IVF treatment and multiple births: Free-market patient rights versus government regulation

July 26, 2011

Elsevier announced the publication of several commentaries in the scientific journal Reproductive BioMedicine Online on the subject of how many embryos it is safe and proper to place in a uterus, and how best to regulate this decision. It is a dilemma faced by all patients anxiously caught between no pregnancies at all or facing the prospect of twins or triplets. In this difficult place it is often all too easy to think that the latter option must be the best. But is it?

The debate was sparked by a paper from Dr Francois Bissonnette et al., which describes the impact of the implementation of new legislation in Quebec, Canada, on the rates of and pregnancy. This legislation was introduced in August 2010 in conjunction with state-finance for treatments. The aim was to reduce , described as "the major negative side effect of ART (), by controlling the number of that could be transferred in any one cycle.

In the first three months of this programme, 1353 cycles of IVF were performed in the five Quebec-based ART centers. Single embryo transfers accounted for 50% of transfers compared with only 1.6% prior to legislation – a big decline. The effect of this was to reduce the overall clinical from 42% to 32% per transfer – for the first time describing a diminishment of overall pregnancy results. Such an outcome is not unexpected, since embryologists cannot always predict the health of the embryos being transferred. In contrast, previous work from Scandinavia and Belgium has claimed that pregnancy rate is not affected (or only marginally so) when embryo numbers are reduced – perhaps an unrealistic routine outcome? However, the multiple pregnancy rate was reduced from 25.6% to only 3.7%. It is suggested that having state-financed ART created an environment in which the more aggressive use of single embryo transfer became possible, patients being prepared to risk a failure first time round, because the subsequent use of frozen embryos and/or a second cycle of treatment was still affordable. The authors say: "It is logical to use the cumulative pregnancy rate or cumulative live birth rate per initiated cycle, combining results from transfer of fresh and frozen embryos, as the standard measure of a patient's chances for a baby."

However, this paper then provoked a responding commentary by Dr Norbert Gleicher of Yale and New York, who attacks both the rationale and the ethics of the Quebec approach. First, he agrees that triplet pregnancies are a high risk to both mother and off-spring. But then he goes on to claim that both the risk to mother and babies, as well as the overall costs to the health system, of two serial singleton pregnancies are as great as, if not greater than, those of a twin pregnancy, implying that the gains of single embryo transfer are at best illusionary. Second, Gleicher objects to the intrusion of government into decisions on the grounds that this interferes with a patient's right to self-determination or "to choose". Indeed, Gleicher vociferously advocates the USA free market model over the European-style sympathy for government intervention in health care, his hope being "to keep government out of medicine".

This blast of free-market proselytizing is countered, appropriately from Europe, in a detailed response from Dr Yakoub Khalaf et al. of Guy's and Thomas' Hospital, London, who claim that practice should be based on solid data rather than personal judgment – and proceed to dissect and question Gleicher's calculations on the relative outcomes of double versus serial single . They set the right of patient self-determination against a doctor's ethical duty to practice in the best interests of her patients, and not to acquiesce passively to requests she knows to be risky, stressing that the risks from twin pregnancies are real and borne by women and children, not their doctors. They end by suggesting that Government legislation, responsibly applied, as described by Bissonnette et al., can and should be an aid to clinical leadership in decision-making with patients, and is demonstrably in the interests of the health of the patients and their children-to-be. "Yes we can" they claim – implicitly aligning themselves with Obama in his political tussle with Congress over health care policy.

More information: Original article: Francois Bissonnette, Simon Phillips, Joanne Gunby, Hananel Holzer, Neal Mahutte, Pierre St-Michel – 'Working to eliminate multiple pregnancies: a success story in Quebec' doi: 10.1016/j.rbmo,2011.05.020

Commentary: Norbert Gleicher – 'Eliminating multiple pregnancies: an appropriate target for government intervention?' doi: 10.1016/j.rbmo.2011.05.021

Commentary: Yakoub Khalaf, Susan Bewley, Peter Braude – 'Reducing multiple pregnancies after ART-Quebec says "Yes we can!"' doi: 10.1016/jrbmo.2011.05.019

Related Stories

Recommended for you

Exploring the potential of human echolocation

June 25, 2017
People who are visually impaired will often use a cane to feel out their surroundings. With training and practice, people can learn to use the pitch, loudness and timbre of echoes from the cane or other sounds to navigate ...

Team eradicates hepatitis C in 10 patients following lifesaving transplants from infected donors

April 30, 2017
Ten patients at Penn Medicine have been cured of the Hepatitis C virus (HCV) following lifesaving kidney transplants from deceased donors who were infected with the disease. The findings point to new strategies for increasing ...

'bench to bedside to bench': Scientists call for closer basic-clinical collaborations

March 24, 2017
In the era of genome sequencing, it's time to update the old "bench-to-bedside" shorthand for how basic research discoveries inform clinical practice, researchers from The Jackson Laboratory (JAX), National Human Genome Research ...

The ethics of tracking athletes' biometric data

January 18, 2017
(Medical Xpress)—Whether it is a FitBit or a heart rate monitor, biometric technologies have become household devices. Professional sports leagues use some of the most technologically advanced biodata tracking systems to ...

Financial ties between researchers and drug industry linked to positive trial results

January 18, 2017
Financial ties between researchers and companies that make the drugs they are studying are independently associated with positive trial results, suggesting bias in the evidence base, concludes a study published by The BMJ ...

Best of Last Year – The top Medical Xpress articles of 2016

December 23, 2016
(Medical Xpress)—It was a big year for research involving overall health issues, starting with a team led by researchers at the UNC School of Medicine and the National Institutes of Health who unearthed more evidence that ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.