4/04/2007

One is the lonliest number

Unlike the US, the UK is not overzealous when it comes to embryo transfer during IVF. A simple two will do by law, with a third possible if you are over 40. I think this is ideal, as my personal opinion is that any more is excessive and potentially dangerous. Your odds of getting pregnant may increase, but at what cost? Knowing there are a lot of women who read this blog and have made different decisions on this matter I'm not going to go on about this. It's simply a lead-in to this story.

The gist is this - Given the rising number of births of multiples, the number of embryos transferred (not implanted BBC) may be limited to one for women under 40. One embryo. I'm wondering what the point would be to going through a heavily medicated cycle and the fun and games that is the transfer, for one measly embryo. I can't say I'd like my £5000 to be spent on the odds of one embryo implanting and hopefully making one of those healthy baby things. £5000 is a lot of money to spend on one little embryo.

The article states (and I have read in other sources as well) that your odds do not increase when more than one embryo is transferred. I struggle to count higher than 10 so I'm no statistician, how can this be? Thalia, I imagine you are able to give me a fabulously well-formed and cogent answer, IVF genius that you are.

I'm off to think about this little conundrum until my head explodes.

12 comments:

Thalia said...

Well, how can I resist that inducement to comment?

The conclusion you drew, and which is hinted at but not explained in the article, is that single transfer results in just the same success as double transfer. That's not entirely true. What is true is that two single transfers from the same stim cycle - i.e., a fresh transfer of a single embryo followed if that fails by a frozen transfer of a single embryo - results in success rates as good as if you transfer both at the same time on the fresh cycle.

The difficulty of this where IVF isn't funded is that (i) you have to pay for the FET separately from the IVF, and that's beyond the means of many, and (ii) it massively underestimates the personal trauma of going through a cycle, whether it's fresh or frozen.

They just did a study in the US where they started off asking couples going through IVF about their feelings about twins, and found most were enthusiastic (get family over in one go, etc.). Then they explained the risks of prematurity, cerebral palsy, NICU time etc., and people's willingness to consider twins fell dramatically. So one of the other actions the HFEA is considering is simply better education about the risks of twin pregnancy. That way they don't have to legislate '1 embryo only if you are under 40 and have not had repeated failures already', they can let ppl choose.

It's an interesting debate. I'm sure it could be used as yet another stick to point out that we're all desparate women with no thought for the health and wellbeing of our future children. But I don't think many of those involved have been where we are.

T said...

I'm so glad then, that I live in the US and can work with my RE based on MY history, fsh, age and all other factors to determine how many embryos to transfer. If I could only transfer two at a time, I would have had to have done 11 retrievals. It's just not appropriate for hard cases like me and a lot of my friends. I think if you were in my/our shoes, you might think differently (in reference to your "excessive"). Perhaps not, but if you were desperate and had already done 6 ivf's?

It's really unfortunate that so many money grubbing RE's have cookie cutter clinics and don't work individually with their clients so that now the multiples issue is such a huge deal (let's not forget that getting a woman pregnant AND delivering is a boost to stats).

Here's another article as reducing multiple embryo transfers is all the rage:

http://www.boston.com/news/globe/health_science/articles/2007/03/26/ivf_patients_ignore_data_keep_hoping_for_twins/?page=1

Jenn said...

My RE told me (at least for my clinic) that their success rates don't increase with higher number of embryos transferred, but their rate of multiples does. It's rare that they transfer more than two.

I think we'll universally be seeing a bigger push for single embryo transfers. But I think the cost is going to have to go down dramatically or the coverage is going to have to up in order to make it feasible.

I had three attempts covered by insurance. Even knowing I had two more cycles covered, I still wanted two transferred. I was lucky enough to have an easy pregnancy with no complications and very healthy boys.

If we decided to do an FET, we'll consider transferring only one. Mostly because that desperation of "what if this never works" has been taken away. Emotionally, I think we can afford for it to take a few times.

DD said...

If my odds don't necessarily go up with two compared to one, why not transfer all fucking 12 (if that's what one is so lucky to produce, which wouldn't be me as I'm lucky to get three semi-normal, albeit mouth-breathing, embryos)?

I really think it should be a case by case consideration from the RE, but I understand that they are tired of malpractice and bad publicity when someone gets knocked up with a litter. I believe statistics will show that high-multiple pregnancies are usually due to IUIs, not IVFs b/c not even in the States are clinics really at free reign to "implant" more than 3 w/o good documentation.

For example, on our 2nd IVF, we transferred 4: 2 afore mentioned mouth-breathers, 1 troll, and 1 embryo so f-up in appearance, they were sure it was amphibian in nature.

Needless to say, I did not get pregnant.

May said...

I wish the HFEA would stop announcing blanket diktats from on high. Surely it depends on the state of the embryos, the health of the woman, whether she has any scarring or other uterine issues, so on, and on and on...

Better education about the risks, yes. Good.

Of course, the debate on several online fora I came across had deteriorated into 'Well, I am/have had twins and we're fine!' versus 'IVF is Satan's work!' The whole issue of informed choice wasn't even getting a mention - too much shouting.

Humans are so... annoying.

Lut C. said...

My government funds a fixed number of fresh IVF cycles per woman. 5, I think. Any resulting FETs are also covered by national health.
When this scheme was put into place, the clinics promised to lower the twin rates. Patients under 35 can only have 1 embryo transferred the first time. If that cycle fails, more may be transferred, though not necessarily.

Studies have shown that the rates of succes per FRESH IVF cycle have remained stable. The rate of twin births has gone down. Like Thalia says, any FETS resulting from a fresh cycle are counted in there.

H said...

I think the big issue here, really, is that NHS IVF provision should not be based on a post-code lottery. I'm all for safety regulations, but at the same time, it strikes me that at 5000 pounds a pop, I would be WANTING twins.

Of course, there are issues with multiples, and I am glad that in the UK we are limited to a max of three transfers, because anything greater than triplets could be hugely traumatic for all involved, and the prematurity rates would rise incrementally, I imagine.

I have to admit, though, that I am always wary of all the literature that says twins=bad. This may be because I am sister to twins, and whilst they were born a month early, they don't seem to have suffered much for it.

Obviously, there needs to be room for case by case analysis, but as a general rule, I'm in favour of anything that increases the chances of success in infertility treatment. To that end, I shall follow the news closely and hope that the right decision is made.

bri said...

This is very interesting. I have to say that my instinct (an American one, maybe... or my Arizona Libertarian roots?) is to say that these things shouldn't be mandated because there are hard cases out there that need to be considered on a case-by-case basis. That said, when Wes and I considered IVF (we were 2 months away from it when TK materialized), we were firmly in the JUST ONE camp. We actually thought it might be hard to find an RE willing to do just one around here, where 2 is the norm and more are done frequently. I agree that they REALLY need to educate people so that the only women having lots of embryos put back are those who really need the increased chances.

Em said...

Ah the UK and IVF...from what I have been reading it's still a lottery as to what kind of treatment you do get. I read just this week that in one PCT you may get one treatment on the NHS and it another you can get three. (I think it was comparing Hammersmith and Fulham with Chelsea & Wesminster?).

I have not gone through an IVF cycle...yet (who knows? I may need to when we resume trying again) but I did see that BBC series, I think it was last year, called Family Man with Trevor Eve. He played a fertility doctor and he had his own clinic. It was pretty interesting and they presented a scenario where he implanted three donor egg embryos in a woman under 40 (it was obviously illegal to do so but he sailed close to the wind with his practises). They all took but then the babies were born prematurely with serious problems and the husband went all nuts on him and listed the various problems the babies had and the long-term care required. It was pretty full-on.

DementedM said...

What I don't like about the whole debate is the idea that IVF is at fault for all preemie baby costs. In the US about 1% of babies are born due to ART while about 12% are born to pre-term labor. ART is not the primary cause of pre-term birth, but the way the media and even the doctors present the info, it suggests ART multiples are the culprit for all the expensive NICU stays.

The idea is, if we just control these ART babies, then no one will end up in the NICU, but the numbers as I know them don't back up the conclusions.

There is great potential for ART to become a public scapegoat. Again. Which opens the door for politicians to legislate our medical options.

And for what? To make women go through more drugs, more cycles and more money to achieve, what? A less than 1% reduction in the preemie rate?

The true irony would be if they do adopt a single embryo transfer and then the extra drugs result in a double digit increase in cancer. (While they haven't done many studies, Lupron for example, does have an increased cancer risk the longer you use it.)

I can see single embryo being a good option for some people and I'm not opposed to it, what I worry about is if the powers-that-be decide we're all just going to transfer one when that is not the appropriate choice for every woman.

M

Karen said...

I'm all for single-embryo transfers. What I'm NOT all for is legislating it. The implication is that ART and associated therapies are solely responsible for raising the burden of the cost of NHS on the government.

I live in the US. I am lucky enough to live in a state with mandated IVF and other fertility treatments coverage up to $100,000 (including drugs). Six Injectible/IUI cycles later, I've spent almost $20K of that.

In my IVF consult, during the 2ww of my last ditch effort of an IUI cycle, my doctor made it very clear that at my age with my history, if the embryos were a high enough quality, he would strongly encourage me to transfer one embryo. He further emphasized that there were no circumstances under which he would encourage transferring more than 2 at my age with my history. I made it quite clear that I had no interest in triplets, quadruplets, or, frankly, twins (but was willing to take the calculated risk of twins).

What pisses me off is that several IUI cycles ago, I asked to please skip to IVF. I made a very compelling argument for not continuing with IVF, but because I'd had one pregnancy on my fourth IUI cycle, resulting in a miscarriage at 12 weeks, I was told that IUI was my best option. Why would I want to go through the cost, invasiveness, and general taxation on my body of an IVF cycle when I could do the easier route of IUI cycles. Except that my fifth IUI cycle failed, and my sixth IUI cycle my response was a little weird, so we got a little more aggressive with the injectibles and I ended up with the highest dose of Follistim I'd ever taken. I had a ridiculously huge response, but only one follicle was big enough to produce an egg, so we triggered. I am now pregnant with triplets being encouraged to reduce. This, to me, is irresponsible medicine. There was an assumption that I'd be on board with reduction should it come to that, and there was no discussion with me of the possibility of higher order multiples from this cycle, though any time I mentioned IVF the doctors were all like, 'Gah! Risk of Twins! Risk of Triplets! No IVF for you!"

So I'm all for limiting the number of embryos transferred (for if we'd gone the IVF route, this probably wouldn't have happened). But I'm strongly opposed to legislating it. RE's should look at individual history, embryo quality, and supporting statistics. While it's fair to have guidelines (in the US the ASRM recently put out a guideline suggesting that the best practice is to limit embryo transfers to no more than 2 for women under 35), mandating it by law is ridiculous. Legislators are not physicians. They don't know patient history. They don't carefully examine medical statistics. They hear "ART increases the risk of triplets. Triplets result in NICU stays. NICU stays are expensive..." and they think that ART = burden on the NHS.

If the US had mandated fertility coverage, single and double embryo transfers would likely be the norm, since one of the biggest driving forces in number of embryos transferred is cost per cycle. BUT legislators can never take the place of a doctor.

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