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.
[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.