Photos by Allen Kramer
A tiny heart monitor beeped incessantly. Cradling baby Carson, Ashley Martin looked up from her rocking chair. Corbin’s monitor was the one going off this time. In another crib, little Abby was getting fussy. And in the adjoining crib, Allie was beginning to open her eyes from an afternoon nap.
Martin didn’t seem alarmed as she waited for the monitor to quiet. The two nurses in the room tended to the other babies as she continued to feed Carson his bottle.
“At first, I freaked out every time I heard the monitors make a noise,” Martin said. “Now I’m used to it. I know they’re okay.”
This was a typical afternoon in room 825 of Texas Children’s Hospital Neonatal Intensive Care Unit (NICU), where the Martin quadruplets were being cared for as they gained the weight and strength to go home.
The journey that brought the Martins to the NICU began more than a year ago. Martin and her husband Larry already had one child — 3-year-old Ella — but they had difficulty conceiving another.
After almost a year of trying, the couple was advised by their doctors in their hometown of Mont Belvieu, Texas, to try fertility treatments. With the help of their physician, they considered their options, eventually settling on intrauterine insemination, or IUI, along with fertility medication. In this procedure, fertility medication was used for ovulation induction, followed by IUI, where the sperm are placed inside the woman’s uterus to promote fertilization.
The Martins’ insurance covered the treatments, but co-pays along with the medication and parking in the Texas Medical Center added up to about $2,000 a month. It took the Martins three months to conceive.
“The last month we tried was the final month we were going to do it,” Martin said. “We just couldn’t afford it, and my body couldn’t handle any more. We were going to do one last push, and then if it didn’t work, we would wait a while and try again later.”
The third month was the charm. During their five-week ultrasound, the Martins’ doctor immediately saw there was more than one successful conception.
“First, there were three sacs grouped together, then he found a fourth,” Martin said. “After that, I don’t remember much. I was in absolute shock.”
There was another week of waiting until the next appointment, during which they heard four tiny heartbeats, confirming they were expecting quadruplets. The Martins had been warned of the possibility of multiples due to fertility treatments, but they never envisioned four babies.
“We got our money’s worth, that’s for sure!” Martin said.
The Martins are part of a national trend toward increased numbers of multiple births. The most recent report on multiple births from the U.S. Department of Health and Human Services (dated 2010) shows that out of nearly four million births in the U.S., more than 132,000 were twins, about 5,500 were triplets, 313 quadruplets, and only 37 were higher-order multiples of more than five. On average, there is one set of sextuplets born in the U.S. each year.
Manisha Gandhi, M.D., is chief of the Maternal Fetal Medicine Clinic, director of the Program for Multiples at Texas Children’s Pavilion for Women, a Baylor College of Medicine assistant professor of obstetrics and gynecology, and an associate residency program director. Gandhi said the increase in multiple births in recent years is due in part to the increased effectiveness of fertility treatments, and in part to increased maternal age at time of conception. As women decide for a variety of reasons to wait longer before having kids, their statistical chance of having multiples increases.
Adding to that are fertility treatments and their increased potency. Gandhi said the highest recurrence is twins, and most higher-order multiples are a product of ovarian stimulation rather than in vitro fertilization, or IVF.
“These are the ones where the woman gets hormones to stimulate her ovaries and then she ovulates,” Gandhi said. “Sometimes she ovulates multiple ova, and that’s leading to the higher-order multiples. It’s very rare these days to get higher-order multiples from IVF because [physicians specializing in reproductive endocrinology and infertility] are rarely doing three, four, five embryo transfers anymore.”
This change has come about because physicians have become more confident in their ability to fertilize just one or two eggs along with the fact that higher-order multiple pregnancies are associated with significantly increased maternal and neonatal risks. Physicians consider each case separately when deciding which method to use.
A local boom
On March 26, 2012, Texas Children’s Pavilion for Women opened its doors for inpatient services and began delivering babies. Within two months, the Martins’ quads would be one of 18 multiple births at the facility. Among them were 14 sets of twins, three sets of quadruplets, including the Martins, and a sextuplet pregnancy — the “Perkins Pack” of three girls and three boys. Born at the Pavilion on April 23, the Perkins sextuplets received a surge of local and national media attention. By the end of October, 81 sets of multiples had been delivered at Texas Children’s Pavilion for Women.
While there was an obvious multiples boom at the Pavilion, Gandhi said it’s not necessarily a forecast of what’s to come nationwide.
“Texas Children’s is a premier facility, so we can get a skewed view because this is where people come with higher-order multiples for both the maternal and neonatal care. So, we’re not seeing a general population.”
Preparing for multiple arrivals
A multiple pregnancy can be daunting for the parents-to-be. Since 2010, the Texas Children’s Program for Multiples (PFM) has provided prenatal support to the parents of multiples, helping them come to grips with the challenges and responsibilities of a multiple pregnancy.
Texas Children’s PFM specialists see each patient for a half-day visit, which includes an ultrasound to determine the kind of multiples the mother is having; genetic counseling; advice from a dietitian about her dietary needs; and a visit with a maternal-fetal-medicine specialist to clarify the pregnancy risks.
“This is a comprehensive visit that basically outlines for the patient and her referring physician the best plan for managing the pregnancy and improving the outcomes for both mom and babies,” Gandhi said.
Gandhi advises her patients of the risks of multiple births and tries to help them find the path to the best outcome for their own health and that of their babies. The risks include loss of pregnancy, premature delivery and growth restrictions of the baby, which could lead to complications that affect the child throughout life. According to Gandhi, mothers of multiples also face much higher risks of gestational diabetes, anemia and preeclampsia.
Martin said she was advised to gain about 80 pounds for the healthiest babies. She was hospitalized for two months of bed rest and knew the risks to both herself and her babies. She said it was nothing like her first pregnancy.
“There was more pain, swelling and discomfort, but worse than anything was the fear that comes with carrying multiples,” Martin said. “The pregnancy was the hardest part. Just not knowing whether they would all make it and be healthy when they were born.”
A successful outcome
The Martin quads stayed in a room in the neonatal intensive care unit in four side-by-side cribs. They were born at 28 weeks and five days gestation, weighing less than 3 pounds each. Abby was the smallest at 2 pounds, 6 ounces. Carson came in weighing 2 pounds, 11 ounces. Corbin and Allie were the biggest at 2 pounds, 13 ounces each.
Martin visited her babies every afternoon, driving an hour each way from Mont Belvieu. Allie, Abby, Carson and Corbin always slept comfortably in their tiny cribs, despite having to wear oxygen and feeding tubes.
On one of her afternoon visits, Ashley sat with her newborns, enjoying the occasional squeak from one of the babies. Two nurses tended to them, and the NICU was bustling with activity. Asked if she felt calm, Martin admitted that she wasn’t quite calm yet and that she definitely wasn’t calm when she found out she was having quads. But, sitting in her babies’ room counting down the days until they go home with her, Martin said she couldn’t think of having it any other way.
“It was worth every second of the worry,” she said. “It was worth all of the pain. Knowing they’re healthy and how loved they make me feel. It was all worth it.”
And will there be more little Martins in the family’s future?
Considering a moment, Ashley peered down at Carson, soundly asleep in her arms. “I think we’re good,” she said softly.