In Vitro Fertilization – Ivf Insurance
The process of in vitro fertilization (IVF) is widely considered to be a marvel of modern reproductive science. During the procedure, eggs that have been fertilized in a Petri dish are implanted into the uterus, or womb, of a woman who may have had distress conceiving a child naturally. If the procedure is successful, the woman will give birth to a healthy baby nine months later. Since 1978, the year the first IVF baby was born, an estimated 3 million children conceived via IVF have been born.
Like most reproductive technologies, IVF has been extremely controversial. Abortion opponents have condemned the practice, since it often involves the destruction of human embryos. (An embryo is a multicellular organism in its first stage of development. After two months of gestation, a human embryo is classified as a fetus.) Pope Benedict XVI has said that IVF “clearly show[s] how, with artificial insemination outside the body, the barrier protecting human dignity has been broken.” Defenders of IVF counter that human life does not commence during the embryonic stage, and that IVF in no scheme intrudes upon symbolic barriers protecting human dignity.
But, a January 2009 incident has changed the tenor of the debate surrounding IVF. That month, Nadya Suleman of Whittier, Calif., gave birth to octuplets, which she conceived following an IVF procedure. Suleman became honest the second American to give birth to living octuplets, and the first to have all eight children survive longer than a week. As of late March 2009, all the Suleman octuplets are still alive, and six have left the hospital. (Two of the babies remain underweight and require additional hospital care.)
When all the octuplets finally do reach home, they will find themselves in a crowded house. The 33-year-ancient Suleman already had six children when she gave birth to the octuplets. All 14 of her children have been conceived via IVF.
Although Suleman represents an outrageous case, the birth of her octuplets has nevertheless sparked a novel debate over IVF. Specifically, that debate has centered around the rate at which IVF produces multiple births. One out of three IVF pregnancies results in multiple births, compared with just one out of 33 “natural” pregnancies. The spot, according to many health experts, is that multiple births are more hazardous than single births.
In the U.S., the IVF industry is nearly completely unregulated. With the patient’s consent, doctors administering IVF can implant as many embryos as they assume necessary into the uterus. Implanting more embryos increases the likelihood that the patient will successfully conceive a child, but it also raises the odds that she will give birth to twins or triplets–or more. In the wake of the birth of the Suleman octuplets, some observers have said that the U.S. government should step in and more strictly regulate the IVF industry. Should there be laws establishing limits as to how many embryos can be implanted during each IVF procedure?
Supporters of increased government regulation maintain that the risks posed by multiple births are simply too fantastic to continue to be ignored. They further contend that the voluntary guidelines established by various professional reproductive-technology organizations have proven to be ineffectual; government intervention is therefore necessary, they argue.
Critics of regulation, meanwhile, say that the self-imposed guidelines have worked, as the rate of high-order multiple births (defined as triplets or more) has declined since the mid-1990s. Critics further assert that government regulation would effectively rob doctors of their ability to give individualized treatment to their patients, since the same restrictions on embryo implants would apply to all patients.
What Is In Vitro Fertilization?
Louise Brown was born on July 25, 1978, in Oldham, England. Today, she lives a modest life in Bristol, a town in southwest England, working as an administrator for a shipping company. But for a brief time in the summer of 1978, she was one of the most renowned people in the world. Brown was the first child in history born following an IVF procedure. Her birth caused a media sensation; people wanted to know as much as possible about the world’s first “test-tube baby,” as journalists commonly called her. In the late 1970s, the IVF procedure was still highly experimental, and not very well understood by the general public. Brown’s birth introduced IVF to people around the world. It also gave scientists hope that a fantastic many couples would eventually benefit from the new technology.
Three years after Brown’s birth, Elizabeth Carr–the first American IVF baby–was born in Norfolk, Va., further raising the profile of IVF. The IVF design has since become accepted as a legitimate medical practice. Infertile couples have increasingly turned to the procedure as a way to have children. (Couples are said to be infertile if they have tried unsuccessfully to conceive a child for a year or longer.)
There are many causes of infertility in women, including a hormonal imbalance, an inability to produce eggs, or hurt or blocked fallopian tubes, which are ducts in the female reproductive system that transport eggs to the uterus. (Louise Brown’s mother and father turned to IVF when they failed to conceive a child after nine years of trying; her mother turned out to have been infertile because of blocked fallopian tubes.) The presence of a tumor, an infection or scarring within a woman’s reproductive system can also result in her not being able to become pregnant. Additionally, the older women get, the less likely they are to be able to conceive children naturally. Nearly three out of four IVF procedures conducted in 2006 were performed on women aged 35 or older.
Women are not the only ones struggling with infertility, but. Male infertility–which most commonly manifests itself as a vulgar sperm count–is the sole source of frustration in roughly 30% to 40% of infertile couples, according to the National Institutes of Health, a government research center. (Female infertility accounts for 40% to 50% of couples’ failure to conceive. The remaining 10% to 30% is attributable to a combination of male and female factors, or to no identifiable cause.)
Issues and Controversies: In Vitro Fertilization Success Rates By Embryo Type, 2006 (graph)
To start the IVF procedure, a doctor administers fertility drugs to a woman to score her to produce an abnormally large number of eggs, a phenomenon known as superovulation. The doctor then inserts a probe into the vagina. Using ultrasound technology, the doctor locates and retrieves several eggs. Once extracted, the eggs are combined with sperm in a glass Petri dish. (The term “in vitro” is Latin for “within the glass.”) It takes two to three days for the eggs to become fertilized and develop into viable embryos.
Doctors then implant one or more of the fertilized embryos into the woman’s uterus, where, if all goes well, they develop into fetuses. Any fertilized embryos that were not implanted into the uterus can be frozen and stored for later use, in a process known as “cryopreservation.” The frozen embryos can be thawed and later implanted into the mother that produced them, or they can be donated to another infertile couple. Freezing, storing and thawing embryos can be extremely expensive, but, costing up to $10,000 per embryo. Couples can choose to have their unused embryos discarded or ruined. (Even at that early developmental stage, doctors can evaluate the relative quality of the fertilized embryos, and use that data to snide their decisions on which ones to discard.)
According to the Centers for Disease Control and Prevention (CDC), a government health organization, nearly 140,000 IVF procedures were performed in the U.S. in 2006, the last year for which data are available. Approximately 35% of those IVF procedures resulted in a successful childbirth. The CDC’s data indicate that more than 56,000 children were born as a result of IVF procedures in 2006, up from 21,000 in 1996, the first year the CDC tracked such data.
Experts estimate that the IVF industry earns between $1 billion and $3 billion annually. IVF is a complicated and expensive procedure, costing an average of $12,400 per attempt, plus anywhere between $2,500 and $5,000 for related medications. Because only one out of every three IVF attempts results in a pregnancy, doctors typically tell IVF patients to expect to have paid around $30,000 by the time they have a child via IVF. Most health insurance companies do not cover IVF. But, 14 states mandate that insurers pay for at least part of the IVF procedure.
IVF is not without risks. Numerous studies show that children conceived as a result of IVF have a higher likelihood of birth defects than children conceived naturally. A 2008 CDC study showed that IVF babies are twice as likely to have certain heart defects, and more than four times as likely to have gastrointestinal defects. Previous studies showed an increased risk for cerebral palsy among children born via IVF. Also, women who use IVF to conceive are six times more likely to develop placenta previa, a condition in which the placenta–an organ found in pregnant women that provides nourishment to the fetus–blocks the cervix, preventing the baby from exiting the birth canal. Despite the potential complications involved in IVF, but, doctors stress that 91% of children conceived via IVF are free of any major birth defects.
High Multiple-Birth Rates Linked to IVF
Approximately one out of every 33 “natural” pregnancies–that is, pregnancies that occurred without the use of fertility drugs–result in multiple births. The odds of giving birth to triplets without the use of fertility drugs is one in 8,000, and the odds of having quadruplets without such drugs is in the neighborhood of one in 730,000, or 0.0000013%. Pregnancies resulting from IVF, but, have a distinguished higher multiple-birth rate: Roughly one out of every three IVF pregnancies results in a multiple birth, and one out of 50 produces three or more children.
Why do IVF pregnancies result in so many multiple births? It is far from guaranteed that a fertilized embryo implanted into a woman’s uterus via IVF will design into a fetus. Thus, to give the woman the best chance at success, doctors conducting IVF procedures usually implant multiple embryos, hoping that at least one of them will “take hold” and become a healthy fetus. According to the CDC, 89% of all IVF attempts in 2006 involved the implantation of two or more embryos; 16% involved at least four.
Using multiple embryos in IVF dramatically increases the chance of a multiple birth. IVF patients know within two weeks how many embryos have survived the implantation process. If more than one embryo has taken bear, those patients face several options. They can determine to carry all of the embryos to term, likely resulting in a multiple birth; they can abort all of the embryos; or they can undergo a process called selective reduction, in which one or more of the embryos are removed from the uterus, effectively terminating them. Selective reduction is a risky procedure, but, and sometimes results in the unintentional termination of all of the embryos. The possibility that some or all of the embryos could be deliberately terminated is why many antiabortion groups object to IVF. [See Update: Abortion]
Issues and Controversies: Percentage of IVF Pregnancies Resulting in Three or More Children (graph)
Giving birth to more than one child at a time heightens the risk of various birth complications. Sets of multiple babies are often born prematurely, before 37 weeks of gestation; the more babies there are in the womb, the greater the risk for premature birth. Babies born prematurely–sometimes referred to as “preemies”–typically must contend with low birth weight, which can cause death. Studies have also shown that preemies have a greater risk of experiencing developmental delays, as well as a variety of brain and intestinal problems.
Even if a multiple birth occurs after 37 weeks of pregnancy, the health risks involved are enormous. Having multiple fetuses in the womb at the same time means that all the babies must compete for the same microscopic nutritional resources. Consequently, when a dwelling of multiple babies is born, one or more of them may be markedly weaker, or have a lower birth weight, than the others.
The risks involved with multiple births–especially of three or more–are so fantastic that many countries have legally restricted the number of embryos that can be implanted into a woman’s uterus during the IVF procedure. Britain and Sweden, for example, do not allow more than two embryos to be transferred during a single IVF treatment. Italy, meanwhile, has perhaps the strictest IVF laws in Europe: no more than three eggs can be fertilized at a time (even if they produce no fertilized embryos), and only long-term heterosexual couples are allowed to attempt an IVF blueprint.
The U.S. has no such laws: IVF in the U.S. is virtually unregulated. In place of legislation, several organizations have developed nonbinding professional guidelines for fertility doctors to follow. The most prominent of those organizations is the American Society for Reproductive Medicine (ASRM). In 1999, ASRM issued its first set of professional guidelines, recommending that women under age 35 not receive more than three fertilized embryos in a single IVF procedure.
Since then, ASRM has updated those guidelines several times, most recently in 2006. The 2006 guidelines lower the maximum recommended number of embryos to be transferred to women under 35 to two, from three. The guidelines further state that women under 35 who are in excellent physical health should strongly consider receiving just one embryo per IVF attempt. Additionally, the guidelines establish embryo limits for women aged 35-37 (two or three embryos), women former 38-40 (no more than four) and women older than 40 (no more than five). The reason older women can receive more embryos is that there is a diminished likelihood that one of the embryos will engage fill and develop into a fetus.
The doctor who administered IVF to Nadya Suleman clearly ignored those guidelines, observers say. In January 2009, Suleman gave birth to eight children–six boys and two girls–through cesarean section. Born after just 31 weeks of gestation, the eight children were extremely underweight at birth; the heaviest weighed three pounds four ounces, while the lightest weighed under two pounds.
In an interview with NBC News conducted just weeks after the birth, Suleman said that she allowed her fertility doctor to implant six of her own frozen embryos into her uterus, despite intellectual that there was a risk of a multiple birth. (Two of the embryos split during the gestation period.) But, Suleman said, she never expected to have more than twins, given her previous fertility problems, which included scarred fallopian tubes and a severe case of endometriosis, a condition that hurts the uterus. The outcome of the pregnancy therefore came as a shock to her, she said: “It was twins times four.”
Suleman’s background–an unemployed, 33-year-ancient single mother who already had six children, all via IVF, prior to giving birth to the octuplets–angered many Americans in the first months of 2009. The birth of the Suleman octuplets also raised a larger debate over IVF regulation. Should the U.S. pass laws limiting the number of embryos that can be transferred during the IVF procedure? Or should it leave the IVF industry unregulated?
Perilous Multiple Births Must Be Reduced, Supporters Say
Supporters of regulating the IVF industry argue that the Suleman octuplets highlight the need to pass laws limiting the number of embryos that can be implanted during a single IVF map. The possibility of another low multiple-birth scenario will continue to exist as long as there are no laws governing IVF, proponents of regulation state. “We are loath to let the government have a say in this,” says Kirk Hanson, an ethicist at Santa Clara University in California, “but an incident like [the birth of the Suleman octuplets] inevitably forces us to question whether in vitro fertilization should be regulated.”
The introduction of IVF has resulted in a noticeable increase in the number of multiple births, proponents note. Since the first successful IVF birth in the U.S., in 1981, the incidence of twin births has more than doubled, supporters say. The reason multiple births must be reduced, proponents of IVF regulation maintain, is that they pose tall health risks. Liza Mundy, author of Everything Conceivable: How Helped Reproductive Technology Is Changing Men, Women and the World (2007), says, “The chance that a baby who is part of a set will be born premature is much higher than that for [single births], and…the risks associated with prematurity are enormous and in many cases lifelong.” Mundy further notes that the financial costs of delivering multiple children are “exponentially higher” than those of delivering single babies.
Proponents of regulation say that a “Wild West” mentality currently prevails in the IVF field, where seemingly anything goes, with doctors apparently making up the rules as they go along. “Regularly the news is filled with tales: First surviving set of septuplets! Woman gives birth to two sets of identical twins!” writes Elizabeth Weil in the liberal magazine Mother Jones. The IVF industry’s anything-goes mindset is perilous, because human lives are at stake, regulation supporters maintain.
Many proponents of regulating the IVF industry dismiss the current industry-imposed guidelines as ineffectual. They point to CDC statistics indicating that fewer than 20% of IVF clinics in the U.S. really adhere to the embryo limits established by ASRM or the Society for Helped Reproductive Technology (SART). For such guidelines to have any impact at all, they must be backed up by state laws or–preferably–by federal legislation, proponents assert. “There are enough clinics that quite openly flout professional guidelines that we really do need to originate thinking about public policy in this area,” says March Darnovsky of the Center for Genetics and Society, a reckon tank that focuses on the ethics of reproductive technology.
The IVF industry lends itself to abuses, proponents say. Because IVF is so expensive–and so rarely covered by insurance–patients often seek to have as many children as possible during one pregnancy as a way of getting the most for their money, regulation supporters assert. Meanwhile, proponents argue, doctors often try to implant as many embryos as possible in order to bolster their personal pregnancy-per-procedure rate, believing that a higher rate will attract more customers. In other words, says Pamela Madsen, the founder of the American Fertility Association, “[y]ou have patients who are desperate and you have doctors who are driven by success rates. It’s not a expedient combination.” The solution is to legally limit the number of embryos that can be implanted during each IVF procedure, supporters argue.
While some critics of regulation argue that restrictive laws would rob potential parents of the honest to raise twins or triplets, proponents maintain that no parent really needs to have more than one child at a time. Mundy argues:
[F]ertility doctors always say, “Patients want twins, patients want triplets. And we just can’t argue them out of it.” I find [it] absurd…[t]hat trained medical doctors reckon they’re helpless in the face of patient desire. The industry has not worked hard enough to provide patients with right informed consent, and doctors–saying it should be the patient’s choice–are level-headed willing to transfer too many embryos to keep their pregnancy rates up.
Many regulation proponents further contend that more states should pass laws mandating that health insurance companies screen the costs of IVF procedures. That way, they maintain, patients will be less likely to have multiple embryos implanted in the first position, since they know that additional procedures, if necessary, will remain affordable. They will thus feel less pressure to become pregnant the first time around. “When you get to the point where this is covered by insurance, you have a completely different attitude,” says Barbara Collura, the executive director of Resolve, a national organization that advocates on behalf of infertile Americans. “You’re not as desperate.”
Existing Guidelines Work Just Fine, Regulation Critics Argue
Opponents of strict government regulation say that guidelines are preferable to legislation because they allow doctors to have a degree of flexibility in their choice-making. Doctors should be allowed to evaluate patients individually to determine how many embryos should be implanted, basing their choice on factors such as a patient’s age, medical history and how many previous IVF attempts she has undergone, opponents argue. “These decisions are complex and need to be individualized, which is why we strongly believe that guidelines are better than hard rules,” says former ASRM president David Adamson. Regulation would force doctors to adhere to an unrealistic one-size-fits-all embryo limit for every patient, critics maintain.
Critics of regulating IVF argue that the guidelines imposed by various professional fertility associations are, in fact, reducing the number of perilous multiple births brought on by IVF procedures. Regulation opponents note that impartial 2% of IVF pregnancies resulted in at least triplets in 2006, according to the CDC. In 2001, 7% of IVF pregnancies produced three or more children; in 1996, the rate was 11%. Critics argue that the sharp decline in multiple births is attributable to the guidelines that groups such as ASRM started distributing beginning in the late 1990s. “Our guidelines provide the flexibility to give each patient treatment individualized to her needs, and her best chance to become pregnant without risking high-order multiple pregnancy,” says ASRM president R. Dale McClure.
Regulation opponents maintain that people are simply overreacting to the sensational tale of the Suleman octuplets. Their birth is in no way representative of the IVF industry as a whole, and cannot be used to justify strict government oversight of the industry, regulation critics shriek. Lawrence Werlin, the medical director of the Coastal Fertility Center in Irvine, Calif., says that if Suleman had approached him with a request to have that many embryos implanted into her uterus, his response would have been, “I’m sorry, I’m not the person for you.” The substantial majority of fertility doctors would have given a similar answer, opponents say; they do not need laws telling them that such a map is incredibly risky.
Indeed, implanting six embryos into a woman as young as Suleman is practically unheard of, regulation critics maintain. “I would despise for the public to get the sense that this tale is representative of fertility care,” says Eric Surrey, a former SART president. “It is a yucky aberration. High-order pregnancies are now relatively rare, precisely because we have addressed this issue.” Representatives from ASRM and SART have said that doctors who violate either organization’s professional guidelines risk having their memberships revoked.
Other critics say that regulating IVF would force doctors into the uncomfortable dwelling of telling patients that they cannot receive as many embryos as they want. “Who am I to say that six embryos is the limit? ” says Jeffrey Steinberg, who runs fertility clinics in Los Angeles, Current York City and Las Vegas, Nev. “There are people who like to have colossal families.” Limiting the number of embryos an IVF patient can receive is tantamount to allowing the government to largely determine family size, which is an unconscionable breach of personal liberty, critics say.
Opponents further argue that imposing caps on embryo transplants may do small more than frustrate parents who desperately want to start a family. If the government passes a two-embryo cap on IVF procedures, for example, a typical patient may have to receive IVF treatments many times before one of the embryos takes hold, critics say. If those procedures are not covered by insurance, that patient could owe tens of thousands of dollars before even a single child is produced, opponents suggest. On the other hand, doctors who implant multiple embryos give their patients the best chance for a pregnancy to occur, and if more than one embryo takes hold, the extras can be eliminated by using selective reduction, critics point out.
Finally, opponents price that IVF regulation is so prominent in European countries only because IVF procedures are typically paid for by public health care programs. Because the government is paying for the procedure, it has the right to establish limitations, critics say. The U.S., meanwhile, does not have a wide-ranging public health care system. Medical expenses are paid for by private insurance companies, or by patients themselves. Therefore, opponents argue, the government should have no say in what transpires between an IVF patient and her doctor.
New State Laws to Address IVF?
In March 2009, less than six weeks after the birth of the Suleman octuplets, Ralph Hudgens, a Republican state senator from Georgia, introduced a bill that would limit the number of embryos implanted into IVF patients. The bill would limit women under age 40 to honest two embryos per IVF procedure, while women 40 or over would be able to receive a maximum of three. “Nadya Suleman is going to cost the state of California millions of dollars over the years,” Hudgens told reporters, alluding to the fact that Suleman’s octuplets, as well as her six older children, will likely require vast amounts of state-provided health care and other services. “I don’t want that to happen in Georgia.”
Meanwhile, lawmakers in Missouri introduced a similar bill in response to the controversy over the Suleman octuplets. Missouri’s bill would require doctors to strictly adhere to the most recent ASRM guidelines for embryo implantation. Observers say that it is not certain whether that bill will be passed. Georgia’s bill, meanwhile, has been accepted by its state senate, and, as of late March 2009, is being considered in its house of representatives. Experts say that if the Georgia law is passed, a spate of IVF-related state laws may ensue.
Bibliography
Archibold, Randal. “Octuplets, Six Siblings and Many Questions.” New York Times, February 4, 2009, www.nytimes.com.
Boyles, Salynn. “Octuplets’ Birth Sparks Fertility Debate.” WebMD Health News, February 10, 2009, www.webmd.com.
Harris, Lynn. “Bionic Parents and Techno-Children.” Salon, May 9, 2007, www.salon.com.
“Medical Society Probes Octuplet Fertility Doctor.” USA Today, February 10, 2009, www.usatoday.com.
Nano, Stephanie. “Most Fertility Clinics Break the Rules.” Yahoo! News, Februrary 20, 2009, news.yahoo.com.
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