Assisted Reproductive Technology: Let’s Focus on One Healthy Baby at a Time

Jennifer Rogers

Federal law and financial incentives lead to incredibly costly and potentially dangerous multiple births through assisted reproducitve technology (ART). The law should be reworked to create incentives for having only one baby at a time through ART, which is more cost effective and safer for mothers and babies. 

The hubbub of Kate Plus 8 and Nadya Suleman is largely over. One year ago, articles covering multiple births and stories of in vitro fertilization were front-page news, but today I’m hard-pressed to name even a celebrity who has had a high-order multiple in the last few months. While I take this as good news, the data on assisted reproductive technologies (ART) tells a slightly different story.

Assisted reproductive technology includes fertility treatments in which both eggs and sperm are handled in the laboratory—this includes in vitro fertilization (IVF). It is well-documented that women who undergo IVF are more likely to deliver multiple-birth infants than women who conceive without assistance.  In fact, almost half of all IVF pregnancies result in multiple-birth deliveries.[i] Pregnancy with multiples is usually a direct result of multiple embryo transfer. This means that two or more embryos are transferred to a woman’s uterus at one time. And although the percentage of triplet-or-more births has declined from 6 percent to 2 percent from 1998 to 2007, the percentage of twin births remained stable at about 30 percent.

Because the use of ART has doubled since 1998, many of us now know a friend, family member, colleague, or, at the very least, know of a celebrity who has undergone the procedure. We have become accustomed to the idea of twins, a remarkable conceptual change given the relative rarity of natural twin births in humans. But the problem is that, in comparison to singletons, pregnancy with multiples, including twins, raises health risks—for both a woman and her infant. For women, these risks include higher rates of cesarean section, maternal hypertension, preeclampsia, hemorrhage, and death. Infants are more likely to require neonatal intensive care, and experience higher rates of low birth weight, preterm birth, and cognitive and physical impairments.

Single embryo transfer (SET), however, nearly eliminates pregnancy with multiples because only one embryo is transferred and, thus, decreases the health risks for a woman and her child as well.

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Compounding these health risks is an economic consideration, something made more pressing in the midst of health care reform and our economic crisis. Policymakers, health care providers, and insurance companies are paying more attention than ever to the bottom line, and we know that—at least in the short term–multiple versus single embryo transfer is less expensive. In fact, if we kept our current insurance policies and, at the same time, created a universal SET policy, it would cost patients an extra $100 million to achieve the same pregnancy rates.

But this would be a short-sighted and eventually hugely expensive misunderstanding of the issues. Because of the long term health risks associated with multiple births, moving to SET-alone would save in overall healthcare costs.[ii] For instance, in the United States alone, maternal and newborn hospital charges per family were $9,845, $37,945, and $109,765, respectively for singleton, twin, and triplet births.[iii] Thus, creating policies that promote single embryo transfer (SET) are becoming the talk of the ART town. These estimates indicate an elective SET policy could improve the overall health of women and infants while at the same time save million of dollars in health care costs.

So, why hasn’t SET become the standard of care?

This question raises several issues.  The first problem lies with current federal policy. The Fertility Clinic Success Rate and Certification Act of 1992 requires fertility clinics to only report their pregnancy and birth success rates. This regulation creates incentives for physicians to transfer multiple embryos to ensure better success rates. Although the American Society for Reproductive Medicine (ASRM) has released voluntary guidelines that recommend physicians transfer only one embryo and no more than two to women 35 and younger,[iv] the emphasis on better numbers versus better health means that providers are still willing to transfer more embryos despite the potential risks to a woman and her newborn. This practice also assumes that multiple embryo transfer leads to higher pregnancy rates. Although, in the past, this has been the case, more recent research suggests single embryo transfer does not compromise the pregnancy rate, especially for younger women with high quality embryos.[v],[vi],[vii],[viii]

Second, many insurance companies do not cover IVF treatment in the United States. In fact, two states—California and New York—have laws that specifically exclude coverage for IVF. For instance, California’s law requires health care plans that cover expenses on a group basis must “offer coverage for the treatment of infertility, except in vitro fertilization.” And even in states where infertility is covered, coverage may be limited to a one-time only benefit for expenses arising from the procedure. This means that many patients bear the full cost of IVF and, thus, feel pressure to transfer multiple embryos in order to achieve a pregnancy on their first try. And having twins is less costly initially than having successive singletons. Older women may even feel more pressure to have twins because they may not be able to become pregnant a second time.

Third, the health risks arising from pregnancy with multiples, even twins, is not widely known. As a culture, whether through shows like Jon & Kate Plus 8 or the popularity of celebrity twins, we celebrate and even glamorize multiple births. However, studies show that when IVF patients receive information about the health risks, they are more interested in pursuing SET.[ix],[x]

Thankfully, instead of working reactively to propose regulations or new policies based on outlier cases (i.e. Ms. Suleman and her octuplets), there are proactive steps women’s health advocates can promote built on support and honesty to help improve the health and well-being of women and their children. Forward thinking policies—like encouraging SET—are concrete solutions to these issues.

As we implement health care reform, we have a unique opportunity to require insurance coverage of infertility diagnosis and treatment, including STI screening and treatment (a leading cause of infertility) and multiple IVF cycles. Studies have found that if insurance covers multiple embryo transfers, patients are more willing to choose SET.4 This coverage must also be coupled with patient education on the health risks associated with multiple births. Research has found time and again that accurate information about the risks associated with multiple embryo transfer can lead both women and men to choose SET.

We also need better and more robust data collection. We can change our policies to define “success” in terms of healthy pregnancies, safe births, and healthy babies, rather than the superficial live birth count currently used in federal law. Clinics should be rewarded for responsible medical practices such as the quality of the counseling they provide women and men before they begin down the ART path. This also means providing individualized care—because, for some women, especially women of advanced age or those who have previously gone through IVF with no success, SET may not be the answer.

Last, but not least, as reproductive health advocates, we must look closely at the benefits ART provides in alleviating the burden of infertility as well as the challenges it presents in exacerbating poor health outcomes and high health care costs. We must provide women and men the tools—education, support & respect—to make the best decisions for themselves and their families. An open and honest conversation about ART can lead to policies that support the health of women and children, help bring down our long-term medical costs, and better speak to the personal crisis of infertility. Free from sensationalism, we can do all three.


[i] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5805a1.htm?s_cid=ss5805a1_x

[ii] Petok, W. D. (N.D.). Single Embryo Transfer: Why Not Put All Your Eggs In One Basket? American Fertility Association. Retrieved from http://www.theafa.org/library/article/single_embryo_transfer_why_not_put_all_your_eggs_in_one_basket/

[iii] Collins, J. (2007). Cost efficiency of reducing multiple births. Reproductive BioMedicine Online, 15, 35-39.

[iv] American Society for Reproductive Medicine [ASRM] (2009). Guidelines on number of embryos transferred. Fertility and Sterility, 92, 1518-9.

[v] Stillman, R. J., Richter, K. S., Banks, N., & Graham, J. R. (2009). Elective single embryo transfer: A 6-year progressive implementation of 784 single blastocyst transfers and the influence of payment method on patient choice. Fertility and Sterility, 92(6), 1895-1906.

[vi] Saldeen, P., & Sundtrom, P. (2006). Maintained pregnancy rate after introduction of elective single embryo transfer in women 36-39 years. Fertility and Sterility, 86, S76.

[vii] Anderson, A. R., Graff, K. J., Distefano, J., Seegers, J., Whelan III, J., & Crain, J. L. (2006). When is a single embryo transfer appropriate? Fertility and Sterility, 86, S191.

[viii] Komaba, R., Maeda, M., Sugawara, N., & Araki, Y. (2007). The effective prevention of multiple pregnancies by elective single embryo transfer. Fertility and Sterility, 88, S154.

[ix] Newton, C., & McBride, J. (2005). Single embryo transfer (SET): Factors affecting patient attitudes and decision-making. Fertility and Sterility, 84, S3.

[x] Hope, N. J., Phillips, S. J., & Rombauts, L. (2010). Can an educational DVD improve the acceptability of elective single embryo transfer: A randomized controlled study. Fertility and Sterility, 90, S67.

Commentary Family

Stigma Around ‘Non-Traditional’ Families Won’t End With Assisted Reproductive Technology

Bianca Campbell

New research suggests the use of skin cells and stem cells to create biological children for couples or individuals with difficulty conceiving may one day become a reality. The thing is, it's not only necessary to make this assisted reproductive technology accessible to all people seeking to parent, but to make sure all the ways we form families are affirmed too.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

A new study from Cambridge University and the Weizmann Institute of Science predicts the use of skin cells and stem cells to create biological children for same-sex couples, single parents, and heterosexual couples with difficulty conceiving within two years. As a queer full-spectrum doula of color considering mamahood in the near future, I want as many parenting options as possible. But I wonder if this assisted reproductive technology will be truly accessible to me and my community, and if it reinforces a nuclear family ideal that further stigmatizes our choices.

Queer and trans folks have been making babies for a long time, and it’s rarely ever easy. Even when we create biological children, we have to fight to be recognized as their parents. Last year, a Texas same-sex couple fought for custody of their two biological newborns. (They used a surrogate, so they are each the father of one of the two boys.) The parents’ names weren’t even allowed on the birth certificates of their respective biological child. Without addressing the legalized discrimination against our families, the new technology won’t be enough to shield our reproductive choices from attack. Respectability through biological reproduction (and government-sanctioned marriage, might I add) will not save us.

“There’s a lot of weight that’s put on biology and often that’s too much,” said student-midwife Courtney Hooks, who has helped several queer and trans families give birth in Oakland, California.

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The biological emphasis in family planning creates an ableist culture at infertility clinics that focuses on “correcting” our bodies instead of celebrating our sexual lives and family choices. Many queer and trans folks, Hooks said, are fertile. “We just haven’t been having that kind of sex.” Instead, the language and framework at many clinics, not to mention the language in state and federal policies, see our bodies, transitions, and sexualities as a problem, and this new technology should be acknowledged with that in mind.

If it weren’t for the high cost, social stigma, and legal barriers, many of us could have children with the support of our community, co-parents, and partners using the variety of methods already available. It’s not only necessary to make skin cell and stem cell technology accessible, but to make sure all the ways we form families are affirmed too. 

Barriers to Having the Families We Want

For most people, access to health insurance is essential to comfortably and safely sustaining and growing families. In 2014, however, 25 percent of LGBTQ adults could not afford medical care, compared to 17 percent of non-LGBTQ people, according to Gallup. The poll reported that people identifying as bisexual and lesbian were the most likely of all groups categorized by sexuality to forgo care due to cost and the least likely to have developed a relationship with a medical provider. Further, a different survey found that trans people are disproportionately affected by a lack of insurance, affirming providers, and access to essential medical care.

Insurance isn’t the only barrier to having the families we want. In Atlanta, Jhavia Etheridge, a wellness counselor, and her partner plan on starting a family in five years, shortly after the technology is expected to be available. Etheridge is excited about possibly of using stem cells to have biological children with her partner. However, even with insurance, she fears that the technology, like others in the past, will be financially out of reach. A single IVF treatment costs an average of $12,000, and pregnancy is not guaranteed on the first treatment. Some families then incur the additional expense of surrogacy.

“More power to folks who can afford it, but I definitely cannot,” Etheridge said. She intends to stick with her plan to adopt, which has its own financial hurdles.

Right now, many of us are still trying to find and afford insurance. Once we get it, we seek a network of doctors we’ll actually use.

Reproductive justice activist Amir Jones focuses primarily on improving health-care access for queer and trans people in Atlanta, Georgia. When asked about the top health issues he hears when out in the community, Jones said, “People want to look at holistic health and wellness. They want to build relationships with affirming providers.”

We’re already less likely to seek medical care due to the transphobia and homophobia in the medical industry that we experience or anticipate. Fifty percent of the respondents to that survey on transgender health reported having to teach their medical providers about transgender care and 28 percent said that they had been refused care. It’s not very surprising, then, that 28 percent of the respondents said they had postponed or avoided medical treatment when they were sick or injured and 33 percent delayed or did not try to get preventive health care. It is not as easy for our community to enter a fertility clinic as it might be for other groups. We want to connect with a provider we can trust with our major decision to parent.

Many of us also face legal barriers to creating and sustaining the families we want. Some states, for example, require fertilization to occur at a medical center in order to revoke the parental rights of the egg or sperm donor. There are less expensive, more intimate options to create families outside of clinics, but families are at risk of entering taxing legal battles with sperm or egg donors.

Resiliently, we have dealt with these stigmas and barriers by creating and loving dynamic, non-nuclear families.

The Families We Already Have

Many of us either grew up in or descended from a family that did not look exactly like the white, American, heteronormative, patriarchal suburbanites we’ve been told to aspire toward. My grandmother never gave birth, but she raised five children, including me. (We referred to her as grandmother, even though she wasn’t our biological grandmother, out of respect.) People of color, queer people, and trans people buck against those societal expectations all the time, and have for decades.

Play cousins, neighbors dubbed auntie or tia, stepparents, and co-parents… Not being able to create biological children is not the same as not being able to create a family.

Raquel Willis of Beyond the Label, a YouTube series that often affirms the experiences of queer and trans people, said the potential for biological children is positive, but it’s a path toward a family she is no longer pursuing.

“Even as a kid, I thought about having children. I used to cry because I thought I couldn’t have kids,” she said.

“A lot of my worry was that my family wouldn’t accept my adopted children as much as my [siblings’] biological children.” Willis said it’s a worry she still occasionally has.

“But then, I realized good parenting goes beyond the biological.” Willis said she would adopt queer and trans youth specifically, a group facing disproportionate rates of homelessness. She said she hopes to use her lived experience to support her children as best she can.

We need to uplift the beautiful, multiple ways we already create families and demand the access to sustain these families. I want all of us to wake up on Mama’s Day and open up cards that praise the ingenuity and love of resilient LGBTQ parents. Our society, from the way we celebrate national holidays to the way we roll out new reproductive technologies, should do more to remind us that we are enough, our partners, our families are praiseworthy regardless of marriage and biological connection.

What can you do? You can visit MamasDay.org for messaging and amazing visuals that reflect the vast beauty of families like the one that raised me and the one that I and many others plan to create.

Commentary Law and Policy

Personhood Amendments Would Hurt Families Who Want Children

Keiko Zoll

The amendments in Colorado and North Dakota giving legal rights to fetuses would leave people seeking in vitro fertilization in the dust.

Read more of our articles on “personhood” measures here.

Next week, voters in Colorado and North Dakota will take to the polls to vote on amendments that would give legal rights to zygotes, embryos, and fetuses, also known as “personhood” laws. Measure 1 in North Dakota seeks to recognize and protect the “inalienable right to life of every human being at any stage of development”; meanwhile, Colorado’s Amendment 67 asks voters to add “unborn human beings” to the state’s criminal code. Though Personhood USA, which is backing Amendment 67, may define “personhood” as the “cultural and legal recognition of the equal and unalienable rights of human beings,” make no mistake: The personhood movement is an attempt to undermine the legality of reproductive choice in America. This doesn’t just put abortion in danger; it also leaves some of the people wanting children the most—the infertility community—in the dust.

My own journey to motherhood was a textbook case of in vitro fertilization (IVF). Five years ago, I was diagnosed with premature ovarian failure, a sort of “end of the line” infertility diagnosis. In order to get pregnant, my doctor told us, I had a single choice: IVF with donor eggs, as my own were virtually nonexistent at the age of 26. While I grieved the loss of having a child with my own genes, I found hope and healing in the possibility of experiencing pregnancy and birth. Without IVF, we wouldn’t have the family we have right now.

I still have the grainy black-and-white photograph, taken just before my embryo transfer, of our two three-day-old, ten-cell blastocysts. I often wonder which of those two nearly transparent spheres became the charming, talkative toddler I now chase after.

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Even though I know that my son and one of those two balls of cells are the same, however, at no point when I look at that photo do I see a family portrait, much less a person. At that stage of human development, they were merely dividing tissue to me: They had no names, no genders, no sentience. But proponents of the personhood movement, who would legally define life as beginning at conception, evidently see a completely different picture. And it’s one that could make it much more difficult, if not impossible, for the as many as 7.4 million American women with infertility to create a family of their choice by seeking the treatments they need.

Here’s a basic primer of how IVF works: A woman’s ovaries are stimulated to produce multiple eggs. She may be the prospective parent, an egg donor, or even a gestational carrier who both donates her eggs and carries the pregnancy. Doctors then retrieve the eggs and fertilize them in the lab with the prospective father’s sperm from a provided sample. Three to five days after fertilization, medical professionals transfer one to three tiny embryos into the recipient uterus. Any excess embryos—on average, there are about 15—are often frozen and kept in cryopreserved storage until patients use them or discard them.

If personhood amendments were to pass, doctors would presumably have to treat all those embryos, or even the fertilized eggs, as if they had human rights. This, care providers point out, has no basis in medical fact—and it could severely hamper their ability to do their jobs safely and effectively.

“Among the many, many problems with these so-called personhood measures is they simply do not in any way reflect scientific reality,” Sean Tipton, chief advocacy and policy officer for the American Society for Reproductive Medicine (ASRM), told Rewire. “For physicians providing infertility care, the disconnect between the legal language and actual medicine is very dangerous. The reality is that most fertilized eggs will not develop into babies.”

Tipton fears that Amendment 67 and Measure 1, among other personhood measures, would place a question of potential murder on physicians trying to give their patients the best care possible. About those extra embryos, for example, he wondered, “Will doctors be forced to transfer them into their female patients anyway? Do they provide the best care for their patient, or do they risk facing a homicide charge?”

When it comes to the matters of how many embryos to transfer at once, there is no “one size fits all” recommendation. However, current ASRM guidelines call for the use of elective single embryo transfer (eSET) whenever possible in most favorable conditions, such as if it is the patient’s first IVF cycle or the embryos are of good quality. For most women younger than 37, ASRM recommends that doctors transfer a maximum of two blastocysts at once; for patients older than 38, it recommends no more than three. ASRM and the Society for Assisted Reproductive Technology (SART) specifically set up these guidelines to reduce the number of potentially dangerous multiple births resulting from IVF, including twins, triplets, quads, and higher-order multiples.

In our case, our egg donor—with whom my husband and I are close friends—provided us with 20 eggs then fertilized with my husband’s sperm. Six of those developed into embryos. My doctor transferred two embryos into my uterus; one implanted. Currently, we have four high-grade embryos “on ice”—and no hard-and-fast decisions yet on what to do with them.

Had personhood been in effect at the time of my IVF cycle, however, I wouldn’t have had the option to transfer only two embryos. Our donor would have had to understand that any of the extras couldn’t legally be discarded. We, as prospective parents, would be left with only two options: Donate the remaining embryos to another couple trying to conceive, or transfer them all to my uterus.

The first option, explains New Hampshire reproductive and family lawyer Catherine Tucker, could dissuade known donors from trying to give an altruistic gift to a close friend. “Your known donor might be willing to donate only to you and not to strangers,” Tucker noted. “So [she] might refuse to donate to you simply because she’s not comfortable with her genetic material going to other prospective parents in the event you cannot use all the embryos yourself.”

With our donor, after careful consideration, discussion, and legal negotiation, we collectively decided that any excess embryos would be ours, and ours alone, to use for future cycles, discard, or donate to scientific study as we saw fit—but not to another recipient couple. Our friend made her generous offer to be an egg donor for us, and for no other third parties. Even in cases where the donor is open to the idea of embryos going elsewhere, though, finding other recipients would be a logistical nightmare, especially with no way to guarantee any excess embryos at all.

On the other hand, transferring all of the embryos could put patients’ safety at risk. Assuming my same 50 percent implantation rate, for example, if I had transferred all six embryos, I could have had a triplet pregnancy—and that’s outside of the risk of any of those embryos splitting into multiples of their own. These types of high-order pregnancies put the woman and the fetuses at risk for serious complications, including preeclampsia, gestational diabetes, premature birth, miscarriage, and even maternal death. This is to say nothing of the costs of raising an unexpected additional child, which can be an immense burden on infertility patients who have already spent thousands of dollars on their treatments.

Personhood laws could also cause a number of other legal ambiguities for those involved in the IVF process. Barbara Collura, executive director for RESOLVE: The National Infertility Association, pointed out to Rewire that the vague language of the proposed amendments generates myriad potential gray areas that voters likely haven’t considered.

“What about the infertility patient scheduled for her IVF procedure on November 5?” she pointed out. For that patient, Collura noted, it would be unclear as to whether she had a right to refuse any of her embryos, or if she must cancel her treatment entirely—which would still leave any fertilized eggs retrieved and created before the ballot vote in legal limbo.

Collura also brought up the issue of unused embryos awaiting possible transfer. She raised the questions, “If Amendment 67 and Measure 1 pass on November 4, what will happen to embryos that are currently frozen and in storage in those states? Will infertility patients be able to cross state lines now with these so-called ‘pre-born people?’” After all, if embryos do not survive the trip, their transporters could be held responsible.

Tucker, too, noted that such an action might leave individuals liable to prosecution. “Under personhood laws, IVF physicians and lab personnel who handle the embryos could face criminal punishment should anything happen to these embryos,” she noted in an email to Rewire.

As a result of potential ramifications like these, personhood laws would have devastating effects for reproductive facilities. Reproductive endocrinologists in North Dakota have warned that Measure 1 would effectively shut down the sole fertility clinic in the state, rendering them unable to treat their patients. Amendment 67 would also either shutter Colorado fertility clinics entirely or severely limit their doctors’ abilities to practice recommended standards of care. Although Personhood USA claims that the amendments would not affect IVF, the very nature of the treatment means that some fertilized eggs or embryos are going to be discarded—which is blatantly at odds with the provisions outlined in personhood laws.

Ultimately, personhood initiatives could have a chilling effect on the entire practice of reproductive medicine. While the average person “might think that an IVF laboratory shutting down on account of a personhood law sounds far-fetched,” noted Tucker, “the bottom line is that personhood laws will end the ability of prospective parents to form their families with the help of IVF, egg donation, and even gestational surrogacy.” When legal rights are granted to ten-cell balls of tissue, every aspect of the handling, care, diagnostics, and treatment of those embryos must be taken into consideration. Personhood rights would upend decades of improving standards of best practice.

Personhood proponents argue that they are “working to respect the God-given right to life” and “protecting every child by love and by law.” But for people like me in the infertility community—who want nothing more than to have children of our own—personhood would actually prevent us from having those children in the first place.

I’ll never forget what our friend said when she made her incredible offer to donate her eggs to me and my husband: “I think everyone who wants to have a family should be able to. If I can give you that chance, I want to help because you two deserve to be parents.” If personhood proponents had their way, we’d never have had that chance at all.