There are risks and benefits to transferring multiple embryos per transfer but one thing is undeniable: we do more of it in America than almost any other developed country. While countries like Japan, Sweden, Finland and Australia have virtually eliminated multiple-embryo transfer, in the U.S. it still comprises 70% of our IVF procedures.
Since the data establishes younger patients, and patients with PGS-tested embryos are better candidates for single-embryo transfer, you’d imagine few, if any, still have multiple embryos transferred, right? As you can see from the data below, that is not the case.
This is a clear source of frustration for both the CDC and ASRM. While the percentage of multiple-embryo transfers is dropping, many feel it is not happening fast enough. Here are some thoughts on why that may be.
Clinicians Shape Decisions With Non-Standardized Information
The prevailing wisdom is that since U.S. patients are the customers and can shop around, they are the ones making this decision and thus to understand the broader issue, we need to focus on patient motivations. Patient perspectives are important, and we will get to those in a moment, but we cannot ignore the role doctors play in this process.
Here is what our own survey work found. First, the majority of patients believe their doctor has an equal say in this process. Second, doctors often make a recommendation and that guidance is followed.
So what are doctors telling patients? A wide variety of things. For instance, 39% of patients were not educated on the risks of multiple-embryo transfer to the offspring. What patients are told correlates with treatment decisions. Patients who are more educated on the risks of multi-embryo transfer were more likely to elect for single-embryo transfer. Those better educated on the benefits of multiple-embryo transfer were more likely to go that route. What doctors are telling patients, and recommending, clearly influences our rate of multiple-embryo transfer in this the country.
Clinicians Feel Pressure To Push Success Rates With Too Little Disclosure On Embryo Transfer
Patients care about outcomes and want to be at the clinic with the best success rates. Multiple-embryo transfers improve success rates because they increase the likelihood any given transfer will deliver a baby. Comparing success rates for clinics who do a lot of multiple-embryo transfer with those who are mindful of the risks, and thus do less, is an apples-to-oranges comparison when it comes to deciding which clinic is more skilled.
While the CDC and SART have tried to level-set this, most patients get their success data from the clinics, not from CDC or SART. We counted that 78% of clinics in California that market their success rates online do so like the clinic does below: with no mention of the number of embryos transferred, the frequency of multiple-embryo transfers, or twin rates.
Why does this matter? In this case you can clearly see in the chart below, this clinic does far more multiple-embryo transfers than the national average. They may be more skilled, or simply more willing to foist greater risk upon their patients. It’s hard to tell. But what has been shown is that when clinics post higher success rates, they take market share, and so until we force clinics to report “embryos transferred” data in their promotional material, incentives will align towards more multiple-embryo transfer.
Everyone Wants To Save The Patient Money
Generally speaking, transferring multiple embryos in a single transfer delivers a baby more quickly than doing multiple, single-embryo transfers. Since each transfer costs $3,000, doing a multiple-embryo transfer may save the patient money in the near-term.
Clearly this is a factor. In our survey work we noted fertility doctors were more likely to recommend a single-embryo transfer when the patient lived in a state with mandated IVF insurance. The implication being this patient would not pay personally for an extra transfer.
However, we don’t think this fully explains the issue of multiple-embryo transfer in the U.S.. First, as you can see in the above, 40% of patients living in mandated states are still actively guided towards multiple-embryo transfer. Second, when you look at the 2014 CDC data, it’s clear younger patients (good candidates for single-embryo transfer) living in insurance states still overwhelmingly have multiple-embryo transfers. Below is the data from Massachusetts, Illinois, New Jersey and Maryland. Conversely, a state like Delaware has no insurance mandate and only 25% of its IVF patients elect for multiple-embryo transfer. When it comes to multiple-embryo transfer, why does Illinois, a state with good reimbursement, look the rest of America and Delaware, with no reimbursement, look more like Japan? This is not just an insurance issue, in our minds.
Patients Are Divorced From Long-Term Financial Costs
As we mentioned, multiple-embryo transfer can save time and money having a baby, so it’s a tempting option. But multiple-embryo transfers lead to higher rates of multiple gestation pregnancies which are dangerous, and as you can see below, costly. In the U.S., most fertility patients don’t pay for these downstream costs, and as a result are divorced from the financial impact of a multiple-embryo transfer.
That is not the case in foreign countries, where the government pays for IVF cycles and all future medical expenses. These governments thus worry about the downstream costs of multiple-embryo transfers and overnight have practically eliminated them (Sweden in 2004, Japan in 2006).
We do have analogies in the U.S. and those would be employers like Apple, Google, Facebook, JP Morgan and Goldman Sachs. All of these business will only pay for IVF, or pay for more of it, by requiring the employee to be treated at clinics that have a track-record of single-embryo transfer. As a result, these employers claim to have employees who do far less multiple-embryo transfer. This is a good example of how a single payer & decision-maker winnows use of multiple-embryo transfer in an American construct.