American IVF: And Then There Was One ... Embryo
WHY YOU SHOULD CARE
More and more Americans are adopting the single-embryo treatment.
By Ian Graber-Stiehl
The hope and despair of in vitro fertilization are well-known to the family of Dr. Irfana Koita, director of IVF Matters, the United Kingdom’s first online fertility clinic. When Koita’s cousin went through IVF, she decided to be implanted with multiple embryos to have the best shot at conceiving. She did get pregnant, with twins, until 23 weeks in, when she lost them both. The experience, says Koita, was so traumatic, that her cousin “couldn’t dare think of putting herself through any more treatment.”
Her loss was far from rare for women using multiple embryos, a realization that for more than a decade has made Europe shift its IVF practices. The United States, long behind, is finally catching up.
The higher cost of IVF in the U.S. — 35 states do not legally mandate that insurance cover infertility treatment — compared with other Western nations has for years encouraged women to pick multiple-embryo therapy (MET) to increase their chances of getting pregnant in one attempt. But improvements in single-embryo therapy (SET) technology are increasing the likelihood of pregnancy through this technique, leading an increasing number of American clinics and prospective parents to turn to it, thereby reducing the risks of what happened to Koita’s cousin.
[Single-embryo therapy is seen as] the gold standard.
Christophe Blockeel, medical direction, UZ Brussel’s Center for Reproductive Medicine
Until 2007, only 5 percent of all IVF treatments in the U.S. involved SET. That rose to 23 percent by 2013, when the first of the recent wave of technological improvements started to kick in. By 2015, more than a third of women under the age of 35 who underwent IVF received SET. Between 2014 and 2016, the overall share of IVF procedures conducted through SET went up by a fourth.
This shift has the potential to be transformative for millions of American couples who turn to infertility treatment, experts say. Miscarriages with MET are nearly twice as likely as they are with SET, research shows. Premature births are three times more likely for MET-born children, and MET-born babies spend 4.7 times longer in neonatal intensive care units than SET babies and can cost nearly twice as much to deliver. Overall, twins are 12 times more likely to be born premature, 16 times likelier to be born underweight and nearly five times likelier to have respiratory complications or jaundice. These findings, coupled with advances in SET technology, are creating a new norm in the fertility industry.
SET, says Christophe Blockeel, medical director of UZ Brussel’s Center for Reproductive Medicine, is increasingly seen as the “gold standard” in infertility treatment.
This growth in SET use in the U.S. is being driven in large part by IVF clinics finding ways to more successfully cultivate and implant blastocysts — 5-day-old embryos that have divided into roughly 100 cells. Next-generation genetic screening, like that first used in 2013 to help conceive Connor, a baby boy born in Pennsylvania, is also allowing health care professionals to sample blastocysts, for more accurate testing. “A high percentage” of embryos may appear healthy but may not actually “result in a healthy pregnancy,” says Kevin Doody, a former president of the Society for Assisted Reproductive Technology. Enabling couples to spot abnormalities in the number of an embryo’s chromosomes can improve the success rate of IVF procedures. There’s also a new class of fertility drugs poised to enter the market, such as Nolasiban — it’s undergoing clinical trials — which not only aids in extracting more eggs, like traditional medicines, but also fosters the growth of implanted embryos and has been shown to increase successful birth rates.
Health care professionals too are taking on the responsibility to better educate patients about the risks of multiple-birth pregnancies, and to fight for the expanded use of SET, says Koita.
That was not the case just a few years ago. Since the first “test-tube baby,” Louise Brown, was born in 1978, more than 8 million people across the world have used IVF. It started with single-embryo therapy, but as fertility drugs improved, enabling doctors to extract more eggs from mothers, and as IVF caught on in the U.S., doctors shifted to implanting several embryos, to improve the chances of at least one sticking. MET has a 35 to 46 percent chance of producing twins or triplets, and initially, that might sound like good news to many couples, says Koita.
“The first consultation is all about ‘We want to have two! We want to have two!’” she says. “It’s only when they start to get all the information and they see the risk involved that they don’t want to put themselves through it.”
For women older than 40, MET is still usually recommended because of their lower rates of conception. But some specialists, like Doody, are recommending that older women use SET combined with genetic testing. MET doesn’t make sense for younger women, say experts.
Since the early 2000s, SET has grown increasingly popular in Europe. In 2009, the U.K.’s Human Fertilization and Embryology Authority, after discovering incidents of multiple births in 23 percent of IVF procedures, mandated that clinics expand their use of SET. By then, Belgium had already mandated that patients younger than 36 be treated primarily with SET. Scandinavian countries have gone even further, using only SET for women under 40, says Blockeel.
In the U.S., the shift has taken longer, he says, because of the absence of a legal mandate in most states for insurance to cover infertility treatment — despite the World Health Organization recognizing infertility as a disease. But while the idea of planting as many embryos as possible in one go may appear to make sense financially, it can actually prove costlier.
In 2013, the average cost to patients and insurers in the U.S. was estimated to be $26,922 for single IVF-conceived babies, $115,238 for twins and $434,668 for triplets and higher-order infants. The national bill for preterm IVF births — likelier with MET — alone was estimated to be nearly $1 billion annually, according to a 2011 study.
Then there’s the mental trauma that comes from the higher risk of miscarriages. “Nobody seems to be talking about it,” says Koita. “She [her cousin] certainly didn’t tell anybody else.”
But with SET’s increasing popularity, that’s finally changing. A little over two years ago, Blockeel had a patient who, like Koita’s cousin, lost two babies as a result of having two embryos implanted. Blockeel’s patient then decided to trust in just a single egg. Nine months later, she safely delivered a healthy baby boy.
- Ian Graber-Stiehl, OZY Author Contact Ian Graber-Stiehl