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Why IVF is a mixed bag for me

Guest blogger Dr Yong Tze Tein on the new In-Vitro fertilisation rule by the Ministry of Health.
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Published on November 16th, 2011

Dr Yong Tze Tein
By Dr Yong Tze Tein

yong.tze.tein@sgh.com.sg


'Congratulations!'

I beamed happily at Kim. It was the 1990s, when I was still a trainee in Obstetrics and Gynaecology. Driven by the desire to have children after 10 years of marriage, and having saved enough money, Kim had come for an In-Vitro fertilisation (IVF) cycle.

Moments later, however, my enthusiasm wavered while I was doing the ultrasound scan. On the screen before me was, not one, not two, but three little fetal hearts.

Uncertain about how she and her husband would receive the news, I called the consultant in charge to convey the news.

To the layman, having multiple pregnancies is a novelty. One usually pictures cute little babies in a row and jokes about the IVF cycle being a case of 'buy one, get two free!'

To an IVF clinician, however, it is a mixed bag. This is because as much as we want our patients to get pregnant, multiple pregnancies bring with it a host of potential complications, spanning almost everything covered in our obstetrics textbook.

Everything in pregnancy is exaggerated in a multiple pregnancy: A higher risk of miscarriage, morning sickness, anaemia, high blood pressure, diabetes, etc.

The major concern is that of babies being born way before term, weighing a mere few hundred grammes, needing intensive care unit (ICU) support just to breathe and being at risk of cerebral palsy.

Twins have four times, and triplets up to 10 times, the risk of cerebral palsy compared to a singleton pregnancy. There is also the social and economic cost of looking after two or more babies at once. Most of us struggle coping with just one. Imagine having three!

Over the past two decades, the number of twins and triplets born in Singapore has spiked. But now, a new rule from the Ministry of Health (MOH) mandates that a maximum of two embryos, instead of three, can be implanted in a woman through IVF at any one time. (Hyperlink to http://www.straitstimes.com/BreakingNews...94135.html)

It begs the question: Knowing the risks involved, why in the world do doctors want to put in so many embryos in the first place?

When IVF first started, the major goal was to achieve a pregnancy. Just having a positive urine pregnancy test was a reason to celebrate. When we replace more embryos, we increase the possibility that one of them will be implanted. At the same time, however, it increases the risk that more than one will.

But the reason this strategy was chosen was that we couldn’t quite predict which embryo would eventually be implanted. Hence, in order to increase the pregnancy rate, we put in more embryos.

It made sense in those days. Often, even after three embryos were transferred, we would only end up with one foetus.

But as IVF progressed and embryo quality improved, we became a victim of our own success. More embryos successfully implanted and multiple pregnancy rates began to soar. In natural pregnancies, only one in 70 births results in twins. In IVF, however, one in four does.

The burgeoning multiple pregnancies brought with them heavy medical and financial burdens. It was neither easy nor cheap to watch over high-risk pregnancies and babies. And the problems did not end after the delivery, as the sequela of prematurity can be life-long.

Expectations also began to change. Higher standards meant that we measured IVF success with live birth rates, as opposed to celebrating when a positive pregnancy test popped up.

A healthy baby is what couples expect now. It no longer seems like too much to ask.

Kim’s pregnancy appeared to be doing well until the 26th week when her water bag broke. Soon after, she delivered the first triplet.

However, because of extreme prematurity, the baby did not survive. The umbilical cord was cut but the placenta was left in situ. We knew that there was a very high risk the other two fetuses may be delivered soon afterwards, but we also wanted to see if we could keep them in utero for a bit longer.

Kim cried and cried, but dried her tears and decided to do what she could to salvage her two other fetuses.
The next few weeks were a heart-wrenching watch for both Kim and us, her doctors. We were worried about possible infections that could be life-threatening, as well as the threat of premature delivery.

We treated her aggressively with antibiotics and she was sent to the labour ward multiple times for closer monitoring. In those days, complete bed rest was prescribed. (This is, however, no longer the practice as it carries the potentially-lethal risk of blood clot formation, without evidence of benefits.)

Kim was a prisoner on her hospital bed.

Amazingly, her pregnancy lasted another six weeks, one of the rare few that did.

She was determined to remain cheerful and, because she stayed so long, she got to know the doctors and nurses very well. She also downgraded her hospitalisation status from A to C class.

At 32 weeks, Kim went into labour. She delivered safely and afterwards, faithfully went to the neonatal ICU to see the little girls every day, going through the emotional roller-coaster ride that comes with taking care of such vulnerable babies.

Thankfully, after one long month, she went home with two healthy daughters. Kim still comes faithfully with her girls when we hold our annual IVF Babies’ Party.

I admire Kim’s tenacity, but seeing her also reminds me of the physical, emotional, medical and financial burdens of multiple pregnancies in IVF. She had a happy outcome. But for many others, things do not turn out so rosy.

It is hence only timely that something is done to reduce the rate of multiple pregnancies in IVF.
What can be done though?

One may think it is simple enough to just put in fewer embryos. The downside is that there will be a fall in pregnancy rates. For the couple who have never been pregnant before, this may not be a compromise they are willing to accept.

One can talk about informed consent and choice but with IVF being such an emotional experience, and the couples vulnerability, it is hard for them to see beyond the first hurdle.

For IVF centres, the pressure to maintain a good pregnancy rate is also high. It is little wonder that despite it being the right step forward, the adoption of this strategy is slower than expected, especially in countries where many of IVF cycles are funded by the patients.

Hence, it is in countries where IVF is regulated and funded by the government, like in Scandinavia, that this strategy has been highly successful and widely implemented.

It is found that if only one embryo is transferred while the excess is frozen and put in one at a time at another cycle in younger women, the cumulative pregnancy rate is comparable to one single transfer of multiple embryos.

The pregnancy rate for the initial cycle would fall by a few per cent, but the multiple pregnancy rates would fall significantly.

Upfront, the initial cost appears higher because one needs to freeze the excess embryos and come back for subsequent transfers. But if we look at the bigger picture, it means fewer premature and vulnerable babies.

A recent study in Quebec, Canada found that after the legislation of such elective single embryo transfers, the pregnancy rate fell from 42 to 32 per cent, sparking another debate about the cost-effectiveness of this strategy. What they overlooked was this: The multiple pregnancy rates fell from 25.6 to 3.7 per cent.

The debate will rage on for a while. But if we return to the starting point and think about what IVF is about and why couples want to go for IVF, then the way forward is clearly to limit only one embryo transfer, especially in younger patients. It is just a matter of how fast we want to follow.

Dr Yong Tze Tein, senior consultant, Department of Obstetrics and Gynaecology, Singapore General Hospital, is an accredited IVF specialist. She has special interests in sub-fertility, menopause, adolescence and female sexual dysfunction. She is an educational supervisor for medical students and house officers and is also the clinical quality chairman, Department of Obstetrics and Gynaecology, Singapore General Hospital.