ASRM BULLETIN
Volume
16, Number 21
April
15, 2014
New
Report Recommends Policy and Practice Changes in Fertility Treatment for Fewer
Multiple Births
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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