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USA Today Examines New IVF Technique That Reduces Risk of Multiple Births

March 4, 2009
National Partnership for Women & Families

USA Today on Wednesday examined elective single-embryo transfer, or eSET, a "fairly new approach" to in vitro fertilization that reduces the risk of multiple births. The birth of octuplets in January to 33-year-old Nadya Suleman, who has six other children conceived through IVF, has heightened attention to the issue of multiple births after IVF. According to USA Today, prior to the Suleman case, many U.S. residents "hadn't given much thought to the risks of multiple births," which include prematurity, low birthweight, disability and other health problems. According to the American Society for Reproductive Medicine, about 1% of U.S. infants are conceived through IVF. The procedure involves removing eggs from the ovary and combining them with sperm in a petri dish. After a few days, physicians either freeze the resulting embryos or transfer them to a woman's uterus.

The eSET procedure, which was developed after advancements in culturing embryos in laboratories, allows doctors to offer many younger patients an increased likelihood of conceiving with a single transferred embryo. According to a study published in November 2008 in the journal Fertility and Sterility, patients who received eSET had a 65% pregnancy rate, nearly the same rate as those who received two transferred embryos. In addition, only 1% of eSET patients had twins, compared with 44% of women who received two embryos. Robert Stillman, medical director of the Shady Grove Fertility Center and author of the study, said that in the past, the chances of conceiving with a single transferred embryo were slim. "Five years ago, 10 years ago, one embryo would not at all have been appropriate," he said.

Before ASRM first issued IVF guidelines in 1999, physicians often transferred "excessive embryos" in attempts to "ensure their patients' success and boost their practice's pregnancy rates," which led to a steady increase in multiple birth rates, USA Today reports. However, since ASRM issued the guidelines, which take into account patient age and embryo quality, the rates of triplets and higher-order births have declined. The society recommends that women younger than age 35 receive one or two embryos and that women older than age 40 receive up to five embryos. According to 2007 data from the Society for Assisted Reproductive Technology, Suleman's fertility doctor, Michael Kamrava, reported transferring an average of 4.1 embryos to patients younger than age 35. According to USA Today, the octuplet birth has "sparked debate" over whether the U.S. should follow the example of countries, such as Belgium and Sweden, that have enacted laws restricting the number of embryos that physicians can transfer at one time. Missouri lawmakers already have introduced a bill that would require physicians to follow ASRM's guidelines, and a proposed bill in Georgia would limit women under age 40 to receiving two embryos and those over age 40 to receiving three embryos.

According to USA Today, many fertility patients and physicians in the U.S. face incentives to transfer more than the recommended number of embryos. Health insurance plans often do not cover IVF, which costs an average of $12,500 per cycle, so some patients without coverage "view twins or triplets as two or three for the price of one," USA Today reports. In addition, transferring several embryos is more likely to result in a pregnancy than transferring a single embryo in most clinics. According to Stillman, patients with insurance plans that cover IVF and those who enroll in "shared risk" programs are more likely to choose a single-transfer technique such as eSET. At the Shady Grove clinic, the shared risk program allows couples to pay a flat $20,000 rate for up to six IVF cycles, and they receive their money back if the cycles do not result in a pregnancy. Barbara Collura, executive director of the infertility group Resolve, said people with insurance plans that cover IVF "have a completely different attitude" about the procedure and are "not as desperate." She added that restricting embryo transfers without addressing insurance issues would "create more trauma and more problems." Collura said, "Let's look at the coverage issue first. If somebody is willing to pay for it, then they have the right to put parameters on that." According to Sean Tipton, an ASRM spokesperson, health plans in Connecticut that cover maternity care are required to pay for IVF. However, they are allowed to limit the number of transferred embryos to two, he said.

According to Collura, Resolve encourages women to consider their health and the infant's health when they weigh options to transfer more than the recommended number of embryos. However, "it's tough to reach all of them so that they're acting in a rational way, when they're in perhaps the biggest crisis of their life," she said. Stillman said physicians at the Shady Grove clinic review the risks of multiple births with their patients at several points during the IVF process and have laminated sheets illustrating these risks. He said that although physicians at his clinic support eSET, this is not necessarily the case at other health centers. In addition, many fertility doctors only work with the women until they become pregnant, Stillman said. He added, "We're insulated, as reproductive endocrinologists. We hand the baton off and we don't deal with the consequences." Lawrence Grunfeld, clinical associate professor of obstetrics and gynecology at Mount Sinai School of Medicine, said fertility physicians should place more emphasis on low numbers of embryo transfer when calculating success rates. "IVF is not a way of creating triplets. IVF is a way of preventing triplets," he said (Rubin, USA Today, 3/4).

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