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How many embryos to transfer - and who should decide ?

Posted Nov 18 2008 12:14am

This still remains one of the most contentious issues in IVF treatment today. If the technology was perfect , we would all transfer 1 embryo ( or 2 for patients who want an "instant family") for all our patients, so they would all get pregnant at their first shot. However, the sad fact is that the technology is not perfect, which means that most embryos do not become babies ! One way of improving success rates is by transferring more embryos - but there is a price to be paid for this decision too ( as is true for most things in life !); and this is the increased risk of a high-order multiple pregnancy ( with an increased risk of complications during pregnancy , the biggest risk being that of prematurity).

In order to get around this problem, many countries have passed a law which allows doctors to transfer only 2 embryos. While this dramatically reduces the risk of high order multiple births ( which is good for the government which would have to pay the bills for caring for the premature babies), this sort of "one-size-fits-all" policy can be harmful for patients who have a poor chance of getting pregnant with IVF - for example, the older woman; the one with poor quality embryos; or the one who has failed multiple IVF cycles in the past. Logically, they should be allowed to transfer more embryos, as their chance of getting pregnant ( even with a singleton) is pretty low in the first place, which means their chances of having a high order birth is extremely poor. Unfortunately, bureaucracy cannot formulate flexible policies, and this sort of rigidity is very patient-unfriendly !

It is my personal belief that patients should be allowed to decide how many embryos they want transferred - after all, they are the ones who are going the pay the price for whatever decision they take, so why shouldn't they be allowed to take this ? I feel it is very patronising and unfair to tell intelligent, well-informed couples what they are allowed and not allowed to do. They are adults who are capable of weighing the pros and cons, and making their own decision for themselves !

Their are 3 possible outcomes to any IVF cycle:

1. A pregnancy with a singleton or twins. This is a "good outcome", and is what all of us are aiming for ! Whether we achieve this outcome by transferring 1 or 2 or 3 or 4 embryos does not matter - it's not the number we transfer - it's how many finally implant, which is what matters. If the outcome is good, everyone is happy, so there's no need to discuss this any further !

2. No pregnancy. Unfortunately, this is still the commonest outcome for most IVF cycles. Treatment is financially and emotionally expensive , and for most patients, it ends in failure. This is a major personal disaster - but the only one who gets hurt in the process is the couple. The government does not really care - because this is a personal and private loss.

3. High order multiple pregnancy ( triplets or more). This is a major problem - for both the couple and the government ( who has to pay the neonatal intensive care unit bills for the premature babies). This is why the government does its best to prevent this particular outcome, and does not allow the transfer of more than 2 embryos. However, from an infertile couple's individual point of view, a triplet pregnancy may be better than no pregnancy at all - and they have a safety net, as they can still salvage the pregnancy by performing a selective fetal reduction.

Let's look at the individual case of a 38 year old woman who is doing her 5th IVF cycle after 4 IVF failures, and has 4 embryos in the incubator. The law will allow her to transfer only 2 - and she is forced to discard the other 2 ( which are not good enough to freeze). Imagine the heartburn and pain this must cause her if she fails to get pregnant ( once again). She will always be left with the dreaded nagging feeling that she might have had a baby if she had been allowed to transfer all the four embryos !

Is it ethical to force her to discard these embryos ? Shouldn't she be empowered to decide for herself ? If she is willing to take on the risk of a high-order multiple birth, shouldn't she be allowed this right ?

The body which has the longest track record for regulating IVF is the HFEA ( Human Fertilisation Embryology and Authority) in the UK. When it was set up, IVF was a very new enterprise and it was established with the best of intentions - to ensure that the human embryo was respected. However, IVF has now been around for over 25 years and has become a part of mainstream medicine. Patients - and their doctors - should be allowed to make their own decisions for themselves , just like they do in other complex areas such as the treatment of cancer. In factm the Department of Science and Technology even recommended the dismantling of the HFEA 2 years ago, because it felt that it has outlived its utility . However, no action was taken on this recommendation . After all, given the nature of the best, every bureaucracy will ensure that it will perpetuate itself for ever !

The biggest tragedy is that instead of learning from these mistakes, India seems hell-bent on repeating them all over again, and is in the process of passing a law to regulate IVF and IVF clinics. Who will this really help ?

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