ETHICS

In Vitro Fertilization: Babies, Babies, andMore Babies

Heather Rivera, MS III

Department of Medical Humanities, Brody School of Medicine, East Carolina University, Greenville, NorthCarolina

In vitro fertilization is one of the most popular mechanisms forinfertile couples to genetically create a child that is entirelytheirs. It is common with in vitro fertilization to implant be-tween 3 and 8 embryos into the mother’s uterus during theprocedure. Hence, with 1 in vitro fertilization procedure, themother may deliver as many as 8 offspring. With the exceptionof the United States, countries have developed regulations thatlimit how many embryos may be implanted per cycle of in vitrofertilization.1 I will argue that to prevent a variety of personaland social harms, generally strict guidelines and regulations forreproductive fertility technological services should be put intoplace limiting the number of implanted embryos. Restrictionsare necessary not only to benefit the physical and emotionalhealth of the women and the children who will be born, but alsoto relieve stress on society and the community by maintaininghealth care costs and adequately allocating resources.

There are a number of strong reasons to limit the number ofembryos implanted during in vitro fertilization procedures to 2,rather than between 3 and 8. The American Society for Repro-ductive Medicine (ASRM) has urged practitioners to take stepsto minimize the incidence of triplet pregnancies and to elimi-nate the creation of higher order multiple pregnancies.1 Tobegin with, there are considerable risks to the physical health ofboth the newborns and the mother with multiple birth preg-nancies. According to the ASRM, perinatal mortality is 7 timesmore likely for twins and 20 times more likely for triplets as it isfor singletons.3 Multiple births represent increased morbidityrisks for the infants as well as for the mothers. Fifty percent oftwins, 90% of triplets, and virtually all quadruplets are bornprior to full term. Such infants are at increased risk of respira-tory disease of the newborn, intracranial hemorrhage, blind-ness, and low birth weight.3 Maternal complications of multi-ple births include preeclampsia, premature labor complications,abnormal hemorrhage, and gestational anemia and diabetes.3

Thus, in order to decrease such severe health risks for themother and the infants, in vitro implantations should be lim-

ited to 2 or less embryos per procedure. Clearly the odds forcomplications decrease as the number of implanted embryosdecreases, and implanting 1 or 2 as opposed to 5 or 6 embryoslessens the likelihood of the above complications for the motheror the fetus.

In addition to increasing morbidity and mortality to infantsand consuming resources, such multiple births are costly toboth the family and society. The increased financial cost ofmultiple births relates to the increased risks for complications aswell as premature infant needs and hospital care. Thus, there isa stress on the family to cover these expenses for lengthy hospitaltreatment for multiple infants and for the mother. Such ex-penses do not end when the infants leave the hospital.

In addition to increasing costs for the family, multiple birthsare also costly to society as well. Such expensive hospital treat-ments may increase the costs of health care and insurance pre-miums in order to create funding to care for the increasedincidence of premature infants. Insurance companies oftencontend that it is less costly financially to attempt the in vitrofertilization process a second time versus caring for outcomes ofmultiple births and complications that arise.4 Hence, limitingthe number of embryos would alleviate the risk of creating afamily, which may be burdensome to society, as well as to theimmediate family.

Physicians active in fertility treatment argue that an increasednumber of embryos are essential to ensure a positive pregnancyand oppose a 3-embryo limitation on implantation. For in-stance, Dr. Hugh D. Melnick, MD, the director of AdvancedFertility Services, P.C., states that, “In fact, even after successfulfertilization, most embryos, even those that appear to be per-fectly formed, have genetic molecular defects, the ultimatecause of implantation failure. Only 25% (or less) of embryosbecome clinical pregnancies. The 75% (or more) which do notsurvive will have had some type of genetic or chromosomalabnormality.2” Thus, implanting as many as 8 embryos is nec-essary to assure a successful outcome of the procedure, andlimitations on the number of embryonic placement will limitthe success of in vitro fertilization. Second, defenders argue thatit is cost-effective to implant more than 3 embryos. Accordingto the International Federation of Fertility Societies, each pro-

*Correspondence: Inquiries to Heather Rivera, MS III, Department of Medical Humanities,Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Brody Build-ing 2S-17, Greenville, NC 27834; fax: (252) 744-2319; e-mail: heather1178@netscape.net

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cedure costs between $6000 and $7000,4 and it requires mul-tiple prescription medications, laboratory tests, and other diag-nostic procedures. Hence, it is to the patient’s benefit toimplant as many embryos as possible to assure a pregnancy willresult. Defenders of multiple implantation argue that restrict-ing the placement of multiple embryos may unfairly discrimi-nate against less fortunate infertile couples as high costs of thisprocedure may prevent repeated attempts if a pregnancy is notinitially achieved. Finally, defenders of implanting more than 3embryos argue that regulation unjustly restricts the liberties ofpatients to obtain the services they seek. Limitations on in vitrofertilization implantation violate the decision-making capabil-ities of the patient and limit their optimal care.

Despite the force of these arguments, their chief problem isthat they focus narrowly only on the benefits to the peoplewishing to become parents. In vitro fertilization technology hasprovided physicians the resources to assist infertile couples tocreate a family, but attention must also be focused on costs tothe children and to society. Such technology, like any medicaltreatment, does not present free of risk, and physicians andregulators must assess the benefits and costs of these risks verycarefully. The risks and costs, human and financial, involved ina multiple birth of as many as 6 or 7 infants are too high to beignored. Two possible solutions exist.

First of all, selective abortion of multiple pregnancy embryoswould reduce the number of embryos taken to term and thusdecrease the incidence of multiple gestations. Patients must bemade aware ahead of time of the possibility of multiple success-ful implantations and the imperative nature of the abortions toreduce multiple gestations. Because the ethical implications ofselective abortion may present future controversy, blastocysttransfer may be a better solution to the multiple gestation issue.As blastocyst transfer allows for additional embryonic growth

prior to implantation, there is greater certainty in the survivalfor the future embryo for 2 reasons. The uterine lining accom-modates a blastocyst better than does a younger form and thegenetics of the blastocyst are more reassuring of survival than arethose of the earlier product.4 Hence, blastocyst transfer mayresult in the best 1 or 2 blastocysts being transferred rather than3 or 4 younger embryonic forms to assure a positive pregnancyoutcome.4

Although in vitro fertilization may be a blessing for infertilecouples, such measures are unethical if they put the patients andsociety at inappropriately high and possibly biologically unnec-essary risks. Hence, limiting the number of implanted embryosfor patients would be a justifiable solution to decrease the inci-dence of multiple births and the associated risks.

REFERENCES

1. New York Task Force on Life and Law. Executive summaryof assisted reproductive technologies. Analysis and recom-mendations for public policy [online]. Available at: http://www.healthstate.ny.us/nysdoh/taskfce/execsum.htm. Ac-cesed March 29, 2001.

2. The Pregnancy Prescription [online]. Available at: http://www.advancedfertilityservices.com/embrytransfer.htm.Accessed November 6, 2001.

3. American Society For Reproductive Medicine. Complica-tions of multiple gestations [online]. Available at: http://www.asrm.org. Accessed November 7, 2001.

4. International Consensus on Assisted Procreation [online].Available at: http://www.mnet.fr/iffs/a_artbis.htm. Ac-cessed November 7, 2001.

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