVF or you have to be able to afford it.

GROSS: My guest is Liza Mundy. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World." Let's take a short break here and then we'll talk some more. This is Fresh Air.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Liza Mundy. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World."

In Europe, there are governments in which if they pay for in vitro fertilization through health insurance, they will restrict the number of embryos that can be implanted in any one time. Are there guidelines in the United States for the number of embryos that can be implanted during one treatment, during one round?

Ms. MUNDY: Well, guidelines is exactly the right word because there aren't laws in this country about that. The American Society of Reproductive Medicine does have guidelines. They are voluntary guidelines, and they are certainly encouraging doctors to transfer fewer embryos than formerly. Their guidelines say that if a woman is under 35 and has pretty good indications for success that doctors should strongly consider transferring one embryo now and no more than two; that if she is between 35 and 37, they should strongly consider transferring two and no more than three. And the numbers go up slightly the older the woman gets. But you know, even after 40, the ASRM urges no more than five embryos, or if they've been cultured for five days under what's known as blastocyst, no more than three.

So there are guidelines, and doctors, I think, do take these seriously, but there is still a fair amount of decision-making power left to the doctor and to the patients.

GROSS: So how often are the guidelines followed? Do you have any idea?

Ms. MUNDY: Well, I think they're followed pretty often. The Centers for Disease Control and Prevention publish a report every year in which participating clinics specify how many embryos they transferred into women and at what ages. And over the years, we've been seeing the average number of embryos transferred go down. It's just that clinics don't have to participate in this government monitoring. Clinics don't have to join the umbrella organization called SART, and so there's nobody policing the number of embryos transferred, and if a clinic wants to join none of these organizations and doesn't want to participate in government monitoring, they don't have to.

GROSS: Do you think women are typically warned about the high likelihood of multiple births through fertility treatment?

Ms. MUNDY: I think that there could be and often is a sort of a perfunctory warning, but it's not an in-depth discussion. And I suppose it depends on how you define informed consent because it really would take a lot of discussion and maybe some video showing of what it really is like - what a multiple pregnancy can really be like, a multiple-delivery, what raising multiples can really be like. You know, there are studies that show that mothers of triplets are much more likely to experience depression than mothers of singletons.

It's such a gamble because multiple pregnancies can turn out fine, but they can also be disastrous, and there's really no way to know in advance going in how it's going to work out for you. And increasingly, on cable television, we see these parents of super-multiples and their lives and their ups and downs, and there's this kind of public fascination, and increasing, I think, publicity opportunities for these big families. And so I think that patients are much more likely in reading about multiple births to encounter the word miracle than they are to encounter the word disaster or infant mortality. So no, I just don't think that patients are prepared.

GROSS: One of your chapters is devoted to what does choice mean now in the area of reproductive technology. We've always thought of choice as revolving around abortion - are you for it or against it? But you're saying that with reproductive technology, there's a lot of new reproductive choices that have to be made, and it's very confusing for a lot of people to figure out what side you're on on these issues, and where you stand on abortion doesn't necessarily indicate where you're going to stand on these issues about reproductive technology. Give us an example or two of these new choice, complicated decisions.

Ms. MUNDY: Well, we've already talked about a couple of them, as you say, the choice of how many embryos to transfer and who should make that. And this sort of principle of reproductive freedom has guided the development of IVF medicine in this country, the idea that patients largely should be able to choose, you know, whether to go through IVF, how many embryos to transfer. The other choices that we've talked about are the choice of whether to go through with the multiple pregnancy or whether to selectively produce it.

The choices that we haven't talked about yet are all the choices that arise with what's called collaborative reproduction, and that's where a third party is brought into the equation, and this is an explosively growing area of reproductive medicine in which either a sperm donor is used or an egg donor is used and generally paid and/or a surrogate. And this raises all sorts, again, of issues involving choice.

You know, for example, people, I think, generally, are troubled when egg donors who are tall and attractive and Ivy League graduates are paid $50,000 for their eggs. This seems unseemly to people, but again, is largely governed right now by reproductive freedom, that if somebody is willing to pay $50,000 for the eggs of an Ivy league graduate, they should be able to do so and she should be able to donate. And it questions, you know, how many times should an egg donor be able to donate? How many times should she go through this procedure? If I'm a mother and I believe in reproductive freedom, how do I feel about my daughter donating eggs to another couple?

I have a chapter in my book in which a gay couple availed themselves both of an egg donor and a surrogate, and this is an increasingly common situation in which a surrogate carries embryos that are not genetically related to her because it sort of makes the whole process cleaner, but they had to decide how many embryos to transfer into the surrogate because the lab had thawed more than they wanted. And who makes that choice? Does the surrogate make that choice or do the fathers make that choice? So it's dizzying, and the choices really don't stop.

GROSS: Liza Mundy will be back in the second half of the show. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World." I'm Terry Gross, and this is Fresh Air.

(Soundbite of music)

GROSS: This is Fresh Air. I'm Terry Gross, back with Liza Mundy. We're talking about her book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World." She's a staff writer for the Washington Post. Part of her book is about the new kinds of ethical decisions fertility patients have to make.

A lot of people now are faced with the question of what to do with their discarded embryos after finishing in vitro fertilization. And there is a lot of choices that parents or would-be parents have to make that they might not be prepared for. What are some of those decisions?

Ms. MUNDY: Yes, this is so interesting to me. I have a chapter on my book called "Souls on Ice," and it's so interesting to think about how patients feel about their embryos. Often, when a woman goes through an IVF cycle and they have more embryos than they can transfer, they freeze them. And embryos can thaw pretty successfully and be used, and this is good because women don't have to take as many fertility drugs and can go through multiple cycles.

But what happens when patients have leftover frozen embryos and they're done with fertility treatment is they have a great deal of difficulty knowing what the right thing is to do with these frozen embryos. And as a result of this, we have probably about a half million frozen embryos in storage around the country. In many cases, patients have just stopped paying the so-called storage fees, and the embryos are sort of in limbo, unclaimed, and in some cases, doctors hire collection agencies to try and track them down. And doctors, although they theoretically could thaw the embryos and destroy them, are afraid to do so because the moral and even the legal status of these embryos is just pretty undefined.

And many patients go into the process thinking, OK, well, if I end up with six frozen embryos and I've got a couple of children as a result of these treatments, then I'll donate these embryos to another couple because I feel sorry for anybody who has to go through what I've had to go through. And then when they get to the end of a cycle, if in fact they've had a child or more than one child and they're done, they realize that these embryos, if born, would be the full siblings of their existing children, and it becomes much harder to give them away and donate them to be raised in a completely different family.

There are some agencies that are almost like adoption agencies that exist to try and facilitate these transactions, but studies have shown that patients almost always change their mind when they're going through this procedure about what is the right thing to do with their embryos and even how to think about their embryos. You know, do they think about them as sort of just little pieces of tissue or do they think about them as property or do they think about them as potential children? Even if you go into the procedure thinking of yourself as, say, as pro-choice, you might at the end still have a hard time thawing those embryos, and I've talked to any number of patients who've gone through this.

And I think an important point to make is right now we have a moratorium on federal funding for embryo research, and this is affecting the multiple births issue because if doctors could perform embryo research, it would be easier for them to identify a good and likely embryo and easier for them to make the argument for just transferring one. But right now, it's very difficult for scientists to identify which embryo is mostly likely to take, so it's sort of a vicious cycle. If we could perform more embryo research, I think we would be less likely eventually to be looking at so many multiple births because the science could become more precise about embryo diagnosis.

GROSS: So if President Obama lifts Bush administration restrictions on embryonic stem cell research, how will that affect the decisions that have to be made about what to do with embryos?

Ms. MUNDY: Well, yes, ultimately it would make it easier for patients to donate their embryos to scientific research, and while not everybody would be comfortable doing this, I think that more patients would choose that. Up until now, it's been very difficult for patients who want to donate their embryos to research to find a lab that could take them because of this moratorium on any embryo research, including embryonic stem cell research. And so, if that is lifted or when that is lifted, that moratorium, then the pipelines should kind of open up, and it will become easier for patients to donate their embryos, and I think many would be happy doing that, although not everybody would.

GROSS: Now some people are opting for fertility tourism, going to other countries where the options will be cheaper. What are some examples of that?

Ms. MUNDY: Well, an example that people talk about is going to third-world countries where women can be hired as surrogates more cheaply than they can in this country. So again, collaborative reproduction tends to be something that would cause people to leave this country and go to other countries where egg donors and/or surrogates might be procured with less expense. But it's also interesting because patients from countries where there are more restrictions will sometimes come to this country because, say, they want to be able to transfer more embryos or at least have a choice, a say in how many embryos were transferred. I was at a clinic where a couple from another country who had been through a couple of failed rounds of IVF, which was so emotionally difficult for them, had come to this country because they wanted to be able to transfer three embryos, they wanted to increase their chances of success, as they saw it. So interestingly, it works both ways.

GROSS: On the whole, do you think that reproductive treatments for men and for women are getting more difficult or easier?

Ms. MUNDY: Well, I think that they're getting easier in the sense that they're getting more successful. You know, one of the ironies of the current state of the science is that infertile man - and men are infertile as often as women are - infertile men have benefited more from the science than women have. IVF was created and envisioned as a treatment for women and specifically as a treatment for married women under 35 with blocked or missing fallopian tubes, and the conception in the petri dish was basically a substitute for what would happen in the fallopian tube.

And there was a procedure that succeeded, sort of to people's surprise, in which a sperm could actually be directly injected into the egg. It's called ICSI. It's been around, I think at this point, for more than a decade. And as a result of ICSI, a man with a very low sperm count or practically no sperm can become a genetic father. And so for a man who typically decades ago might have availed themselves of a sperm donation secretly - and this used to really be the only solution to male infertility and it was done quietly in the doctors office and the child was never told about it - but now, thanks to the IVF and then the improvements on IVF, almost any man can become a father, a genetic father, and in some cases pass along his genetic infertility to his sons.

So I suppose you can say that it's become easier because the science is much better than it was 20 years ago in their procedures. You know, but emotionally, of course, it's still quite difficult to go through these cycles, and as we talked about at length now, the emotional and sort of moral burden of working your way through all these choices doesn't seem to have become any easier.

GROSS: My guest is Liza Mundy. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World." Let's take a short break here and then we'll talk some more. This is Fresh Air.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Liza Mundy. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World."

We were talking about difficult decisions that parents or would-be parents have to make regarding reproductive technology. If someone succeeds in in Vitro fertilization or in having, you know, a surrogate carry their child, they have to decide whether or not to tell their child the identity of the sperm donor, the egg donor, the surrogate mother. What are some of the issues this question raises about identity?

Ms. MUNDY: Well, I think the central issue it raises is how much genetic relationship matters to the parent and to the child. You know, an increasing number of women are availing themselves of egg donors. This is a really growing aspect of the technology because the unfortunate fact is that if a woman is over 40 or in some cases in her late 30s, IVF is much less likely to be able to help her with her own eggs because our eggs do age and just become less viable as we get older. And so more and more women are turning to egg donors and justating(ph) the pregnancy, justating the embryos, but the embryos they're justating are not genetically related to them. And they struggle with the question of whether and how and when to tell their child that they are not the genetic mother. And this is something that has been an issue ever since sort of the beginning of fertility treatment.

I mentioned decades ago for infertile men, it was commonplace but highly secretive for a sperm donor to be procured and for a woman to be artificially inseminated. It was not uncommon that it might be the doctor himself or a med student. And decades ago, the parents would be counseled, you know, absolutely do not tell the child that he or she is the product of sperm donation. And so there are a group now, the dolopal(ph) spring, who are making the argument that they, like adopted children, have the right to know the genetic identity of their parent, and this is becoming less of an issue with regard to male infertility, but again, women now, availing themselves of egg donors, are asking themselves these same questions.

And because they actually go through the pregnancy and give birth to the child, it is quite feasible to never tell because the child was born to the mother, and it would be reasonably easy to keep this secret. And right now, parents do have the choice. They can make their decision of whether or not to tell their child that they're the product of sperm or egg donation and also whether or not to disclose the identity of the donor. Of course, in order to be able to do that, they have to know the identity of the donor, and in many cases they don't.

GROSS: The difference, it seems to me, is that if a mother gives away a aby for adoption, the mother has carried the child, the mother has mostly likely seen the baby and might feel a connection to the baby that I think a woman who just donated an egg would be unlikely to feel.

Ms. MUNDY: I think that's true, and I think that most egg donors do feel that way. I think most people who can be egg donors, you know, emotionally and psychologically don't feel very proprietory toward their eggs, and they're happy to think that they are helping another couple. This seems to be a big part of it, and the money is actually motivating, as well. So I think that you're right, for the egg donor, there's not the sense of having carried the pregnancy and surrendered a child.

But I think for the child, you know, issues of who am I genetically related to - and if a child doesn't even know that they are the product of a sperm or egg donation, then when they go for their annual or physical, I know that I'm always asked about my parents' history and that my doctor considers this a major aspect of diagnosis in determining what to look for. If you think you're genetically related to somebody you're not genetically related to, it could affect your own medical treatment.

GROSS: More and more, too, because genetic medicine is becoming more and more developed, so that's the direction we're heading in.

Ms. MUNDY: And this, again, is one of the ironies. I mean, we're becoming as a society more and more, I think, aware of the importance of genetic connection, and yet parents going through what they call collaborative reproduction - using an egg or a sperm donation - you know, might be trying to tell themselves, well, genetic connection doesn't really matter. And that's a sort of a hard kind of duality to hold in your head. It may be that it doesn't matter as far as the emotional bonds. I mean, I think the science largely shows that it's nurturing and raising the child, it's the labor and the love of physically raising that creates that bond and that attachment. But when it comes to our medical histories that genetics do play a part, and at the very least the child shouldn't be misled into thinking they're genetically related to someone they're not genetically related to.

GROSS: If you're just joining us, my guest is Liza Mundy. She's a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction Is Changing Our World."

The first article that you wrote on reproductive technology had to do with the fact that - it was news to me - which is that it's poor women who are most likely to be infertile. Why is that?

Ms. MUNDY: Because, you know, much female infertility, particularly sort of tubal blockages, are the results of infections, you know, fairly simple infections that if left untreated can have that effect of blocking the tubes. And so if you are poor, you are less likely to have received the medical treatment that a more affluent person has received and more likely to be infertile. In third world countries, there is a fair amount of infertility that is the result of one-child birth - having a child and then having medical complications that result in later infertility. So infertility rates are quite high in third world countries as well, and the opportunities for poor and low-income people to avail themselves to fertility medicine are few and far between. There are some programs that provide free or reduced priced IVF, and they are hotly competed for.

GROSS: What are some of the issues revolving around insurance coverage of infertility treatment? Some people's plans cover certain treatments, other people's don't. What are some of the issues about medical insurance in infertility?

Ms. MUNDY: Well, I think that up until now, insurance companies have been able to sort of get away without covering IVF, in part because there's this widespread view that fertility is - infertility is not a disease, that's it's kind of a self-inflicted condition that is experienced by women in their 40s who didn't get started soon enough, and that's just not true. It is, in most cases, a medical condition. And when insurance companies cover IVF, it is, of course, more feasible for fewer embryos to be transferred because generally, a patient will be given, say, three IVF treatments, and so there's more opportunity for the doctor to transfer, say, one.

And there are just a few states that mandate insurance coverage for IVF treatments, and I believe that the state of Connecticut does so but also imposes a limit on how many embryos can be transferred. In other words, they say, if this is going to be paid for, then it's in our interest for fewer children to be born at a time. And I think that, you know, in the long run, that's a very sensible policy and results in fewer medical issues in the children who are born as a result of the treatments.

GROSS: You've written a little bit about something I want to ask you now. You have a daughter, and how old is she now?

Ms. MUNDY: Thirteen.

GROSS: So, when she thinks about motherhood as a possibility in the future, is she thinking about options that are very different from options you ever thought about when you were a teenager looking ahead to your future?

Ms. MUNDY: Well, I certainly think so. I mean, when I was reporting my book, I would talk about this with both of my children to the point where I'm sure they became - they became very tired of it and had heard about sort of egg and sperm much more than they wanted to. You know, but they do have schoolmates who are IVF children, and they have schoolmates who, you know, have photographs on the wall of themselves as three-day-old embryos. So this is - you know, the idea that children can be conceived through medical technology is certainly something that they're very aware of.

And I think my daughter is probably more aware than I was of the concept of a biological clock, say. We've talked a lot about that. We've talked a lot about the importance or not of genetic relationship in parenting. And I think in part because I live in an urban area, my children are very familiar with all sorts of different family relationships and feel that they are all very, very workable and viable parental relationships.
But I do think that she has the sense that there are complexities and choices out there for her that were not there for me. And I do know that, you know, for college students, for female students, there are lots of signs up in student unions, you know, advertising for egg donation. And many women, you know, ask themselves whether this is a way to help finance their college education, and that certainly wasn't the case when I was in college, so even that one choice is something that she'll face that I never had to.

GROSS: Well, Liza Mundy, I want to thank you very much for talking with us.

Ms. MUNDY: It was a pleasure. Thank you so much for having me.

GROSS: Liza Mundy is a staff writer for the Washington Post and author of the book, "Everything Conceivable: How Assisted Reproduction is Changing Our World."

Coming up, Maureen Corrigan gives us her take on the incredibly popular "Twilight" series of vampire novels and reviews the supernatural novel "Drood" inspired by Charles Dickens' final unfinished novel. This is Fresh Air.
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'Drood', 'Twilight' Offer Old Horror, New Thrills

TERRY GROSS, host:

A fascination with the unknown, whether it's the missing details in a famous author's life or the truths lurking in age-old myths guarantee that stories about the supernatural will always commend a rapt audience. Book critic Maureen Corrigan has succumbed to two fictional attacks by ghosts and ghouls.

MAUREEN CORRIGAN: All writers are grave robbers, but genre fiction writers have to be the most brazen of all. Of necessity, to write a romance or mystery or horror story means sticking to the narrow confines of a formulaic plot and generally digging up literary turf that's been worked and reworked to the point of exhaustion. That's why it's a special pleasure to stumble upon two authors - one a literary phenom - who've breathed new life into what must be the creakiest of genres: the tale of terror.

Dan Simmons' fictional filching begins with the title of his thick novel, called "Drood." Dickens' last unfinished novel, "The Mystery of Edwin Drood," has bedeviled generations of writers who've taken a crack at completing what would have been Dickens' first mystery story. Simmons, however, is more interested in the supernatural possibilities lurking in Dickens' skeleton of a plot.

The novel opens on June 9th, 1865, when Dickens, along with his mistress, Ellen Ternan, and her mother actually were passengers on a London-bound train that was derailed. Here's a description of Dickens comforting a trapped female passenger whose arm is sticking through a window.

(Reading) Dickens squeezed the woman's hand. Her pale fingers squeezed back, the first finger closing, opening, and then curling and closing again around his first fingers much as a newborn baby would instinctively but tentatively grasp its father's hand. Oh, Christ, cried someone. Dickens crawled forward to offer his help and finally saw into the space. There was no woman, only a bare arm severed just below the shoulder lay in the tiny open circle amidst the debris.

"Drood" is a giddy scare fest replete with zombies and brain-eating bugs. But to tell you the truth, around page 600 or so, it became a bit wearying, like listening to someone shriek for hours and hours. Maybe that's why I was receptive to turning to tales about calm, controlled vampires in the rainy Northwest. In other words, I finally decided to investigate what all the fuss is about Stephenie Meyer's "Twilight" series. The "Twilight" series - which is composed of four novels about a 17-year-old human high school student named Bella Swan and her boyfriend, Edward Cullen, who's a vampire - has even been credited, along with the Harry Potter books, by the National Endowment for the Arts for boosting American reading statistics this past year. I've read two of the novels in the series so far, and I confess, I have joined the legions of the bitten and smitten.

If you're familiar with Bram Stoker's "Dracula", you know that vampires are about sex. The whole "I vant to suck your blood" routine is a cover story to cloak co-mingling. And therein lies the brilliance of Meyer's revision of the "Dracula" tale. Because in the "Twilight" series, vampires are still a cover story for talking about sex, but this time round, the emphasis is on abstinence. Edward, whose character is indebted to 19th-century brooding bad boys like Mr. Darcy and Mr. Rochester, is a vampire vegan. In other words, he keeps his fangs, uh, "zipped up." Here's Bella explaining their boundaries in the second novel, "New Moon."

(Reading) Edward had drawn many careful lines for our physical relationship with the intent being to keep me alive. Though I respected the need for maintaining a safe distance between my skin and his razor-sharp, venom-coated teeth, I tended to forget about trivial things like that when he was kissing me.

Much has been made of the fact that Stephenie Meyer is a Mormon and that her series invests "Dracula" with conservative Christian values, but that take doesn't account for the series' power. Because what the "Twilight" books gain from this chaste storyline - at least in the first two novels - is a heady, passionate emphasis on yearning. Desire in these novels isn't just tethered to sex; it's free-floating and intense, and it particularly emanates not from the male vampire, but from our heroine, Bella, who's gutsy and hungry for release from ordinary girly-girl concerns. Meyer's vampire tales aren't so much about "I vant to suck your blood" as they are simply about "I want, I want."

Both Meyer and Simmons are inventive inheritors of the tale of terror, but Meyer is the writer who really proves that "the undead" is a term that refers not just to vampires, but to the supernatural genre itself.

GROSS: Maureen Corrigan teaches literature at Georgetown University. She reviewed "Drood" by Dan Simmons and books from the "Twilight" series by Stephenie Meyer. You can download podcasts of our show on our Web site, freshair.npr.org. I'm Terry Gross.

We'll close today's show with a final goodbye and thank you to Harrison Ridley Jr., who for over 30 years hosted a Sunday night jazz program on one of our neighbor public radio stations in Philadelphia, WRTI. Harrison played early jazz recordings on his show, a show he called "The Historical Approach to the Positive Music." It became increasingly difficult to find early jazz on the radio, and his devotion to the music made him an institution among jazz fans in Philadelphia. Harrison died last Thursday of complications of a stroke. He was 70. He will be missed by many listeners. We'll go out with his theme, Sidney Bechet's 1944 recording, "Blue Horizon."

(Soundbite of song "Blue Horizon")
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