Last week, the New York Times focused on the issue of multiple births from fertility treatments, including IVF and intrauterine insemination. Stephanie Saul begins with a two part series, here and here, which is followed by a Room for Debate discussion. Several of the Room for Debate contributors raise interesting points, many of which I address in the recently-published Why We Should Ignore The “Octomom.”
In Octomom, for example, I argue that -- though sad and disturbing -- the Suleman octuplets case is a rare event, and the attention and controversy that followed in its wake distracted from the more pressing public health concern – rising twin rates. CDC data suggest that the far higher incidence of twins as a percentage of live ART births, rather than the lower incidence of higher-order multiples, is both the most logical source for public concern and the multiple-birth rate most amenable to reduction through increased attention to embryo transfer practices.
Mark I. Evans, president of the Fetal Medicine Foundation of America and the director of Comprehensive Genetics in New York, echoes this sentiment in his Room for Debate contribution:
The “octomom” may have gotten much of the media attention on multiple births this year, but the more mundane epidemic of twins actually costs the American health care system and affects the lives of families far more.
Perhaps not surprisingly, most of the Room for Debate discussants (many of whom are fertility specialists) resist embryo transfer regulation as a means to address rising multiple birth rates from IVF, advocating instead patient and doctor education and responsible industry self-regulation. Although I’m generally skeptical of self-regulation as an effective means to address public concerns, in this case I agree with the industry that the benefits of embryo transfer regulation in the United States are unlikely to outweigh the costs.
As I elaborate in Octomom, the U.S. fertility industry is making progress in reducing multiple births from ARTs while maintaining pregnancy success rates, and is likely to continue to do so. This ability, however, depends on a variety of factors, including the patient’s age and the underlying cause of infertility, the ability to fund multiple ART cycles, individual clinical expertise and conditions, embryo quality, and cryopreservation techniques. Particularly in the U.S. system of private (or private insurance) payment for ARTs, under which some customers cannot afford multiple IVF cycles, mandatory policies risk reductions in pregnancy success rates that some customers will find unacceptable. It is thus no coincidence that the countries experiencing the greatest success with strict embryo transfer limits are those with both a well-developed and technically advanced fertility practice, and broad public funding of multiple IVF cycles.
Admittedly, there is more room for improvement in ART twin rates. But the U.S. lacks the political will for the strict embryo transfer limits—or, even less likely, the aggressive selective fetal reduction—that have reduced the rate of twin births from ARTs in some countries. As I elaborate in the “octomom” article, this reflects both some sound policy judgments and some political realities.
Arthur Caplan, a professor of bioethics at the University of Pennsylvania School of Medicine, favors limiting the number of embryos transferred in infertility treatments, yet concludes that:
there is no chance that the practice of embryo transfer will ever be regulated by legislation in the United States. In a nation still deeply divided over abortion and the moral status of embryos, politicians have little interest and no stomach for opening up a public debate on any aspect of infertility treatments.
I conclude with a similar point in “Octomom”:
In a perfect world, there may be a regulatory model that maximizes public welfare by appropriately balancing this interest [concerns re: multiple birth rates] against parental desires and the differing medical needs of fertility patients. We do not live in that perfect world. In addition to the usual regulatory problems of institutional competence, bureaucratic red tape, and political capture, questions of embryo transfer and multiple pregnancies in many countries, including the United States, inevitably intersect with other politically contentious issues, including the moral and legal status of embryos and abortion. . . .
Because the solutions to multiple pregnancies from IVF that are most likely to preserve pregnancy success rates include selective fetal reduction, the creation of many embryos from which only the highest quality are transferred, and cryopreservation of excess embryos for possible future cycles, advocates of embryo-transfer limits must recognize that embryo-protection goals are not only distinct from, but are often incompatible with, multiple-birth reduction goals. . . . The political minefields of abortion and embryo rights thus render it highly unlikely that the United States will implement comprehensive embryo transfer regulation effectively designed to reduce multiple births anytime soon.
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