The Debate About IVF Twins
After laying dormant for quite some time the debate on the ethics of IVF twins has reared its head again.
Prompted by an article published this month in the New York Times discussing the practice of “reducing” IVF twins and higher multiple births to a single pregnancy through selective abortion, proponents from both sides of the ethical dilemma have come out swinging.
A rising voice of opposition says that it is time to end in vitro fertilization (IVF) practices that result in risky multiple births and social dilemmas.
However, others argue that these treatment practices are not only safe, but a blessing for those who have invested so much emotionally (and financially) into reproductive technology.
IVF Often Result in Twin Pregnancies
By the nature of IVF reproductive technology, the risk for a multiple pregnancy such as twins or triplets (or more if you're the Octomom) is great. Women are given fertility medications which stimulate their ovaries to mature multiple eggs in order to increase their chances that at least one will result in a healthy pregnancy. When the eggs are mature, a physician removes them from her ovaries, fertilizes them in a lab with sperm, and then evaluates the resulting embryos for any abnormalities or genetic problems. Depending on the age of the woman, typically 2-3 of the healthiest embryos are then transferred into a woman's uterus for pregnancy.
In as many as 33% of cases, two of the embryos will result in a twin pregnancy.
While most welcome the news of IVF twins, not all couples are emotionally, physically, or financially prepared for the burden of two children at once. As highlighted in the recent New York Times article, some couples are so distraught by the idea of a multiple birth that they choose to reduce their pregnancy down to a singleton baby.
“I felt like the [triplet] pregnancy was a monster, and I just wanted it out,” said Shelby Van Voris to the NYT after reducing her pregnancy. Shelby and her husband had been trying for years to get pregnant when she finally conceived through an IVF procedure while her husband was deployed overseas. However, the news of triplets was too much for her to bear. Shelby recalled yelling at her doctor, “This is not an option for us! I want only one!” However, all but one of many doctors she contacted declined her request to reduce her pregnancy to a singleton, saying they would only reduce her to twins.
“My No. 1 priority was to be the best mom I could be, but how was I supposed to juggle two newborns or two screaming infants while my husband was away [at war]? We don’t have family just sitting around waiting to get called to help me with a baby,” she explained.
It is not only social situations that have opponents concerned about the practice of transferring multiple embryos in IVF. Health risks are also greater to both the mother and baby when there is more than one baby in a pregnancy. According to the Center for Disease Control and Prevention (CDC), 60% of all twins in the US were born prematurely compared to 11% of singletons. Twins are also more likely to have birth defects such as cerebral palsy and have a 5 times greater risk for death within one month of birth. Mothers are also at a greater risk for hypertension, gestational diabetes, placental issues, heart problems and other complications with twin and higher order pregnancies.
For these reasons, advocates for “single embryo transfer” in IVF have begun pushing hard for practice changes. Already in the UK the Human Fertilization and Embryology Authority (HFEA) have officially endorsed the single transfer policy.
However, many fertility specialists and parents of multiple children say that this type of policy is not only unnecessary, but counterproductive to the intentions of IVF treatment.
In the United States the average cost of a single IVF cycle is approximately $12,500 while the chances of it actually resulting in the birth of a child (even with a multiple embryo transfer) in the best of circumstances remains less than 50%. If you are a woman in your 40's, these chances dwindle all the way down to 12%. Should the first cycle fail and there are leftover embryos to transfer, a woman still must wait up to two months, pay an additional hefty fee, and then repeat the grueling cycle of IVF treatment all over again.
According to Dr. Norbert Gleicher, medical director at the Center for Human Reproduction in New York, most couples are happy to welcome a 2 for 1 deal when it comes to their IVF treatment. "The majority of my patients want twins," he told Slate magazine. "The older they are, the more they want them. And the longer they've been trying to get pregnant, the more they want them."
Gleicher and his colleague Dr. David Barad wrote an article published in the medical journal Fertility and Sterility challenging the current medical environment advocating against the practice of intentionally creating IVF twins. In their paper they assert that the benefits of twin pregnancies outweigh the risks and therefore should actually be encouraged in infertile patients who desire more than one child.
The basis for their argument is that twins who are conceived through IVF have a 40% reduction in risks compared to those conceived naturally, due to the high level of monitoring and management typical in infertility treatment follow-up. Women who do not know they have twins until later in their pregnancy, as often the case with natural twins, do not receive the same level of prenatal care and therefore develop a higher rate of complications.
Gleicher and Barad also point out that the risk for two singleton pregnancies carries the same risk as one twin pregnancy.
While, the debate remains left unfinished, perhaps the best solution is not an outright ban of multiple embryo transfers, but rather to improve the way we talk about IVF risks and benefits with patients. Doctors have an important roll in encouraging the discussion about the emotional, financial, and physical risks that come along with IVF twins and multiples which need to be realistically considered by patients.
By fully educating couples who are considering IVF twins and only transferring multiple embryos when it is determined that the parents are ready for the responsibility, then the necessity for twin reductions, emotional turmoil, and international debate among infertility experts could finally be laid to rest.
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