We’ve had a lot of passionate responses to Karey Harwood’s recent guest post about the ethical issues surrounding the California octuplets case. Harwood gave some helpful responses for further reading in the comments thread to that post. Here, we’re pleased to have a follow-up post from her, in which she addresses the pressures on patients and providers in the fertility industry, the health care and health insurance systems in which the industry operates, and the ethical distinctions between being a patient and being a consumer. Harwood is author of The Infertility Treadmill: Feminist Ethics, Personal Choice, and the Use of Reproductive Technologies.
What the octuplets case has clarified for me has nothing to do with Nadya Suleman. In fact, I would prefer to know less rather than more about this woman and her family of origin. Suleman has become a too easy target for Americans’ exasperation with excess, and it is disheartening to witness the vilification of this 21st century version of a despised archetype — the welfare queen (alternatively: the irresponsible mother, the hysterical woman, etc.). Even if Suleman is herself not a particularly sympathetic character, she is not the heart of the problem.
The larger, more important problem has to do with our health care system and its many inherent flaws, including the financial incentives that perversely encourage multiple embryo transfer and our collective inability or unwillingness to define a boundary between fertility treatment as legitimate therapeutic procedure and fertility treatment as elective and highly profitable consumer good.
The Atlanta Journal-Constitution recently reported that fewer than 20% of U.S. fertility clinics actually follow the recommended guidelines regarding how many embryos should be transferred in a single cycle of in vitro fertilization (IVF). Since these guidelines are written by a professional organization, the American Society of Reproductive Medicine, and do not have the force of law, it is not surprising that many clinics would ignore them. It is nevertheless quite startling to realize that more than 80% of clinics openly flout professional guidelines. The AJC explained that doctors are “bowing to patients and competitive pressures.” It is important to understand what these pressures are and where they’re coming from.
The competitive pressures include, first of all, the pressure on fertility clinics to demonstrate a decent success rate, usually defined as the live-birth rate or “take home baby rate” following IVF. The one law we do have in the United States regulating the infertility industry is the Fertility Clinic Success Rate and Certification Act of 1992, which requires fertility clinics to report their success rates to the Centers for Disease Control and Prevention. The CDC, in turn, is required to publish its annual ART Report, a wealth of statistical information that serves many purposes, including providing a handy caveat emptor to prospective patients who can compare the success rates of different clinics before choosing the one where they will spend their money (generally more than $10,000 per IVF cycle) and take their chances.
In an effort to improve their clinic’s success rates, fertility doctors around the country no doubt use multiple embryo transfer to improve the odds of pregnancy. Statistics show that the probability of a successful pregnancy is proportional to the number of embryos transferred to a woman’s uterus. Even though one might surmise that if the conditions are right for one embryo to implant, the conditions will be right for eight embryos to implant, and, conversely, if the conditions aren’t right for implantation, it matters little how many embryos are transferred, in actuality success with embryo transfer is generally not an all or nothing proposition. Because there are so many factors involved in any given IVF cycle, including the “quality” of each individual embryo, the specific infertility problems being circumnavigated by IVF, the age of the woman, etc., the seemingly crude approach of putting in several embryos at once and hoping against hope that one of them “takes” has become a standard medical practice – at least in the United States — even though the serious risks of multiple gestation pregnancies have been known for some time.
In addition to the competitive pressure on fertility clinics to succeed, or to try to outperform their neighboring fertility clinics, there is also tremendous pressure on patients to succeed with the very first cycle of IVF. Since many patients pay for IVF out-of-pocket, patients often cannot afford more than one cycle. This creates an obvious financial incentive to do a multiple embryo transfer. Studies have shown that a single embryo transfer followed up with a second attempt using a single frozen embryo is about as successful as one double embryo transfer, and it dramatically decreases the chance of a multiple birth. This is great news! But only for those who can afford that second cycle of IVF.
Currently, there are fifteen states that mandate health insurance coverage for infertility treatment. The vast majority of health insurance plans do not cover IVF, even if they do cover diagnostic or unequivocally “therapeutic” procedures (e.g., treatment for endometriosis) that treat the underlying cause of infertility. It is likely that increased insurance coverage for IVF would encourage the practice of single embryo transfer by weakening the financial incentive (at least on the patient’s part) to do a multiple embryo transfer.
However, insurance coverage of IVF remains controversial. IVF hovers in a gray zone between a legitimate treatment of a legitimate medical problem (infertility) and an elective procedure more akin to cosmetic surgery. Is a single woman “infertile” in the same way that a woman who has blocked fallopian tubes is infertile? Until we can talk openly and civilly about the parameters of reproductive freedom, our hands are tied. The financial incentives that encourage multiple embryo transfer will remain intact.
Finally, we must not forget that our fee-for-service infertility industry works very nicely just the way it is for those who profit from it. In an article about university employees who substantially out-earned university presidents in the 2007 fiscal year, the New York Times reported that fertility doctors are among the highest paid. Dr. Zev Rosenwaks, for example, of the Center for Reproductive Medicine and Infertility at Cornell earned $3,149,376. And Dr. James Grifo, a professor of obstetrics and gynecology at New York University — and the doctor whom I quoted in my last blog post for his ardent insistence that we not “police” reproductive decision-making — earned $2,393,646.
Personally, I’d rather see Nadya Suleman sort out her problems in private and hold the lens of public scrutiny more directly on those who have the most invested in maintaining the status quo.
North Carolina State University
update: This article is cross-posted at womenmakenews.com