Ethical Obligation for Restricting the Number of Embryos Transferred to Women: Combating the Multiple-Birth Epidemic from In Vitro Fertilization

ABSTRACT

In vitro fertilization (IVF) is an increasingly effective and popular means of achieving pregnancy for infertile women, but contributes to a growing incidence of risky twin pregnancies. Despite studies demonstrating cost-effective means to achieve IVF pregnancy while strictly limiting the number of embryos transferred, multiple-embryo transfer remains the most common practice in the United States, and twin pregnancies continue to increase. IVF providers resist restricting these practices, arguing that this is counter to principles of procreative liberty, patient and professional autonomy, and free-market economics. We counter that physicians have a professional fiduciary responsibility to weigh issues of nonmaleficence to patients and just use of health care resources with patient desires. With oversight from professional organizations, providers should follow strict but medically appropriate restrictions on embryo transfer practices and work toward safer means of optimizing IVF outcomes than multiple-embryo transfer.

KEYWORDS

Bioethics - in vitro fertilization - embryo transfer - twin risks

REFERENCES

• 1 CDC .Available at: http://www.cdc.gov/art/ART2007/index.htm Accessed August 25, 2009
• 2 ASRM Practice Committee .Guidelines on Number of Embryos Transferred: ASRM Practice Committee Report. Birmingham, AL; American Society for Reproductive Medicine 1998
• 3 Practice Committee of Society for Assisted Reproductive Technology . Guidelines on number of embryos transferred.  Fertil Steril. 2008;  90(5 Suppl) S163-S164
• 4 March of Dimes .PeriStats. Available at: http://www.marchofdimes.com/peristats/ Accessed August 19, 2009
• 5 Russell R B, Petrini J R, Damus K, Mattison D R, Schwarz R H. The changing epidemiology of multiple births in the United States.  Obstet Gynecol. 2003;  101(1) 129-135
• 6 Reynolds M A, Schieve L A, Martin J A, Jeng G, Macaluso M. Trends in multiple births conceived using assisted reproductive technology, United States, 1997–2000.  Pediatrics. 2003;  111(5 Part 2) 1159-1162
• 7 Centers for Disease Control and Prevention (CDC) . Contribution of assisted reproductive technology and ovulation-inducing drugs to triplet and higher-order multiple births—United States, 1980-1997.  MMWR Morb Mortal Wkly Rep. 2000;  49(24) 535-538
• 8 Centers for Disease Control and Prevention .2006 assisted reproductive technology (ART) report: Section 1—overview. Available at: http://www.cdc.gov/ART/ART2006/section1.htm Accessed August 25, 2009
• 9 Helmerhorst F M, Perquin D AM, Donker D, Keirse M JNC. Perinatal outcome of singletons and twins after assisted conception: a systematic review of controlled studies.  BMJ. 2004;  328(7434) 261-265
• 10 Strömberg B, Dahlquist G, Ericson A, Finnström O, Köster M, Stjernqvist K. Neurological sequelae in children born after in-vitro fertilisation: a population-based study.  Lancet. 2002;  359(9305) 461-465
• 11 Derom R, Derom C. The East Flanders prospective twin survey. In: Keith LG, Blickstein I Multiple Pregnancy: Epidemiology, Gestation and Perinatal Outcome. London, United Kingdom; Taylor and Francis 2005: 39-47
• 12 McDonald S, Murphy K, Beyene J, Ohlsson A. Perinatal outcomes of in vitro fertilization twins: a systematic review and meta-analyses.  Am J Obstet Gynecol. 2005;  193(1) 141-152
• 13 Hansen M, Colvin L, Petterson B, Kurinczuk J J, de Klerk N, Bower C. Twins born following assisted reproductive technology: perinatal outcome and admission to hospital.  Hum Reprod. 2009;  24(9) 2321-2331
• 14 Pinborg A, Loft A, Schmidt L, Andersen A N. Morbidity in a Danish national cohort of 472 IVF/ICSI twins, 1132 non-IVF/ICSI twins and 634 IVF/ICSI singletons: health-related and social implications for the children and their families.  Hum Reprod. 2003;  18(6) 1234-1243
• 15 Callahan T L, Hall J E, Ettner S L, Christiansen C L, Greene M F, Crowley Jr W F. The economic impact of multiple-gestation pregnancies and the contribution of assisted-reproduction techniques to their incidence.  N Engl J Med. 1994;  331(4) 244-249
• 16 Hidlebaugh D A, Thompson I E, Berger M J. Cost of assisted reproductive technologies for a health maintenance organization.  J Reprod Med. 1997;  42(9) 570-574
• 17 Ryan G L, Zhang S H, Dokras A, Syrop C H, Van Voorhis B J. The desire of infertile patients for multiple births.  Fertil Steril. 2004;  81(3) 500-504
• 18 Højgaard A, Ottosen L DM, Kesmodel U, Ingerslev H J. Patient attitudes towards twin pregnancies and single embryo transfer—a questionnaire study.  Hum Reprod. 2007;  22(10) 2673-2678
• 19 Murray S, Shetty A, Rattray A, Taylor V, Bhattacharya S. A randomized comparison of alternative methods of information provision on the acceptability of elective single embryo transfer.  Hum Reprod. 2004;  19(4) 911-916
• 20 Newton C R, McBride J, Feyles V, Tekpetey F, Power S. Factors affecting patients' attitudes toward single- and multiple-embryo transfer.  Fertil Steril. 2007;  87(2) 269-278
• 21 Ryan G L, Sparks A ET, Sipe C S, Syrop C H, Dokras A, Van Voorhis B J. A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates.  Fertil Steril. 2007;  88(2) 354-360
• 22 SART .http://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?clinicPKID‐0 Accessed August 25, 2009
• 23 Martikainen H, Tiitinen A, Tomás C for the Finnish ET Study Group et al. One versus two embryo transfer after IVF and ICSI: a randomized study.  Hum Reprod. 2001;  16(9) 1900-1903
• 24 Gardner D K, Surrey E, Minjarez D, Leitz A, Stevens J, Schoolcraft W B. Single blastocyst transfer: a prospective randomized trial.  Fertil Steril. 2004;  81(3) 551-555
• 25 Gerris J, De Neubourg D, Mangelschots K, Van Royen E, Van de Meerssche M, Valkenburg M. Prevention of twin pregnancy after in-vitro fertilization or intracytoplasmic sperm injection based on strict embryo criteria: a prospective randomized clinical trial.  Hum Reprod. 1999;  14(10) 2581-2587
• 26 Thurin A, Hausken J, Hillensjö T et al. Elective single-embryo transfer versus double-embryo transfer in in vitro fertilization.  N Engl J Med. 2004;  351(23) 2392-2402
• 27 Fertilisation H, Authority E. Available at: http://cop.hfea.gov.uk/cop/ Accessed August 10, 2009
• 28 Ombelet W, De Sutter P, Van der Elst J, Martens G. Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project.  Hum Reprod Update. 2005a;  11(1) 3-14
• 29 Gerris J. The near elimination of triplets in IVF.  Reprod BioMed Online. 2007;  15(3) 40-44
• 30 Gerris J, De Sutter P, De Neubourg D et al. A real-life prospective health economic study of elective single embryo transfer versus two-embryo transfer in first IVF/ICSI cycles.  Hum Reprod. 2004;  19(4) 917-923
• 31 Beauchamp T L, Childress J F. Principles of Biomedical Ethics, 4th ed. New York, NY; Oxford University 1994
• 32 Practice Committee of Society for Assisted Reproductive Technology . Revised minimum standards for practices offering assisted reproductive technologies.  Fertil Steril. 2008;  90(5 Suppl) S165-S168
• 33 Emanuel E J, Emanuel L L. Four models of the physician-patient relationship. In: Steinbock B, Arras JD, London AJ Ethical Issues in Modern Medicine, 6th ed. Boston, MA; McGraw-Hill 2003: 67-76