In the wake of national media coverage of IVF patient Nadya Suleman and her octuplets born in January, we, at Reproductive Science Center of the Bay Area of San Francisco (RSC), say the issue is providing new opportunities to educate the public on avoiding perhaps the biggest risk of infertility treatments: multiple births.

Rapid medical advancements have reduced the need to take such risks. Now, in women younger than 36, we achieve high rates of successful pregnancies with the transfer of just one better-developed five-day-old embryo to the mother’s womb. High-order multiple births – triplets or more – are extremely uncommon.

In the first two decades since the first so-called “test-tube baby” was born in the United States, IVF pregnancy success rates were a fraction of the current levels, so numerous embryos were routinely transferred, and infertility patients accepted the possibility of giving birth to twins, triplets, or quadruplets in hopes of producing just one healthy baby.

We follow the medical guidelines established by American Society for Reproductive Medicine (ASRM) that recommend transferring no more than two embryos per procedure in women under 35 except in “extraordinary circumstances.” We also do extensive statistical analyses on our own pregnancy rates to better advise women on the number of embryos to transfer, since our pregnancy rates are higher than the national average.

For appropriate patients, RSC physicians recommend transfer of a single embryo at blastocyst stage of development (usually 70 to 100 cells) as the best way of achieving a single pregnancy with a term delivery.

We are committed to reducing the number of multiple births associated with infertility treatment. Our policy is two good-quality embryos in women under the age of 40. Except in the rarest of circumstances, we’re not comfortable with the risk of high-order multiple births.

The major risk of high-order multiple pregnancies is preterm delivery, which occurs in more than 50 percent of twin pregnancies, 90 percent of triplet pregnancies, and all other higher order pregnancies.
The earlier a baby is born, the greater its risk of dying or facing significant lifelong problems. Many premature babies face greater risk of:

1. lower birth weight
2. bleeding in the brain
3. intestinal problems
4. cerebral palsy
5. respiratory distress syndrome,
6. developmental delays

What do you think about the number of embryos she had transferred?

It is hard to understand why the doctor put such a large number of frozen embryos in a younger woman with a proven uterus. However, we don’t know all the facts. What were the quality of the embryos? What were her previous fresh IVF cycles like? Did finances play into this decision (i.e. the patient couldn’t afford to do three cycles of two embryos each over the next three to five years)? Did the patient claim a right to embryos and dictate what she wanted done, putting the doctor in a situation where he would have to “abandon” her if he did not agree with her reproductive choice? All of us as reproductive endocrinologists have faced situations where patients do not fully comprehend the implications of their reproductive choices and we need to guide them appropriately with the years of medical training we have received.

What do you think about the CDC/SART reporting statistics of participating clinics?

Reporting “some” of our statistics clearly puts clinics in competition if there are several in a geographic region and with the advent of reproductive tourism. Since the statistics are just a snapshot of patient age (not embryo quality, medical history, religious beliefs, etc) and outcome, they do not fully represent the quality of the clinic. There is however value in the reporting. It allows patients to see the volume a clinic has. A too-busy clinic or a too-small clinic may not be right for them. If the volume is low, statistics will be much less reliable. Using the donor egg pregnancy rates at clinics can also be helpful as a tool to evaluate the embryology laboratory; however, in some clinics, same sex partners and siblings who donate can adversely affect the success rate (if they are older). We still feel donor egg is a valuable service to those patients.

Why doesn’t everyone just get one to two embryos transferred back?

Physicians and patients are always fighting against the likelihood that no pregnancy will result from a given treatment. When IVF first started (about 30 years ago), pregnancy rates were 10-15 percent. Now they are closer to 40 percent per cycle. What this means is that more than half of the patients who need IVF may not conceive in a given cycle. With the cost of fertility treatment being high and few insurance companies covering it, not to mention the emotional toil of going through treatment, patients and doctors wish to maximize the success of each treatment. However, current technology has not allowed us to be able to know whether the embryo under the microscope that looks “good” can really make it to delivery of a healthy baby. By transferring more embryos we can increase the chance of AT LEAST one making it. Therefore, until we get smarter with embryo culture and selection, we will always be struggling between the two extremes: not getting a patient pregnant and getting her “too” pregnant.