Thursday, February 12, 2009

Freewheelin' Fertility Clinics

I've avoided this story mostly because of the sensationalism that surrounds it, but I think this article in today's NY Times is worth a read. Everybody seems most hung up about the idea that this woman might collect public entitlement benefits, as if people in the U.S. don't routinely have kids they can't afford to support, but the really troubling aspect of the story is that fertility clinics operate in what is essentially a legal vacuum:

Nearly a third of in vitro births involve twins or more. The government, along with professional associations, have been pushing fertility doctors to reduce that number, citing the disastrous health consequences that sometimes come with multiple births — infant mortality, low birth weights, long-term disabilities and thousands of dollars’ worth of medical care.

The American Society for Reproductive Medicine, the association of fertility doctors, even adopted guidelines in 2008 encouraging the transfer of only one embryo for women under 35, and no more than two, except in extraordinary circumstances. The guidelines allow more for older women, up to a maximum of five.

But unlike some other countries, the United States has no laws to enforce those guidelines. The Centers for Disease Control and Prevention has a surveillance system that collects data on fertility clinics, but reporting is voluntary and there are no government sanctions for not reporting.

As a result, experts say many doctors are still implanting too many embryos to increase the chance of pregnancy. Only 11 percent of in vitro procedures in the United States involve single embryos, according to 2006 data from the C.D.C.

Given the expense, time and discomfort involved in a single IVF procedure, it's not unexpected that both couples and doctors would hedge their bets and hope to get multiple children at once (so as to avoid a future procedure to have more children) or increase their odds of getting at least one child out of the process. Even so, guidelines provided by the ASRM advise doctors to implant only one embryo because multiple births are frequently risky for the fetuses. The problem of course is that clinics frequently have a strong incentive to implant more than one embryo, money:

The industry has doubled in size in the decade since the C.D.C. started collecting data in 1996. That year, 64,681 procedures were performed in 330 clinics. At last count, the number of procedures was up to 134,260 and there were more than 483 clinics across the country. More than 50,000 children a year are born as a result of in vitro fertilization in the United States. Nationwide, it is a more than $1 billion business.


Part of the reason doctors might acquiesce to a patient’s wish could be the fierce competition in the industry. California has more doctors performing in vitro fertilization than any other state, with many concentrated in the Los Angeles area.

The competition means that sales pitches are not unusual.

The Huntington Reproductive Center offers a refund for some women. No pregnancy? You get 90 percent of your money back.

Want to predict the sex of your baby? That is 99.99 percent guaranteed at the Fertility Institutes.

Dr. Kamrava, Ms. Suleman’s doctor, had previously raised eyebrows in the industry by advocating a procedure called SEED — subendometrial embryo delivery, in which he said he could increase pregnancy rates by using a plastic tube to insert embryos under the lining of the uterus for maturation, rather than in the uterus. The procedure’s value was never scientifically proven, according to Dr. Potter.

So, competition encourages fertility clinics to push ethical boundaries and what discouragement they have from engaging in iffy procedures are "guidelines" provided by a professional organization, and laws in the few states that bother to regulate IVF. I've written about this phenomenon before, but it continues to boggle my mind. When it comes to terminating a pregnancy we're willing to have grand national debates, go to court, and plant bombs over the issue, but when it comes to initiating a pregnancy that might result in multiple births, selection for certain traits, or deformity, the only thing anybody seems to worry about is whether people can pay for their own kids or not. How is that?

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