Correcting the Record on IVF

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Everyone has an opinion about the mother of the octuplets born in California in January.  I’ve been sitting back watching the story unfold, first with interest, then horror, as the media, obviously unschooled in the most rudimentary facts about human reproduction and in vitro fertilization (IVF), has propagated the most shocking sort of ignorance about infertility treatment.  When I heard about the bill that has been proposed in Georgia (more information can be found here and here) based on that ignorance, I said, enough.  I don’t have a media platform, but I have a blog and I’m going to use it.   Settle in, this is a tad long.

First, let’s cover the basics about IVF, because there seems to be a lot of mystery about what it is.   A woman undergoing IVF is injected with hormones in order to stimulate the ovaries to produce several eggs.  The eggs are retrieved surgically and are then taken to a lab, where they are mixed with the husband’s or donor’s sperm to produce embryos that are then matured for three to five days and then transferred (placed) into the woman’s uterus via a catheter.   (Even that description is a simplification, but it’s more than Oprah knows about the process, I guarantee you.  She apparently thinks that eggs alone can produce babies).

Let’s correct the most annoying and common of the media mistakes here — a doctor cannot implant an embryo in a woman’s uterus. Embryos are placed there in a process called a transfer, and whether or not they implant (and they often don’t) is up to nature.   Doctors can try to create a hospitable environment for an embryo by checking and trying to enhance the thickness of the uterine lining before the transfer and prescribing progesterone after the transfer, but implantation cannot be controlled.  If it could, IVF would be a sure thing, and it isn’t — as a quick look at success rates at even the best clinics will tell you.  Success rates for any given transfer generally range from about 40 to 50%.

There is attrition at each step of the IVF process I described above, and some percentage of IVF cycles never make it to transfer.  Different women (and even the same woman in different cycles!) respond differently to the hormones; a few will produce 30 or more eggs in a cycle, a few don’t respond at all (if this happens, the protocol is changed for the next cycle to produce a better result).  And everything in between.  Generally, not all of the eggs retrieved in a cycle are any good (viable).  Even eggs that look viable may not fertilize in the lab.   Even eggs that fertilize may turn out to be crappy embryos that don’t meet the criteria for transfer and have no chance of implanting.  (Embryos are graded on their quality, i.e. their chances of survival, and the best ones are selected for transfer).  So even if you produce, say, 20 eggs, you may only end up with one or two good embryos and be lucky to get any at all.

This is why the Georgia bill is so outrageous, as it would mandate that only two eggs could be fertilized per cycle — meaning that only two eggs could be placed in the petri dish (or whatever they use) with the sperm, vastly reducing the chances of producing even one viable embryo in a given cycle.  It would also prohibit freezing embryos for later transfer.  Thus, women trying to conceive would have to undergo many, many more invasive stimulation cycles in order to produce an embryo that would give them a real chance at pregnancy.  At $10,000-15,000 a cycle.  Whoever wrote this bill obviously has never had a family member or friend who has had to undergo IVF to conceive her children.

Nominally, the bill is supposed to be a response to the octuplets birth, but when you look closely at the facts, it’s obvious that it is both a vastly overinclusive and underinclusive response.  Here’s why:

High-order multiples (triplets or more) very rarely result from IVF. There are several reasons for this.  One is that most reproductive endocrinologists follow their specialty’s guidelines and transfer (not implant!) no more than two embryos at a time in women younger than 35 and no more than three in women over 35.  However, the reason that the guideline does not, and should not, have the force of law is that not all embryos, or uteri, are created equal.  If you have four embryos, none of which look all that hot, for a woman who has had failed IVF cycles in the past, you might transfer all four because the odds of even one of them making it are middling at best, and the odds of all four implanting are one in a million.  Some doctors won’t take even this tiny risk, but I can’t say that it’s reckless to do so for a woman who is on her last IVF cycle or is rapidly approaching 40.   Transferring all four in such a case would give her the best odds of a pregnancy with very little risk of multiples.   This is just one example — there are many factors that affect an individual patient’s situation, and the best person to evaluate how to provide the best treatment is that patient’s own doctor.

Regulating IVF in response to the octuplets becomes even more absurd once you understand that high-order multiples much more commonly result from the use of injectable gonadotropins combined with insemination or sex.  These are the same injectable medications used to stimulate egg production for IVF.  They are also used in women who have trouble ovulating but who don’t need IVF to conceive.  It is very important that injectables be used under the close supervision and monitoring of a fertility doctor, and that if more than a certain number of eggs are produced, the cycle be cancelled.  The goal is always to produce just one or at most two eggs, but since responses to the medication are so variable, sometimes that’s not possible.

Everyone has seen that show Jon & Kate Plus 8.  You know how Kate most likely got pregnant with 6 babies at once?   (I don’t know this for a fact because they’ve never said on the show, but this is the most likely scenario).  They used injectables.  A large number of eggs were produced.  The doctor cancelled the cycle and gave them strict orders not to have sex.  They did anyway, and ta-da!  Six babies.  Which is not to criticize them, because they paid a few thousand dollars for a cycle and wanted a chance at a pregnancy, and even with a large number of eggs the chances of a high-order multiples pregnancy are very, very slim.  (To give some context, I have a friend who did an injectables cycle, produced four eggs, and didn’t get pregnant at all — that’s the more common outcome).  Taking the risk they took was stupid, and I think they acknowledge that, which is why they’ve never revealed exactly what happened on the show.  But my point is that it had nothing to do with IVF at all.  In fact, when I heard this octuplets story, I suspected injectables-plus-sex and was highly skeptical that IVF could have produced this outcome, especially via a frozen embryo transfer.  Frozen embryo transfers are less likely to be successful than fresh cycles, in part because not all embryos survive the thaw and in part because even the ones that do have a lower chance of implanting.

So assuming that the octuplet mom’s story about the conception is true — that six previously-frozen embryos were transferred into her uterus and that all implanted and two of them split to produce identical twins (which does happen sometimes) — it is truly a one in a million occurrence.  Yes, the fact that her doctor (a disreputable quack) transferred six embryos into a 32-year-old woman who had had five previous successful pregnancies through IVF was incredibly reckless, and he should have his license revoked, though even he never imagined or had reason to imagine that octuplets was a possible outcome.  My point is, it’s not as though this kind of thing happens every day, especially not through IVF.  In fact, the percentage of high-order multiples (mostly triplets, anything more than that is quite rare indeed) has declined in the past several years precisely because fertility doctors have made such a vigorous effort to reduce the number of multiple births and because the technology has improved to the point where single-embryo transfers are almost as effective as multiple-embryo transfers in producing pregnancies.

I’m not here to debate whether a single woman of limited means and dubious mental health should be having a lot of children and raising them on the public dole — we’ve pretty much said no to regulating who can reproduce in this country because of a little thing called the Constitution.  There are millions of people out there who you or I might think shouldn’t become parents who do so anyway, and we all live with it in order to maintain our most basic principles as a nation.  What I’m saying is that somewhere between one in 10 and one in 6 couples have difficulty conceiving, and that all those thousands of hopeful parents-to-be who would not be able to have children but for IVF shouldn’t be punished for one doctor’s reckless decision when the vast majority of the doctors out there are practicing their specialty responsibly.

I hope this proposed legislation gets nipped in the bud quickly and is not replicated in other states. However, hearing the public discourse about these topics doesn’t give me much hope.  The extreme ignorance about IVF that is behind such legislation can only be countered with knowledge.  This isn’t much, but it’s my contribution.

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14 Responses to “Correcting the Record on IVF”

  1. Whitney Says:

    For once, I couldn’t agree with you more. Trying to legislate a medical procedure based on the clear quackiness of one doctor and one mentally disordered patient is ridiculous.

    I particularly though this point of the legislation was just dumb:
    “It would also prohibit freezing embryos for later transfer. Thus, women trying to conceive would have to undergo many, many more invasive stimulation cycles in order to produce an embryo that would give them a real chance at pregnancy. ”

    Did you know that couples (like me and Joe, for instance) who are having trouble having a child, but don’t want to go all the way through IVF can actually adopt frozen embryos that for some reason cannot be used by the biological family. Like, adopt, have them implanted, and potentially (which I say based on the statistics) give birth to their adopted child. Some people think it’s just weird. I think it’s totally cool. I probably won’t actually do it, but I still think it’s an awesome alternative to traditional adoption w/out some of the legal messiness of adoption.

    Interesting post, Sandi. Hope you’re well.

  2. Whitney Says:

    I just realized I said implanted. Go figure. I apparently hear the news a little too much, don’t I?

    On that note, I read somewhere that Suleman’s doctor is actually trying a new procedure that does involve attempted implantation during transfer. I didn’t do any research, because I honestly don’t care that much anymore, but just remember it because it sounded interesting (even by a quack.)

  3. Sandi Says:

    Hi Whitney, yes, I heard the same thing about the proposed implantation procedure, but I understand that it’s a pie in the sky hope and not something that’s actually anywhere near being feasible. If someone could come up with a way to do this and have it take every time, there would be quite a bit of money in it for him or her, that’s for sure.

    Embryo donation is a good alternative to traditional adoption; the only problem is that very few people are willing to give their leftover embryos to other people. More are willing to give them to scientific research than to other couples, I read on Slate yesterday (Will Saletan writes extensively about these issues). But for those who do and the people who can benefit from it, it’s a great thing. It’s so annoying for people who’ve never had trouble having their own biological children to say “infertiles should just adopt.” First of all, there’s no such thing as “just” adopting unless you’re willing to take on an older special-needs child or one with emotional/behavioral issues from the foster care system. If you want to adopt a baby, it is a long, arduous, and expensive process whether you do it domestically or internationally. It’s an emotional rollercoaster because so many adoptions fall through. It involves a level of scrutiny that is really invasive (I actually have heard of people being asked, for example, how often they and their spouse have sex). And why should the burden of taking in all those unwanted children fall on people with the biological misfortune of having a fertility issue rather than equally on everyone? If adoption is such a great thing, everyone should be equally obligated do it.

    Isn’t it funny how the men never comment on reproductive issues? You guys are allowed to have opinions, you know. 🙂

  4. mrspeacock Says:

    Amen, Sandi! Great post. I’ve recently found myself wanting to stand on tables and scream, “People, she didn’t mean to have 8 children at once! She was hoping for 1!” Even with my very limited knowledge about IVF, I can tell you that much.

    Confession: I’m probably one of those people you’d rag for saying “Infertiles should just adopt.” Although I would never say “infertiles.” But I am a huge fan of adoption. I’ve had too much experience with adoptive children and families to feel otherwise. I cringed a bit when I read the phrase “the burden of taking in all those unwanted children,” but I do hear what you’re saying in regard to it being everyone’s responsibility. And I agree. But I think adoption is one of the greatest blessing that too many people are missing out on. But that’s probably for another post.

    Where are the men, already?

  5. urbino Says:

    I don’t know anything about it. I’ve heard mentions of a woman having octuplets, but I didn’t know there was controversy over it.

    This is why the Georgia bill is so outrageous, as it would mandate that only two eggs could be fertilized per cycle . . . It would also prohibit freezing embryos for later transfer.

    Hmmmm . . . Georgia . . . frozen embryos . . . I detect anti-stem cell research right-to-life activism.

  6. Sandi Says:

    “right to life activism” — yes, that’s right. The Slate article I link to brings out this point. The purpose of the bill is not to protect the taxpayers of Georgia from the expense of multiple births, it is to give legal rights to embryos. A look at all the provisions of the bill taken together shows this clearly. I chose not to address that in my post because I wanted to direct my argument toward people who don’t know the ins and outs of the bill and who might think it’s perfectly okay to place these restrictions on IVF because they don’t understand how it works. Even in the absence of some of the more outrageous parts of the bill (leftover embryos belonging to the state rather than to the people who contributed the genetic material, for example), I still think that putting the force of law behind a limit of two embryos per transfer — the part that people would be most likely to support — is unnecessary.

    On adoption: it’s a really fraught issue with lots of strong feelings. I think it can work out really well, but it has to be entered into by choice. It’s a very personal decision whether one is cut out to be an adoptive parent or not, as well as what the parameters are on what child in what circumstances one is willing to adopt. My main point here, though, is that because it’s so personal and needs to be pursued by choice in order to have a good outcome, to say that people who happen to have trouble conceiving should have their only choice be adoption is unfair and a recipe for disaster on many levels. It’s an easy thing for people to tell other people that they should do, but not such an easy thing to actually do oneself, emotionally, financially, or logistically. Adoption is a good way to make a positive out of a bad situation, but it doesn’t erase the fact that for adoption to be needed at all, you start out with a bad situation — a child brought into the world who is either not wanted by or can’t be cared for by his or her biological parents. If I was considering adoption, I would be really bothered by the idea of gaining from someone else’s loss. Which is not to knock adoption, but just to say there are lots of issues to think about when considering it.

  7. michaellasley Says:

    Very interesting, Sandi. I hadn’t the slightest about any of this, to be honest. And like JU, I haven’t really kept up with the controversy over this particular case. Seems like the LATimes did a piece on the doctor, but I can’t find it at the moment, and I only skimmed it, so I can’t remember what it said (other than what you said, more or less).

    I like Slate’s take on the logic of the Georgia proposal: “How does this restriction ‘protect the mother’ and ‘reduce the risk of complications’ for her? It doesn’t. If you wanted to protect the woman, you might limit the number of embryos that could be transferred to her womb, not the number that can be created in the dish. In fact, by limiting the number that can be created, you increase her risk of complications.” And: “From the standpoint of respecting embryos, this is all wonderful stuff. But it doesn’t serve the health interests of women seeking IVF, and it certainly doesn’t protect taxpayers.”

  8. urbino Says:

    Given that we’re on the cusp of overhauling our entire health care system with the goal of reducing the over all cost of that sector of our economy, Mikey’s last sentence makes me wonder how the various fertility treatments will be handled in the new system (assuming we get one).

    One of the main points of the whole health care reform movement is that we’re just spending way too much on health care, the main cause being that many of the procedures doctors perform are unnecessary. We’re going to have to start making some choices, the reformers say, and some of them will be hard.

    Where do infertility treatments fit in? Given that infertility is not life-threatening and can be left completely untreated with no negative effect on the patient’s health, I wonder how available the more expensive treatments, like IVF, will be. Will the new public health system pay for them? Provide partial payment? None?

  9. Whitney Says:

    Well, I’m probably the only person on here who is technically speaking part of a socialized health care program and they only pay part for IVF. They pay nothing for embryo storage, and the procedures are only done at civilian facilities.

    I closed the gate on all that, though, so I don’t know their current stance. You’re right, it will be interesting to see how infertility is addressed. For me the emotional/mental health burden was exponentially more difficult than the physical. My faith and the support of my wonderful husband were the only things that got me through it…the healthcare system never even asked about my mental state once it was determined I wasn’t a good IVF candidate and they didn’t know what was wrong. Hmmmm….

    And to speak to an earlier post. We want to adopt, but it is very hard. Made even more difficult by the fact that we move every 18-24 months. By the time we are more stable, we will be 37 and 42. I don’t know where my head will be then. We’ll wait and see where God leads us.

  10. urbino Says:

    Sorry to hear you had such a bad experience, Whit. Unfortunately, that seems to be fairly common. It’s like they’re processing cattle.

    (Oh, and you forgot to thank Darth Major.)

  11. Sandi Says:

    Very good question on socialized medicine, JU, although I would take issue with your statement that infertility has no adverse effect on a person’s health. It very definitely has an adverse mental health effect, which I think is related to physical health. And depending upon the diagnosis, a condition causing infertility can be linked to physical health consequences (for example, PCOS, a condition that 5-10% of women have, is linked to diabetes and heart disease).

    First of all, it’s unclear that what we will end up with once health care reform is enacted is a completely socialized system, so the question may be moot. But in the UK, for example, there is a mandate for IVF treatment to be available but in practice not enough funding to fulfill the mandate. There are also greater restrictions on it in Europe, unfortunately. So socialized medicine as practiced there is definitely not a good thing for people seeking treatment, although as long as the U.S. allows the existence of private clinics for paying customers, those who have money will still be able to seek treatment. I don’t know all the ins and outs of the argument, but I have heard it argued that if insurance coverage of IVF was mandated, the costs would come down.

  12. urbino Says:

    I hear ya, Sandi, but my guess is that the system would take the view that the things you mention infertility potentially leading to are the illnesses requiring treatment — that is, if/when the person develops clinical mental health problems or diabetes or heart disease, the system would provide care for those.

    Personally, I seriously doubt we’ll end up (in the near-term, at least) with a “completely socialized system,” but it sounds to me like cost controls will be part of whatever system we get. And whatever system we get, I can’t imagine it won’t also include/allow people to purchase additional care (or insurance) at their own expense.

  13. Whitney Says:

    Thanks, JU. I hope I didn’t sound whiny. That wasn’t my intent at all, I was just sharing an observation. And I will go pet Darth Major now. :0)

    I think the system–whatever that ultimately is–will continue to treat the secondary causes because they are easier to “manage” that the primary disease is to “cure” or otherwise treat. Happy Monday, y’all!

  14. urbino Says:

    I hope I didn’t sound whiny.

    Not at all.

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