Correspondence

Trends in Assisted Reproductive Technology

N Engl J Med 2004; 351:398-399July 22, 2004

Article

To the Editor:

Jain et al. (April 15 issue)1 report growing restraint in the practice of transferring numerous embryos after in vitro fertilization. This reassuring news should not, however, distract attention from the fact that other assisted reproductive techniques (i.e., ovarian stimulation, followed by artificial insemination) also contribute to the increasing problem of multifetal pregnancies in this country. Earlier recourse to in vitro fertilization would give physicians a better opportunity to reduce the likelihood of triggering such dangerous pregnancies,2 but ovarian stimulation alone remains the preferred first-line treatment for many types of infertility because of its relative cost-effectiveness.3

The technological milieu has changed dramatically in the four decades since the first fertility drugs became available. More primitive first-generation technology competes with refined and now more responsibly used second-generation technologies (i.e., in vitro fertilization and embryo transfer). The original risk–benefit calculus for first-generation treatments for infertility warrants reassessment.4

Lars Noah, J.D.
University of Florida College of Law, Gainesville, FL 32611-7625
noah@law.ufl.edu

4 References

1. 1

   Jain T, Missmer SA, Hornstein MD. Trends in embryo-transfer practice and in outcomes of the use of assisted reproductive technology in the United States. N Engl J Med 2004;350:1639-1645
   Full Text | Web of Science | Medline

2. 2

   Gleicher N, Oleske DM, Tur-Kaspa I, Vidali A, Karande V. Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins. N Engl J Med 2000;343:2-7
   Full Text | Web of Science | Medline

3. 3

   Guzick DS, Carson SA, Coutifaris C, et al. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. N Engl J Med 1999;340:177-183
   Full Text | Web of Science | Medline

4. 4

   Noah L. Assisted reproductive technologies and the pitfalls of unregulated biomedical innovation. Fla Law Rev 2003;55:603-665
   Medline

Author/Editor Response

Noah is correct in pointing out that, in addition to in vitro fertilization, other infertility therapies that promote superovulation contribute to multiple gestations in the United States. Since superovulation pharmacotherapy often results in the production of multiple follicles, multifetal pregnancies are not uncommon.1 Others have also argued that infertile patients should bypass superovulation and proceed immediately to in vitro fertilization.2,3 One reason is that in vitro fertilization provides control over the number of embryos in the uterus, thus providing greater control over the multiple-pregnancy rate. In addition, in vitro fertilization is more successful than superovulation therapy.1,4

However, in vitro fertilization is not covered by most insurance companies in the United States and is more expensive than superovulation therapy.5 Furthermore, in vitro fertilization carries added surgical and medical risks. Given a choice, some patients may prefer to start with a treatment that is less expensive and less invasive than in vitro fertilization, even if it is less efficacious.

We believe that an individualized approach to infertility treatment with the use of multiple techniques is appropriate. However, revisiting the risk–benefit aspect of standard infertility therapy instead of going directly to in vitro fertilization is certainly warranted, as is a federal push for broad insurance coverage of infertility treatment.

Tarun Jain, M.D.
Stacey A. Missmer, Sc.D.
Mark D. Hornstein, M.D.
Brigham and Women's Hospital, Boston, MA 02115
mhornstein@partners.org

5 References

1. 1

   Guzick DS, Carson SA, Coutifaris C, et al. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. N Engl J Med 1999;340:177-183
   Full Text | Web of Science | Medline

2. 2

   Reindollar RH. Should we skip ovulation induction in favor of IVF to reduce the risk of multiple births? Contemp Obstet Gynecol 2000;9:13-34
   

3. 3

   Adashi EY, Ekins MN, LaCoursiere Y. On the discharge of Hippocratic obligations: challenges and opportunities. Am J Obstet Gynecol 2004;190:885-893
   CrossRef | Web of Science | Medline

4. 4

   Jain T, Missmer SA, Hornstein MD. Trends in embryo-transfer practice and in outcomes of the use of assisted reproductive technology in the United States. N Engl J Med 2004;350:1639-1645
   Full Text | Web of Science | Medline

5. 5

   Jain T, Harlow BL, Hornstein MD. Insurance coverage and outcomes of in vitro fertilization. N Engl J Med 2002;347:661-666
   Full Text | Web of Science | Medline