The number of fertility or in vitro treatments continues to rapidly increase, and half of the 54,656 infants born in 2006 as a result were twins, triplets, or higher multiples, according to the latest in a series of federal reports on the issue.
And it's getting increasingly expensive for all healthcare payers. The number of births from these technologies resulting in premature or low-birth weight newborns is an economic burden to hospitals and payers around the country, amounting to $1 billion in 2005 dollars, the Centers for Disease Control and Prevention report said.
Since 2001, the number of live birth deliveries—those in which one or more infants were born—that were made possible by assisted reproduction methods, such as in vitro fertilization, rose 41% and the number of infants born as a result increased 34%. The number of medical centers offering the procedure also has increased, from 421 to 483.
Despite recommendations that reproductive medicine specialists limit the number of embryos transferred to one or two for women under age 35, the CDC paper said that approximately 16% of procedures involved the transfer of four or more embryos and 5% involved the transfer of five or more.
That indicates that throughout the U.S., recommended guidelines are not being followed.
In 2006, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology lowered the number of recommended embryo transfers for women under 35 from 2 to 1. But it maintained recommendations of two embryo transfers for women between 35 and 37 and "no more than three" for women 38 to 40. For women over age 40, the guidelines allow five embryo transfers, and says physicians may modify the practice based on "extraordinary circumstances."
According to the CDC report, "In certain states, ART [Assisted Reproductive Technologies] procedures are not covered by insurance carriers, and patients might feel pressured to maximize the opportunity for live-birth delivery by transferring multiple embryos." They add that many physicians may want to maximize their publicly reported success rates, which may be defined solely as the percentage of total live-birth deliveries.
The popularity of such techniques, however, is a growing public health concern. Because the procedures are more likely to result in multiple births, they also produce higher rates of complications, such as premature delivery, low-birthweight babies, and long-term disability, as well as complications for the mother, the CDC said. The agency has reported birth outcomes on a variety of the procedures since 1997, as required by law.
The field of ART is generally a moneymaker for hospitals because most women undergoing the procedures either pay the cost themselves or are covered by private health insurance, hospital officials said. When complications arise, the costs are absorbed by health plans in higher premiums paid by employers and the insured. But increasingly, administrators are seeing couples saving for the procedure or using stashed-away funds or inheritance, as a last ditch effort as they fear the biological clock running out.
The financial burden comes when complications arise.
"Even though private insurance pays a large percentage of the cost of caring for these newborns, it can be expensive for the health insurance industry overall," says Thomas Moore, MD, director of the Obstetrical Service at UCSD Medical Center.
"At $2,000 to $3,000 a day for intensive care, which can continue three and four months, that's a cost that raises premiums across the board," he says.
These days, many couples may have health insurance when they start the procedures, which can cost several thousand dollars per cycle. But high deductibles or loss of health insurance as a result of a layoff may leave them unable to pay the exorbitant costs of complications, both for their newborns and themselves. In some instances, the government must step in and foot the bill.
ART procedures are most common in California, which claims one in seven procedures performed in the U.S., followed by New York, Illinois, New Jersey, and Massachusetts.
A case in point is the well-publicized case of Nadya Suleman, or "Octo-mom," who was on welfare and Medi-Cal, California's version of Medicaid, when she underwent fertility treatments and subsequently gave birth to octuplets.
The cost of caring for her and her babies was estimated at $1 million.
Past president of one professional society of reproductive medicine, David Adamson, MD, of Palo Alto, CA says the "Octo-mom" incident was an unusual one. "Nobody in our field is arguing for multiple pregnancies as an ideal outcome," he says, adding that endocrinologists have reduced by a factor of four the number of triplet births between 1996 and 2006.
Not all patients are ideal, he adds, explaining that legal issues make the situation more complicated. "I'm not going to tell you there's not tens of thousands of cycles (procedures). But quite frequently patients demand more embryos be transferred. Legally, it's not possible for a doctor to refuse that demand without being sued. The doctor does not have the legal right to tell the patient what to do with her embryos."
CDC officials who authored the report advise stricter counseling and warning for women or couples who want to risk the procedures.
"Assisted reproduction technology-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states," the CDC report said. "To minimize the adverse maternal and child health effects associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened."
The authors added that adverse maternal and infant outcomes should be explained thoroughly when counseling patients considering ART.