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The cost of multiple gestation
Title: Deliveries and children born after in-vitro fertilization in Sweden 1982-95: a retrospective cohort study
Author: T. Bergh, et al.
Address: Uppsala, Sweden
Source: The Lancet 354: 1579-1585 (November) 1999
Summary: Most countries report a 20-30% occurrence of multiple births after assisted reproduction, which leads to 30-40% of all in-vitro fertilization (IVF) babies being born as a result of multiple pregnancies, compared with 2-3% in the general population. No evidence has yet shown that cryopreservation is an additional risk factor for perinatal outcome. Data from all IVF clinics in Sweden were compared with the obstetric outcomes of babies (n=5856) born from 1982 - 1995 with all babies born in the general population (n=1,505,724) during the same time. Researchers examined malformations, cancers, and deaths in the two populations. Data were stratified for maternal age, parity, previous infertility, year of birth, and multiple pregnancies. Multiple births occurred in 27% of pregnancies compared with 1% in controls. More IVF babies were born preterm (less than 37 weeks) than controls (30.3 vs 6.3%) and more had low birthweights (27.4 vs 4.6%). The perinatal mortality was 1.9% in the IVF group and 1.1% in the controls. Malformations occurred in 5.4% of all babies in the IVF group and the rates of neural tube defects and oesophageal atresia were higher than those in the controls. There was no increase in childhood cancer in the IVF group. Researchers concluded that a high frequency of multiple births and maternal characteristics were the main factors that led to adverse outcomes, not the IVF technique itself.
Comment: There is worldwide trend toward the transfer of fewer embryos in an attempt to reduce the rate of multiple gestations. In the United States this has received considerable press, the American Society for Reproductive Medicine has issued guidelines about limiting the number of embryos replaced, and there is a trend toward lower embryo transfer numbers by IVF centers.

The policies of the United States are considered Third World and held in contempt by a sizable portion of the global IVF community. Many countries have legislated that no more than 2 embryos are replaced. A Finnish study reported a 30% pregnancy rate with the transfer of a single embryo. In reviewing the just published 1997 clinic reporting data, some of the "better" IVF centers were reporting a 20% rate of triplets and above. Why is it necessary that these programs transfer an average of over 3 embryos? Is this to prove a point that they are good at IVF, or is it to give patients their greatest chances of success? The American concept that more is better and success is everything prevails. In such good programs, why are so many embryos replaced when the risks are known? Competition is stiff between clinics for IVF patients. Success breeds success. Egos are big. The CDC report states on every page that the rates should not be used to compare programs? Who are they kidding?

Multiple gestation translates into a cost of health care for multiple pregnancies that far exceeds the entire cost for all the IVF therapy to all patients. One might argue that these are acceptable risks, after all we are bringing happiness into families and are making dreams come true. One might argue that if high order pregnancies are obtained, a selective abortion could be performed. Both of these arguments are fallacious. Couples never forget a selective abortion and are left with an emotional scar even when the subsequent pregnancy outcome is good, and it usually is. The above study relating increased malformation to preterm birth and preterm birth to IVF reveals only the tip of the iceberg. The personal costs to the family of a very premature infant birth are staggering. Women who have high order pregnancies often do not return to their professional occupations, and depression and marital problems are common. The solution is unbelievably simple. We can make the problem of high order pregnancies go away - today. Transfer no more than 2 embryos and the problem is solved. If this can not be accepted electively by patients and IVF centers alike, it must be coerced.

Equally important in this equation is that infertility is recognized as the disease that it is and treated as such by insurance. Our greatest barrier to infertility has ceased to be technology and now is the accessibility to that technology. IVF technology is utilized much less frequently in the United States than in other industrialized countries. Assisted reproduction should not be only for the rich or those willing to mortgage their lives in order to pay. It could easily be the case that the total health care budget would be reduced from its present level if infertility, including assisted reproduction, were reimbursed by third party payers. How can the whole system be so inadequate, especially when the answer is at hand?