Wednesday, April 20, 2011

Limiting IVF Embryo Transfers

Everyone knows about "Octomom" and her octuplets born after in-vitro fertilization (IVF).  That was an extreme case, but multiple births resulting from unregulated artificial reproductive technologies have skyrocketed over the last decade.  The increased rate of twins, triplets and even higher multiples are due to in-vitro treatments and those women and infants are at much higher risk of pregnancy complications, premature birth and long term health problems.

New research,  published in the Journal of Pediatrics, looked at admissions at just one hospital in Montreal, Quebec and found multiple embryo transfers was responsible for a significant proportion of admissions to the neonatal intensive care unit (NICU).  These infants were born severely preterm.  Six babies died and 5 developed severe intraventricular hemorrhage or bronchopulmonary dysplasia.  The researchers extrapolated their data to the entire country of Canada and said that a universal single-embryo transfer policy would have prevented 840 NICU admissions, 40 deaths and 42,488 days in the NICU.  The cost was $40 million annually.

There are currently no regulations in the United States that limit a fertility clinic from implanting numerous embryos into a woman's womb.  The United Kingdom, France, Australia and Germany have legislation with limits to the maximum number of embryos to be transferred.  In the USA we believe the decision about how many embryos to implant should be left to the clinical judgment of doctors.  Because of the expense and emotions involved with infertility treatment, couples want to maximize their chances of getting a viable pregnancy...even if it means they will have twins or triplets.

For some patients, the chances are slim that they will get pregnant, despite the best technology.  There is a wide range between women and age is not the only factor.  One 40 year old is not the same as another 40 year old and the embryo quality can vary widely.  Now that technology allows doctors to grow the embryo in the lab for 5 days,  instead of the usual three days, higher quality embryos can be selected. 

It is hard to believe that 100 years ago most doctors didn't even really understand "woman's issues".  Most women had no knowledge of their bodies and birth was a random event...difficult to prevent and difficult to influence.  The changes have been rapid and amazing and we are learning how to be successful without causing harm from our technology.

(Dr. Michael Kamrava, Octomom's doctor, implanted 12 embryos!)


Pissed Off Patient said...

Blogger ate my original comment. Argh.


1. There _are_ guidelines and standards in the US. This is why Octomom's doctor was brought up on charges, almost lost his license, is on probation and lost his ASRM affiliation . (

This blog post is inaccurate on that point and quite simplistic on others.

Which is a personal sore spot as it gives life to stereotypes that make my life difficult. Further, it feeds a policy agenda that isn't a based on reality, which needlessly limits my choices as a patient.

Please be aware that infertility treatments are a target of the Pro-life agenda. If we are not careful of how we shape the discussion, we may end up somewhere we didn't want to go. This post is not even close to a well informed treatise on the subject.

2.I've dealt with 6 REs at 2 clinics, all were deeply concerned about multiples and actively worked to avoid them. This is the norm, not Octomom.

3.If we allow rare outliers to drive policy, we make bad policy. Bad policy hurts patients.

4.Single embryo transfer (SET) is great on paper. In practice, conception doesn't conform well to rigid rules.

Also SET means more cycles,which means more drugs, which increases risk in that vein (i.e Lupron increases cancer risk). It creates new problems that will also be expensive.

Doctors need to have the ability to decide how many embryos to transfers within a regulated limit (I would say between 1-4 embryos).

5.Maternal ages is a huge factor in twin conception. Did the study take that into account?

6. I had ONE baby via IVF. ONE. I am the norm, not Octomom. (Where's my free car, lifetime supply of diapers and reality show?)

7.For all the 'why didn't you adopt' people who invariably enter these conversations 1) Why don't you? 2) Adoption is more expensive than IVF 3) Who said we would never adopt?


Toni Brayer, MD said...

Dear Pissed Off: Sorry you are so angry. The purpose of the blog was to accurately report the results of the Canadian study and to explain the issues to a reader who may not know about the study. I believe I have succeeded.

Just because you do not personally like a certain study or outcome, does not mean it should not be discussed or understood. Good science and good reporting should be apolitical.

Since you are concerned with inaccuracies, let me point out a few of yours.

1. Octomom's doctor's case is still pending and he is able to practice and continue to implant multiple embryos if he so chooses. (Of course the publicity has probably negatively affected his practice)

2. I specifically did not mention SET (single embryo transfer), except to reference the study and I did not advocate for that restriction.

3. I have not seen data that SET means more cycles and more risk. There is still some controversy about the ideal number and most experts agree that it is age and woman dependent (as I pointed out)

4. In Countries that regulate the number of embryo implants, a couple follow SET but most have guidelines that allow flexibility up to a certain number (like 3 or 4 )

5. Poor Octomom has not profited from her experience. She is bankrupt and soon to lose her home. She has turned down a reality show but did do a swimsuit ad and has recently been selling mementos at a publicized yard sale to make money.
Her life is very hard.

6. Congrats on your baby. My grandbaby is a result of IVF and advanced reproductive technology.

Michael Kirsch, M.D. said...

Technology and public demand will continue to stretch and break ethical boundaries. Too often, ethical analysis and reflection come after the fact, when the train has left the station. The system is 'out of order'.

Anonymous said...

Technically, the IVF doctor doesn't "implant" any number of embryos. The embryo's are transferred with the hope that at least one will go on to implant and develop into a viable pregnancy. Get it right, please.