An article in the October 11th edition of the New York Times, “Grievous Choice on Risky Path to Parenthood,” has created an avalanche of comments on blogs on the controversial topic of mandating limits on numbers of embryos transferred. The article cites the obvious: that multiple pregnancies are more hazardous than singletons. We all know that. But this article goes further. Now that the Society for Assisted Reproductive Technology (SART) guidelines have successfully reduced the incidence of triplets and more in IVF cycles, the aim of their efforts will be pointed at preventing twin pregnancies in patients who have a good chance to succeed with a single embryo transfer.

    There is no doubt that the goal to reduce the incidence of IVF-induced twins is a noble effort given the increased incidence of prematurity and its cost both in healthcare dollars and morbidity and potential long-term disability for the babies.

    The most effective answer is to increase the number of elective single embryo transfers (SET) in patients with a good chance of success based on their age and embryo quality. But, how do we accomplish this. Some bloggers advocate legislation to mandate the numbers of embryos that may be transferred. Many countries have such restrictions. In many of those countries, the Golden Rule applies: “the one with the gold rules.” In other words, IVF is covered by national health insurance and government control is an accepted concept.

    Not so in the U.S. where we live in an era of reproductive freedom which means we are all free to reproduce or not reproduce without government interference. In fact legislators are unlikely to become involved and let us hope that they continue to stay out of all reproductive issues.  Our medical specialty societies are formulating new, more conservative guidelines, but if many IVF centers are already not abiding by the current recommendations, they certainly will not embrace newer, more restrictive limitations.

    So it’s up to us- the reproductive specialists to work harder to educate couples that transferring a single embryo when there is a good chance for success is in the patient’s and the baby’s own best interests. It sounds simple. But there are market forces which makes this unlikely to become a wide-spread trend. First, the IVF centers live and die by their reported success rates and are unlikely to embrace any policy which may lower their overall success rates. Secondly, most patients are paying for the procedure and think that a multiple embryo transfer will reduce the chance that they will have to pay for an additional expensive procedure to achieve success. In making this decision they are not mindful of the possibility of creating a more risky pregnancy which can result in the costs of prematurity and the life-long responsibility for a potentially disabled child.

    At Reproductive Partners we have advocated transferring fewer embryos for a long time and now try to educate appropriate patients to consider elective single embryo transfers. But often that is not enough because the many patients still have the incentive and desire to exceed our recommendations. We are currently seeking to develop a program of economic incentives to encourage couples with a good prognosis to consider SET more seriously. What would also help is if the CDC/SART reporting system emphasized singleton pregnancies as a success and did not consider twins or more, or cases requiring selective reduction as a success. Another option would be to have a separate category for the success rate of elective SET. This change might help remove the incentive to IVF centers to transfer more embryos than absolutely necessary.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Redondo Beach, California