by: ASRM Office of Public Affairs
Published in ASRM Bulletin Volume 16, Number 21
In a new study commissioned by The March of Dimes Foundation and published in Fertility and Sterility, researchers from The Hastings Center and Yale Fertility Center examined the practical circumstances of infertility treatment in the US that influence patients and their doctors to make treatment choices that too frequently result in multiple births.
Fertility treatments such as IVF and controlled ovarian stimulation (COS) have enabled millions of people in the United States suffering from infertility to become parents, but they have also contributed to increased rates of multiple births. And multiple pregnancies often leads to pre-term births- not the best outcome for a mother or her children.
For patients, treatment choices are often based on financial considerations. Insurance coverage for infertility is often inadequate, failing to cover the optimal type of treatment or a sufficient number of cycles.
If they pay out-of-pocket for treatment, patients may be limited to COS which is more difficult to control than IVF. If patients are able to afford IVF or have some insurance coverage for it, many request multiple embryo transfer in order to maximize their chances of becoming pregnant in the shortest possible time. Twins are seen as a positive outcome, with the potential to allow a couple to complete their family in a single cycle.
Physicians feel the pressure from patients who want to increase their chances of becoming pregnant more quickly. Yet while they must respect patients' autonomy and choices, they are obligated to provide safe treatments. In addition, the present structure of the CDC's and SART's assisted reproductive technology data reporting system results in lower per cycle success rates for practices when more patients transfer fewer embryos per cycle, creating a disincentive to recommend single embryo transfer (SET) to all but the most promising patients.
Increased use of SET was one of the main ways identified by the researchers to reduce multiple births resulting from fertility treatment. To make it a more appealing and practical option, they suggested a number of policy and practice changes:
- Expand insurance coverage of IVF;
- Limit the use of COS and fast-track patients to IVF;
- Improve patient communication and education about the risks of multiple pregnancy;
- Encourage more patients to have SET;
- Redefine the treatment cycle, including subsequent frozen-thawed SETs of embryos resulting from a single retrieval to be counted as part of the same cycle;
- Increase research on COS to improve protocols, compile data, and identify patients who should move quickly on to IVF;
- Increase research on embryo development to improve embryologists’ abilities to select the most promising embryos for SET.
Charles Coddington, MD, President of the Society for Assisted Reproductive Technology (SART) remarked, "Physicians agree that we need to reduce the numbers of multiple births resulting from assisted reproduction. This report clearly explains the way our current system steers patients to treatments that too often result in multiple pregnancy; and it suggests a number of ways to make needed changes."
Johnston et al, Preterm Births Multiples, and Fertility Treatment: Recommendations for changes to policy and clinical practice, Fertility and Sterility, in press.
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