The recent birth of octuplets to a California woman receiving infertility treatment has raised questions about the practices used by infertility doctors. Dr. Pasquale Patrizio, director of the Yale Fertility Center, discusses the safeguards in place to ensure that nothing similar happens here.
Q. What is your reaction when you hear a story like the one about the woman in California giving birth to octuplets?
A. I am not happy. High order multiple births (triplets or more) resulting from in vitro fertilization (IVF) are considered medical failures. Besides the known pregnancy complications of multiple births—preterm labor and the many health concerns related to premature delivery—there is also the issue of how are you going to raise these children. If someone comes to me and already has six children, like in this particular case, I have a duty to refer this patient to social service. If she’s asking me to transfer eight embryos, something is not right.
Q. IVF treatments can cost $10,000 a piece. What do you do if a patient comes to you and says, “I don’t’ have a lot of money for IVF treatments. Could you please implant as many embryos as possible to improve my chances of getting pregnant on the first try?”
A. We have to follow the guidelines developed by the American Society of Reproductive Medicine. It’s simply not okay to transfer six or seven embryos into a woman who is younger than 35 and has a good prognosis for a successful pregnancy. So, it doesn’t matter if the woman requests that I implant all the embryos. I’m not going to honor that request.
Q. What are the guidelines?
A. For a woman younger than 35 with a good prognosis, the guidelines say one embryo if the transfer is performed on day five after egg retrieval, with a maximum of two if the transfer is performed on day three. The older the woman, the more embryos we’re allowed to transfer. At 40, you can transfer three or four tops. For patients 42 or older, you can transfer up to 5. If someone goes beyond this, you really need a valid justification, and it’s very, very rare.
Q. But these are just guidelines, right? They’re not mandatory?
A. Right. We voluntarily file annual clinic summary reports with the Society of Assisted Reproductive Technologies (SART). The reporting rate is about 95 percent, so we’re doing a pretty good job of making our data available for public scrutiny and information.
Q. What do you report?
A. The age of the woman, the number of cycles started, the number of retrievals, the average number of embryos transferred by age group, the number of pregnancies, the number of deliveries, the number of multiple births and the number canceled cycles. Centers can also be audited, which is one way we protect citizens from cheaters. If a center makes up numbers and is caught, there can be sanctions.
Q. Would there be less pressure from patients to implant multiple embryos if insurance for infertility treatment were better?
A. It’s possible. In Belgium and some other European countries, insurance pays for treatment, and insurers tell you how many embryos you can implant. In the United States only 15 out of the 50 states [including Connecticut] mandate insurance coverage for infertility. Somebody should do a study on whether states that cover infertility have fewer multiple births than states that don’t.
Q. Does competition among centers add to the temptation to implant more embryos to keep the pregnancy success rate high?
A. There’s definitely pressure on centers to compete, and patients do their homework about clinic success rates. There are 425 fertility clinics in the United States, but the number of cycles of IVF has flattened, because the baby boomer generation is now older.
Q. Is the number of high order multiple births going down?
A. The number is indeed going down. The number of triplets is now around 2 percent. A few years ago it was 3.5 to 4 percent, and in 1996 it was 7 percent. The average number of embryo transfers has been decreasing, too, from an average of four in 1996 to 2.6 now.
Q. What about selective reduction (targeting one or more fetuses in a multifetal pregnancy for termination) as a way of avoiding multiple births?
A. We try not to go there, but since women are very well-informed about infertility treatments and procedures, sometimes they ask you, “Please implant three embryos. If they all survive, I’ll have a selective reduction.” I’m personally not very comfortable with this concept. I only want to use it as a last, last, last resort.
Q. Does an incident like the California octuplets undermine the credibility of your field?
A. Yes, of course. You see how much ink has been spent on this issue, and it makes us, as a professional group, look bad. There is so much hard work by a team of professionals behind the scenes to help couples achieve what is perhaps one of the most important reasons we are on the planet: to reproduce, to have offspring.
Q. With all that has been written about the octuplet case, has anything been lost in the debate?
A. What has been lost is the sacrifice, the hours and hours of work that have gone into creating a treatment for infertility that is successful and the incredible amount of joy we have been able to bring to families.
Q. Besides implanting more embryos, what else can be done to improve an infertile couple’s odds of having a baby?
A. Research is being done on identifying the best embryo to implant, trying to find markers of embryo implantation potential. We’re also looking at methods for identifying the best egg.
Q. How is that research going?
A. I predict that five years from now you’ll see many more single-embryo transfers. There has to be a coalition of events: technological advances, better insurance coverage, less competition among clinics, but I am convinced that in a few years, this is going to happen, and higher order pregnancies from IVF will be history.
—Jennifer Kaylin
Photo by Jennifer Kaylin
To find out more about the Society for Assisted Reproductive Technology or to view clinical survey reports from any center in the United States, go to www.sart.org.
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