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.
Others have been writing eloquently for quite some time about insurance coverage as well as eSET.
Twin Peas recently had a post about eSET and states honestly: "Is it more important to get pregnant as fast as possible or to have a healthy singleton pregnancy. Unfortunately, I don’t think there is a good answer to this question. If I was going through IVF right now I’m not sure I would be interested in a single embryo transfer (although I’m too old to fit their criteria now). However, knowing what I know about premature babies, I think I would take the safer route of having a single healthy baby."
Bellyaching and Benedictions wrote about this topic months ago in regards to her own cycle: "So why only 1? To tell the truth it's really hard to transfer one given how much I want this NOW and the fact that single transfers are not done that often (yet). I really, really agonized about this and was not sure what I would do until I was in that transfer chair. But in the end I felt it was the responsible thing to do."
It's Not a Clown Car just did a series of news segments on this topic. As a mother of triplets and a singleton, she is choosing eSET in order to continue adding to her family. She writes: "I simply cannot take that risk, even if it means I don't get pregnant again. And it is that reality - the knowledge that it is my own determination to push forward with eSETs that may be my downfall - that humbles me, reminds me that hope is something I may just have to let go of some day."
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.
Melissa is the author of the infertility and pregnancy loss blog, Stirrup Queens and Sperm Palace Jesters. She keeps a categorized blogroll of 1700 infertility blogs and writes the daily Lost and Found and Connections Abound, a news source for the infertility blogosphere. Her infertility book, Navigating the Land of If, is forthcoming from Seal Press in June 2009. She is the keeper of the IComLeavWe (International Comment Leaving Week) list which is currently open for February.