While it is well known that fertility treatments are the leading cause of increases in multiple gestations and that multiples are at elevated risk of premature birth, these results are not inevitable, concludes an article in Fertility and Sterility. The article identifies six changes in policy and practice that can reduce the odds of multiple births and prematurity, including expanding insurance coverage for in vitro fertilization (IVF) and improving doctor-patient communications about the risks associated with twins.
Financial pressures provide a powerful incentive for patients and doctors to choose fertility treatments that increase the odds of multiple births and, therefore, also prematurity, according the article. Research has shown that 11 percent of twins and 36 percent of triplets are born very preterm (less than 32 weeks' gestation), compared with just 2 percent of singletons. Preterm birth places babies at increased risk of death, neurological disabilities and other health problems, and it costs the U.S. health care system more than $26 billion per year.
The conclusions and recommendations in the article are based on a project by researchers at The Hastings Center and Yale School of Medicine. The project examined the causes and consequences of multiple births after fertility treatment and included a workshop with clinicians, leaders from professional associations, patient advocates, and insurance industry representatives. The project was led by the authors: Josephine Johnston, a research scholar and director of research at The Hastings Center; Michael K. Gusmano, a Hastings Center research scholar; and Pasquale Patrizio, professor of obstetrics and gynecology at Yale and director of the Yale Fertility Clinic.
Few Americans have sufficient insurance coverage for fertility treatments. "This lack of coverage creates a moral hazard, where patients' immediate financial interests are best met by maximizing their pregnancy chances on each treatment cycle, despite the health risks and long-term costs associated with multiple gestations and births," the authors write.
Specifically, financial incentives lead patients to persist with controlled ovarian stimulation (COS), which is less expensive than IVF per treatment cycle and more often covered by insurance, but is also more difficult to control than IVF and results in more multiple births per year than IVF. The fee for a full IVF cycle is more than $10,000, and it is more than $3,000 for each embryo transfer.
The Affordable Care Act "did little for fertility patients," the article states, since its "essential benefit" provision does not mandate coverage of fertility treatment. While a few states do require IVF coverage, the article says that "the total value of the benefit may be capped at as low as $15,000 or the minimum number of cycles that must be covered may be as low as one." In addition, many of the mandates limit access to IVF to patients who have failed to achieve pregnancy with COS, leading some insurers to require as many as six cycles of it.
Patients who do undergo IVF "have a financial incentive to transfer more than one embryo so as to limit the number cycles and transfers they undergo," according to the article. Transferring more than one embryo at a time increases the chance of multiples.
The authors also expressed concern that patients are not making fully informed decisions about which fertility procedures they choose. Studies of IVF patients shows that while many patients accept treatment options associated with high rates of twins, few are fully aware of the risks to mother and babies of twin pregnancies and births. But when patients are better informed, research shows that they are more likely to choose to transfer one embryo at a time.
The authors' first recommendation is to expand insurance coverage for IVF, while also restricting the number of embryos transferred during each cycle or imposing financial incentives for single embryo transfer. The article says that such policies, which have been adopted by Connecticut and a few countries, "have dramatically reduced the rates of multiple births after IVF while maintaining good life-birth rates."
Other recommendations are:
- Fast tracking from COS to IVF. Insurance policies should reduce the number of COS cycles required before covering IVF.
- Changing the definition of a "cycle" for IVF treatment. Currently, one IVF cycle is defined as either a cycle in which embryos are generated and transferred or the transfer of one or more previously frozen embryos. This means that a single embryo transfer (SET) followed by a transfer of a frozen embryo from the first cycle counts as two cycles, while a double embryo transfer (DET) counts as one cycle. Fertility clinics have an incentive to favor DET over SET because it makes their per-cycle pregnancy rate higher. Broadening the definition of a cycle to include two consecutive SETs would mean that two consecutive single embryo transfers would have the same "per cycle" pregnancy rate as one DET, but with almost no multiple births.
- Improving communication about risks
- Encouraging patients to opt for protocols less likely to lead to multiples
- Investing in research to improve fertility treatments