Should IVF Be Regulated?

Should the number of embryos implanted in women be regulated?

November 19, 2008, 2:47 PM

Nov. 20, 2008 — -- Jon and Kate Gosselin, like a growing number of couples who turn to fertility treatments, got more than they bargained for when they became the parents of two sets of multiples.

The Gosselins, who have one set of twins and one set of sextuplets, struggle daily with the demands having such a large family.

Fertility experts told that doctors struggle to strike a balance between the demands of infertile couples, who often ask to have large numbers of embryos implanted to increase their chances of conception, with the inherent risk that more than one of those embryos will take, leading to multiple births.

Multiple births carry a much higher risk of death for the infants, according to the U.S. Centers for Disease Control. The CDC says twins are five times more likely than singletons to die within a month of birth and triplets nearly 15 times more likely to die. Exact numbers for higher multiples aren't available, but the death rate is exponentially higher.

"It's a very, very difficult situation," said Dr. Richard Paulson, chief of reproductive endocrinology and infertility at the University of Southern California. "Here comes a young couple who took a second loan on their home so they could afford fertility treatment and they're very motivated to be successful."

"They'll tell us that that they want to implant as many as possible because this is their last chance," said Paulson. "And if we don't do it they'll just go to another doctor who will."

And evidently, couples do. According to the CDC, multiple births have increased greatly in the last 20 years, thanks to fertility drugs. In 2005, 68 sets of quintuplets or more were born, compared with 13 in 1990.

With Little Regulation, IVF Poses Ethical Dilemmas

Arthur Caplan, director of the Center of Bioethics at the University of Pennsylvania, believes that ethically, doctors must do whatever they can to prevent multiple births.

"I have long argued that nobody should be putting more than four embryos into any woman because of the high risk of super multiple pregnancies which are hugely dangerous to newborns," said Caplan.

"We know that usually every one of these cases has the kids in a neonatal unit, that disability and learning disorders are common and death can even occur," he said. "In my view, the ethical thing to do is to control against the possibly of super multiples occurring."

But unlike in many European countries, where the number of embryos that can be implanted in women is kept to a maximum of three, the U.S. has no such regulation, said Caplan. That makes it harder for doctors to resist parents who want as many embryos as possible implanted.

Even without new guidelines, insurers could help reduce multiples, he added.

"If insurance companies would say that they won't pay for complications resulting from transfers beyond four at time -– that would have teeth," Caplan said. "People are doing it because some insurance companies will say they'll only pay for two cycles, which leaves people to transfer multiple embryos at a time because they think it's their only shot."

Occasionally parents have moral objections against freezing embryos and not using all of them, leading them to argue that all of them should be implanted. Once high numbers of embyos are implanted and become viable, patients often also have moral reasons not to cull or selectively reduce them.

In addition to more specific guidelines by professional medical organizations to inform parents of the risks of high-multiple births, Caplan says he'd like to see insurance cover more IVF treatments with a limit on the number of embryos that can be transferred.

Improved Counseling for High-Risk Pregnancies

Dr. Paula Mahone, medical director of the Perinatal Services at Iowa Methodist Medical Center, who treated the McCaughey septuplets in 1997, said that she doesn't think regulating the number of implanted embryos is the best way to prevent multiple births.

Instead, Mahone advocates improved counseling for mothers carrying high-risk pregnancies.

"The most ethical thing to do is to first let parents know that I realize the path that took them to this point was very difficult and hard and they still have some hard decisions to make," said Mahone. "They may be happy they've conceived but there's a chance they may not have any children to bring home and raise."

In addition to discussing selective reduction procedures, Mahone says she warns expectant mothers to be extra cautious of symptoms they may otherwise ignore. She says that while she -– like most physicians -– does not favor multiples, she does provide care for those patients who carry such high-risk pregnancies to term.

Mahone says that even if a woman has multiples as a result of her first IVF treatment, subsequent implantation should not be scaled back as a precaution against more sets of multiples. In other words, there is no evidence showing that just because IVF produced multiples at one point that it ever will again.

"Medically, we know that if the mom is still infertile [when she tried IVF a second time] then she will still be less likely to have an embryo attach to the uterus," said Mahone. "And because it's such an extensive procedure, I understand wanting to have the best chances at having one viable fetus."

Media Attention Makes Life With Multiples Seem Easy, Docs Say

With families like the Gosselins, who have one set of twins and sextuplets featured on their own reality television shows, doctors worry that the glorification of their hectic lives might add yet another obstacle for doctors in trying to avoid multiple births.

"The media is presenting the side of the story that is fun because that is what people want to hear," said Paulson. "It would certainly take away from the show if they began each episode with a disclaimer about the horrible effects multiple births can have on children -- who wants to hear that?"

Paulson says that this "slice of life" viewers get is far from the reality of raising a family of multiples.

"Unfortunately, the media thinks it's just a great blessing to have multiples because fertility is good and lots of fertility is better," said Paulson. "But the reality is that, with six babies, the probability of there being a major issue is very, very likely."

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