Fertility techniques increase births ... and risks
October 7, 1999
Web posted at: 3:49 PM EDT (1949 GMT)
By John Sussman, M.D.
(WebMD) -- During my years as an obstetrician, I have seen a significant increase in the use of fertility drugs and assisted reproductive technologies (ART), such as in vitro fertilization (IVF), a technique in which an egg is fertilized in a test tube and then replaced into the woman's uterus.
Along with the rise in these procedures, I've witnessed an increase in multiples: twins, triplets and so on. My professional experience is reflective of a nationwide trend: Since 1980, the number of twins born in the United States has more than doubled, and the number of triplets and other higher-order multiple births has increased by more than 400 percent, according to the 1997 National Vital Statistics Report published by the National Center for Health Statistics.
While modern medical technology has allowed many couples to have children of their own, the new techniques have also given rise to an increase in the problems associated with multiples: miscarriage, premature birth and other neonatal complications for the babies, and prolonged hospitalization, toxemia, prenatal and postpartum bleeding and an increased risk of cesarean section for mothers.
Multiples are frequently born premature, putting them at a much higher risk of a number of illnesses and lifelong health complications such as respiratory distress, vision problems and developmental delays, according to the American Association of Premature Infants.
Limiting multiple pregnancies
It is generally agreed among organizations and fertility specialists -- including the American Society for Reproductive Medicine (ASRM) and the American College of Obstetrics and Gynecology (ACOG) -- that limiting the chances of a multiple pregnancy should be the first strategy in dealing with this problem. The careful use of fertility drugs by experienced and qualified ob-gyns and reproductive endocrinologists (ob-gyns with specialized training in infertility) is paramount.
In general, doctors want to minimize the possibility of more than two embryos. The chances of having multiples can be significantly reduced by three things: 1) using the least potent drugs in the lowest effective doses; 2) monitoring the developing ovarian follicles and hormone levels (both being an indication of how many eggs will be ovulated); 3) and judiciously choosing not to proceed with a fertility drug injection in a cycle where too many eggs may result.
Preventing multiple pregnancies can be complicated
With ART, the issues are somewhat different. In this case, multiple eggs are obtained from a woman before ovulation and then fertilized in a laboratory with either her partner's sperm or sperm from a donor. The number of fertilized embryos that are placed back into her uterus (in the case of IVF) or fallopian tube (in the case of zygote intrafallopian transfer, or ZIFT) is largely what determines the risk of a multiple pregnancy.
The pressures to achieve a successful result are considerable and come from both the patient, who is expending considerable money, time and emotional energy with each attempt, and from the treating physician or facility, who have an interest in maximizing their pregnancy rates as they compete for patients. Since the survival rate of transferred embryos is low and the chance of achieving even one baby increases with the number of embryos transferred, the temptation to implant higher numbers of embryos is considerable.
Most ART programs have established voluntary guidelines to strike a balance between the desire to produce a baby and the many fetal and maternal risks that accompany multiple pregnancies.
The push to regulate ART
In England, where ART is regulated, a maximum of three embryos may be transferred in any single treatment cycle, even if the particular patient's age or reproductive history makes it improbable that she will succeed. In the United States, there is no such regulation, and decisions rest in the hands of patients and their physicians.
ASRM issued guidelines in 1998, however, to help guide physicians and their patients in deciding how many embryos to transfer in any given clinical situation.
When multiple pregnancies result despite preventive measures, some patients elect a procedure known as nonselective embryo reduction, a first-trimester procedure for killing one or more embryos from a multiple-embryo pregnancy to increase the likelihood of survival of the remaining embryos.
The ethical considerations and risks associated with this procedure are complex, but it remains an option for patients and their physicians to discuss. In April of 1999, ACOG issued ethical guidelines for multiple embryo pregnancies to help patients and doctors who were faced with the difficult decision.
ACOG recommends counseling patients about the risks of multiple pregnancies before treatment begins. The guidelines also state that, for some of those who are opposed to abortion, nonselective embryo reduction is ethically justified, since the intent is to deliver a healthy child.
John Sussman is co-author of "The Unofficial Guide to Having a Baby" and "Before You Conceive: The Complete Prepregnancy Guide."
Copyright 1999 WebMD, Inc. All rights reserved.
RELATEDS AT :
In vitro fertilization
American Society for Reproductive Medicine
American Association of Premature Infants
American College of Obstetrics and Gynecologists: Ethical Guidelines for Multiple Embryo Pregnancies
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