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Thursday, February 19, 2009

Octomom and the Embryo Transfer Debate

Though single embryo transfer has been a hot topic debated in the infertility world for quite some time, it has been thrust into the spotlight by Nadya Suleman's octuplets, the result of a six embryo transfer. Slate had an article this week asking "Pregnant Pause: Who Should Pay for In Vitro Fertilization" that doesn't truly answer that question, but instead discusses the pros--but not the cons--of a single embryo transfer. If Slate is taking a pregnant pause, I'd like to fill the silence.

The author, Darshak Sanghavi, starts with a great argument in favour of eSET (elective single embryo transfer) but muddles it by contradicting himself and simplifying medicine with a one-size-fits-all approach. Is eSET a good idea when it is no longer elective but instead becomes mandated? No, just as we wouldn't set a single protocol to deal with any other medical condition. Medicine should have guidelines that doctors use to tailor medicine to fit their patient and not expect patients to fit their medical conditions to protocols set absent of all possibilities.

On the first page of the article, Sanghavi states that the reason doctors choose to transfer (yes, they transfer, not implant. You'll notice the term is eSET, not eSEI) is that "Implanting just one embryo leads to pregnancy roughly 40 percent to 50 percent of the time; two embryos are 75 percent successful; and three embryos are 87 percent successful. " Yet his argument in favour of eSET quotes a study: "In 2004, Scandinavian doctors reported that implanting one embryo at a time, repeatedly if necessary, resulted in the same final pregnancy rates as implanting several at once."

Which is it? Is a single embryo transfer just as successful as a multi-embryo transfer? Or is it ultimately successful if you do it 4 times rather than 2? I think the problem with boiling down people to numbers is that we are receiving no information on who was included in calculating the figure.

It all depends on the person and using statistics is reductive in a situation where every body responds uniquely to medication and procedures. Transfer of a single embryo in which woman? The one who also has a 28-day cycle a la the reproductive health books or the one with a luteal phase defect? A woman who is 25, 30, 35, or 40? A woman who has a uterine anomaly? A woman who still has her tubes? A woman who has had a previous pregnancy or a woman who has never carried to term? Sanghavi states these arbitrary numbers, but they are just that--arbitrary numbers. Without information about the people included in the study, we cannot possibly use these numbers against our own life to calculate out our chance for success.

That said, I do agree with Sanghavi that it would help reduce the rate of multiples overall by having fertility treatments covered by insurance. By which I mean, all fertility treatments; not just IVF (it disturbs me that people don't realize that there are more options than IVF and that most of these options are not covered by insurance and need to be). It would steer more people towards eSET when eSET is the best choice in their situation. Of course, eSET is not the best choice for everyone. There will always be cases where time is of the essence or where the doctor weighs the risks of repeated exposure to fertility drugs against the risks of a multiple birth from a multi-embryo transfer.

I think when a doctor can soundly explain their reasoning--and I don't think Nadya Suleman's doctor can soundly explain his reasoning for transferring six embryos in a woman who has had a successful cycle every time she has had a transfer--they should be able to make decisions that are in the best interests of their patients and even with feedback from their patient in terms of what they can handle physically and emotionally.

So, yes, I ultimately agree with Sanghavi, but can't follow the road he took to reach the same spot.

Lastly, it really makes me cranky when doctors do not push online journals to use correct terminology. Yes, it may be Slate's practice to improperly use implant rather than transfer when discussing IVF in an article, but when doctors write for online journals perpetuating the wrong terminology, it is detrimental to me trusting their argument or taking them seriously. Dr. Sanghavi knows as well as I that embryos cannot be implanted. They can be transferred, but implantation is up to the body. Hence why IVF does not have a 100% success rate.

Cross-posted with BlogHer.


Amanda said...

Thank you Mel!

B said...

I've looked into this a bit. The research I've seen supports the second statement that is, the same percentage of births/embryo, but obviously this takes longer if you are transferring one at time rather than two or three at a time. The advantage being the low risk of multiples.
I have chosen to do it this way as there is a high chance of identical twinning with PGD (20%) so there is a real chance of a transfer of two embryos resulting in triplets. Having already experienced loss I'd rather take the longer, more expensive, less risky road thanks.

The research on this from Sydney IVF can be found here

nancy said...

This whole octomom thing. It just makes me not understand how I transferred 4 embryos myself.

(i know that was not a proper comment. nor am i really even saying anything.)

Mama Melissa said...

Very well said. Thank you for saying it.


Rebel With.A.Cause said...

Well, I have it on very good authority that None of that womans babies is a set of identical twins..... So work that one out.....

Baby Smiling In Back Seat said...

You inspired me to crack open the AP Stylebook and see if that's what's been steering all of the journalists wrong.

Unless IF terms have been added in more recent editions than this one, nope. Not a word about implanting, transferring, infertility, IVF, IUI...

According to the journalism bible, we don't exist.

TeamWinks said...

I was told by my RE that multiples occur more frequently from IUIs than IVF procedures. IUIs are cheaper than IVF and typically where most women start off. When paying out of pocket, it's more easy to afford multiple IUIs as opposed to IVF. Wouldn't it make sense for insurance companies to cover IVF procedures then? Wouldn't that reduce the number of multiple births?

Kristin said...

Brilliant Mel...absolutely brilliant!

Anonymous said...

I was speaking with my RE last Saturday while in the stirrups about the same subject. She spoke to me about the policy in Sweden.

One thing I have not noticed however, in reference to the Swede's policy of transferring only one embryo, is that most European countries government health insurance covers IVF for infertile couples. Here in France (wher, incidentally, the RE has the liberty to choose) my husband and I, after passing a series of exams & begin declared infertile, are 100% covered for all procedures until 2012. I would be surprised if Sweden isn't the same. (Does anyone know for sure?)

My point is, it's easier to tell woman who isn't going to dish out thousands of dollars for IVF that she can only transfer one embryo than one who is having to pay for it.

I personally don't think that's the answer for the U.S.

On the other hand, I do think octomom might just eed a good beotch slapping. And her RE.

JuliaS said...

While there is definitely something to be said for good common sense - in that a unemployed woman on welfare with several small children living in her mommy's house (notice I didn't say single as that really was an immaterial point to me other than making it harder for her to take care of everyone)should have exercised a little more restraint; unless they are going to mandate insurance coverage for the ARTs, they are just not going to be able to get away with mandating how many to transfer/not to transfer.

Given that Ms. Suleman's doc is also responsible for transferring over seven donor embryos (from a 21 year old) into a 49 year old woman currently pg with Quads, uninsured and in the hospital on bedrest, there definitely should be some looking into HIS side of things as that seems to fly in the face of "first do no harm" to me and smacks more of a doctor trying to bolster his dismal success rates with little to no regard for his patients or the well being of their potential offspring.

As for the article, while it is nice they are trying to "put this out there" - I really wish they could do so without further perpetuating the errors and especially without contradicting themselves!

I've been hearing from many places - from women with endometriosis (which Suleman claims is why she had to choose IVF) to friends currently undergoing injectible cycles and IUI that this is starting to affect them. One such friend said her RE is completely "freaked out" and as a consequence has been canceling cycles and scaling back on treatment.

Mel - you weren't kidding when you said this woman was just plain out bad for the IF community. (Her doctor too)

Anonymous said...

One of the reasons why IMPLANTED keeps on popping up is that her doctor claims that he has come up with a procedure to implant and not transfer. Most experts don't think his procedure works, but the doctor continues to advertise it.

Also very interesting is that in 2006 he was responsible for 56 IVF procedures , only 2 resulted in pregnancies and only one went to term (and that was Ms Suleman). Raises some eyebrows, doesn't it ?!?

I think her doctor is an unethical quack.

Queenie. . . said...

Very well said, Mel.

To follow up on someone else's comment about IUI's having higher multiple rates. . .my insurance plan covers IVF 100%. . .but only after having 6 IUI's first (which are also covered 100%). So, insurance coverage itself isn't necessarily the answer.

Jess said...

So wait....

I'm like the Epic Fail of under-25 IFers, then, if I had 1 75% chance and 2 80% chances and got pregnant with one baby. And being so young, surely my "chances" were even greater, statisically speaking! Egads, I suck!

And that, right there, is the ARGUMENT for the number of embryos NOT being set by anyone other than GUIDELINE-wise. I mean come ON! I was SO young and SO healthy and we were SO unexplained.

Now...I do think that there could and probably SHOULD be a MAX number of embryos that can be transferred (4 maybe?) as pg rates do not go up and up and up with more and more emryos. At some point they plateu but the risks do NOT.

As for insurance....

It's NOT realistic for EVERYTHING to be covered by insurance. However, we've looked and good IF insurance worth buying isn't really truly available (not to the private or small group buyer). We're INSURANCE AGENTS so I'm relatively confident that in our state this is the case. And I'm talking of buying it BEFORE even ttc, not after diagnosis. The problem with EVERYTHING being covered is simply's already expensive and crap would only get MORE expensive and MORE crap if EVERYTHING was covered for EVERYONE. I am more than willing to pay for lesser treatments, to pay a deductible, and to not have EVERYTHING covered....but even that is not particularly available, and not in a cost-effective way. THAT is the sad part. Because at some point, and that's usually happened by the time IVF is a player, the cost is MONUMENTAL and PROHIBITIVE and infertility is a MEDICAL condition. Do I think there shoudl be coverage available? Yes. Do I think it should be/needs to be absolute? No.

It's not the greedy insurance companies' faults, it's just a fact of life...companies can't stay in business if they pay EVERYTHING, or else if they can, the cost will be prohibitive to the consumer. Insurance is hedging your bets...placing small risks on larger numbers of's simply not DESIGNED to cover EVERYTHING for EVERYONE.

That said, there are logical reforms that could be in place. Especially in state (like mine) with NO mandated coverage. I'm not, in any way, ANTI IF-coverage, but I'm also rather realistic about the facts, too.

I do also agree that to a point IF coverage would decrease the paid claims on higher risk pregnancies, so there is that, too. Statistically speaking, though, I'm quite certain companies have looked into it...after all, that's what they DO.

There are just plain and simple NO good answers for it. eSETS, while less risky, are not always financially feasible. Or medically called for. However, is it EVER really wise to transfer SIX?

I walked around for about a week saying "SIX? Are you KIDDING ME? SIX????" after the news came out about the Octuplets. Six! EGADS!

Anonymous said...

Didn't I read her saying that she had six transferred each time? It seems that was her protocol. Only once before did it result in a multiple. Further, if this pregnancy had been like her previous ones, we would have never heard about it. She had eight and she's being blasted essentially for not doing selective reduction.

Regular Reader

Bec said...

In Australia there are limits in place as to the number of embryos you can have transferred. Most places will only let you have one, if you are over 35 or have had subsequent implantation failures you can have 2, and in absolute exceptional circumstances they MIGHT let you have three.

It is heavily regulated- even though I have had four failed transfers (7 cycles total), I am still ineligible to have more than one embryo transferred. Unfortunately I dont think the 'octomum' has helped my case at all...

bleu said...

Thanks Mel. I also feel like NO ONE is discussing embryo quality in situations. When you have 4 poor quality embryo's the doc may transfer all when with great ones he would only transfer 2.

Science is never really discussed in these articles, just broad sweeping terms with bits of this or that study thrown in to try and justify whatever the author is trying to say.

Betty M said...

An excellent one stop shop for information on eSET around the world is a website set up by the fertility regulator and various stakeholder groups in the UK (where there is an enormous push for eSET) to explain why eSET is a good thing. There are links to lots of research and bits on eSET around the world. Here there is a highly regulated fertility industry already and limits on transfers (2 under 40, 3 over 40). Anyone transferring 6 would lose their licence. There is patchy public funding for IVF with the aim to get up to 3 cycles per person.

Personally I can't see any good reason for transferring over 3 at any time.

Serenity said...

I did a lot of research on this, given my uterine anomoly, and most of the studies I also read concluded that transferring more than two embryos is not correlated with a higher pregnancy rate. However, it IS correlated with a higher chance of multiples.

We transferred two day three embryos on the IVF cycle where I became pregnant (with a singleton). However. He was small, and born three weeks early.

Knowing what I know now, I likely will do only single embryo transfers if we ever get to the point where we're willing to try ART again to conceive.

In my opinion, her doctor was NOT practicing good medicine when he allowed her to make the choice to transfer as many embryos as she did.

The whole situation makes me want to throw up, actually. The media coverage, the doctor, the woman herself. The wondering if now we're going to start regulating pyschological screening in order to qualify for IVF, since her mental health is being called into question.

Which, you know, is fine. Because I have to pass some test that I'm mentally fit to go through IVF, but fertiles don't. Because, you know, they're better parents than me.


Ms. Perky said...

He phrased it poorly - but the research suggests that doing multiple eSET cycles versus one multiple-embryo transfer has the same overall pregnancy rate for a large population of IVF patients (even the ASRM/SART stats are showing this, which is one of the reasons their embryo transfer numbers have gone consistently down over the years).

Also - if embryos could be implanted rather than transferred - it would equal a 100% pregnancy rate, but not a 100% success rate, because implantation does not equal live birth rate and IVF success rates are based on live birth rates.

One of the doctors at Ye Olde Fertility Clinic (who still needs to hang a mobile in Room 1, incidentally), points out that if IVF were covered by insurance (because often IUI and other treatments ARE when IVF is NOT, incidentally), that patients could skip right to IVF and avoid IUI which would also help them avoid the issue of multiples. I find this hysterically funny that he says this NOW, because back in 2006 I went to him and said, "I don't want to do IUI again because I don't want to risk triplets," and he said, "But we know IUI works for you and we never have triplets."

Hah, I say. Hah!

He also points out that it is extremely important to note the word "elective" in eSET because without it, you take away the essence of the treatment.

Turns out, he's a pretty smart guy after all. They don't call him "Medical Director" for nothing.

Bea said...

"Which is it? Is a single embryo transfer just as successful as a multi-embryo transfer? Or is it ultimately successful if you do it 4 times rather than 2?"

Others have addressed this, but I'll give it my bash. Basically, the chance of pregnancy is *per embryo* not per transfer. If you transfer one at a time, you will have to do two cycles to get the same odds of doing two at a time. This is because cycles succeed or fail depending on the embryo, for the most part.

Yes, the conditions in the womb vary a bit from cycle to cycle, but 98% of it is getting the right embryo. This is also why you shouldn't stress too much about eg catching a cold during your cycle.

That said, there are obvious exceptions. If you have a LP defect, and your LP one month is three days and the next month is fourteen, obviously there is a big difference between the conditions in the womb those two cycles. This is and example of why your point about having to ultimately tailor the response to the patient is at the crux of the matter.

The other point is one about emotional capital. We started out strongly in favour of SETs, but we ran out of emotional mileage after a year - that was with good coverage. Then we went to two embryos. Now, it's still a strong argument in favour of coverage, because you're going to reduce the risk across the population quite significantly just by giving people the option (from a financial point of view) and you can certainly justify capping it at two or three, based on risk/reward stats. But you can't just dismiss how hard it is to fail cycle after cycle, even without the financial strain.

Bottom line is, though - funding IVF pays for itself in reduced multiples, and you don't have to mandate SETs for this.


Anonymous said...

OK, color me uneducated here, but when eSET is discussed, at what stage are the embryos? My doctor will transfer no more than 2-4-6 three-day embryos to someone in her 20's-30's-40's, respectively. Are they transferring five-day embryos?

Anonymous said...

I requested a single embryo transfer. I changed my mind when the first time they showed me my two fragmented, straggling, day 3 embryos. I don't make good embryos and I will never be a good candidate for eSET.

Also, you know it's a guy talking about the "bottom line" and not worrying about one or four cycles. Money aside, four cycles? Lets inject him with nut-splitting hormones and then stab him with needles to suck the sperm out. Let's see if he still thinks that four is just the same as one.