Preventing Octuplets: An insider's perspective...
Tuesday morning, as I cared for a patient going through in vitro fertilization (IVF) at our infertility center, I cringed at an interview with Ms. Suleman, the now famous mother of octuplets. This case casts our field in a terrible light. I am pleased that Ms. Suleman is doing well and that her children are somewhat stable, under intensive care. I also understand that the health and outcome of these children will not be known for some time.
What we do know is that carrying multiple babies at once leads to prematurity and low birth weights, which are both risk factors for lung disease, cerebral palsy, and other conditions which can lead to lifelong disability. Our bodies were simply not designed to nurture so many fetuses at once. Unfortunately, it is hard to judge which egg will develop into a healthy pregnancy and therefore we often put more than one embryo back in hopes of achieving a singleton pregnancy.
Dr. Kamrava has appropriately come under professional scrutiny. While I share concerns that he may not have followed the guidelines of our professional society and performed procedures that were outside of our standard practices, I have yet to hear anyone asking critical rather than judgmental or voyeuristic questions. How did this happen? Have we done anything to encourage this? And how can we prevent this from happening again? I want to examine the circumstances that could permit and even encourage this?
The Fertility Clinic Success Rate and Certification Act of 1992 mandates that IVF clinics report pregnancy rates to the Centers for Disease Control, and that these numbers are made available to the public. This creates an incentive for competing clinics to transfer more embryos to increase their pregnancy rates and attract more patients (especially at places like the West Coast IVF clinic, where the implantation and pregnancy rates are below those of many other successful practices). If the law were revised to mandate only reporting the probability of a pregnancy or live birth for each embryo transferred, patients would have a more realistic measure of quality when comparing programs and IVF centers would no longer have an incentive to transfer more embryos to boost their pregnancy rates. Healthy pregnancies should be the goal.
Another issue relates to the way we pay for IVF in the United States. Multiple gestations (especially triplets or more) are expensive to care for and tend to have worse health outcomes for both the babies as well as their mother. Yet our system encourages patients to transfer more embryos because most insurance plans do not cover the procedure; patients usually pay all or most of the costs out of pocket. Given that each cycle costs upwards of $10,000, economic pressures may influence patients to request that more embryos are transferred back each cycle. More embryos however, means a greater risk of multiple gestations (twins, triplets, or more).
In the United States, nearly a third of IVF pregnancies result in twins, half of which will be born premature. Similarly, the rate of triplet pregnancies in the United States has more than quadrupled since the introduction of IVF in the early 1980s, and 90% of triplets are born premature. Again, in IVF the single biggest risk factor for multiple gestations is the number of embryos transferred. Yet, by separating the cost of IVF (paid for by patients) from the cost of obstetric and pediatric care (paid for by insurance), our system indirectly encourages patients to demand that more embryos transferred in order to maximize her chances of getting pregnant. In the end, the cost to society (in dollars and in health) is higher.
Many European countries pay for IVF as part of their national health programs. Since such governments also pay for obstetric and pediatric complications, public health officials deemed it more economical to pay for the IVF procedure but regulate the number of embryos transferred. The result is that more people who need it are able to get IVF infertility care and fewer twins and triplets result. Within the United States, when a few states mandated that insurance cover IVF procedures, a similar trend emerged. The rate of multiple gestations has fallen and the number of infertile patients who are able to receive IVF has increased.
Reducing the number of embryos transferred is fairly well proven to be cost effective, once the loss of productivity and obstetric costs are considered.
Many questions have been raised about whether Dr. Kamrava and the West Coast IVF clinic ignored the ASRM guidelines on number of embryos to transfer, which place the patient's health at a premium. That said, it is important for us to consider the existing factors that encourage such practices. The United States strongly favors state and individual autonomy in our political culture and this does not easily permit regulation of new technologies, including IVF.
The current rate of multiple gestations from IVF is unacceptably high and results in unnecessary health and economic burdens. Yet laws regulating the disposition of embryos risk interfering with privacy rights that lie at the core of women's reproductive rights. And neither I nor my patients want a politician or lawyer dictating the care that I provide. So can we find balance between government regulation and the rights of the patient?
Some suggestions: For starters, clinics should only be mandated to report births or pregnancies per embryo transferred. Patients should be encouraged to transfer no more than the recommended number of embryos (as determined by professional guidelines and the specific history and conditions of each patient). If patients demand to transfer more embryos, perhaps they could be asked to bear part of the economic burden of that choices. A surcharge could be added if patients transfer more than the recommended number of embryos (as the ensuing obstetric and pediatric costs to society will be higher. Such economic risk sharing might encourage patients to be more conservative about their embryo transfer strategies.
I am not sure our system can afford to universally cover IVF or that people would accept the restrictions that would likely follow, but in the absence of clear regulatory jurisdiction or mandates, an appropriate first step would be to reduce irrational incentives when healthier alternatives exist.