Reuters Health Headlines
Monday, December 6, 1999

Doctors debate ways to prevent multiple births

NEW YORK, Dec 06 (Reuters Health) -- Should doctors refuse to continue with infertility treatment when a multiple
birth is likely? Should insurance companies expand their coverage of infertility treatment? These questions are
addressed by two specialists in the December issue of the journal Fertility and Sterility.

Advancements in assisted reproductive technology in recent years have led to ``grand multifetal pregnancies'' in which
four or more fetuses develop. According to Dr. Carson Strong of the University of Tennessee, Memphis, fetuses in
these pregnancies are at high risk for birth defects, growth retardation, premature birth, and even death. Once born,
they are more likely to have serious respiratory and heart problems, cerebral palsy, mental retardation, and learning

Strong reports that infertility treatment guidelines are needed that will reduce the chances of grand multifetal
pregnancies. The difficulty, he points out, is that controlling the number of possible fetuses is more likely with in vitro
fertilization procedures, where a limited number of embryos are transferred into a woman's uterus, than with the use of
drugs that stimulate egg production by the ovaries. Use of these drugs can result in many eggs that could be fertilized
via intrauterine insemination, a potential risk for a high order multiple birth.

Physicians should discuss the possibility of multifetal pregnancy with patients before treatment, and come to an
agreement on how it would be handled, suggests Strong. He adds that physicians have the right to refuse to continue
treatment if patients will not agree to take steps to reduce the number of fetuses.

In an editorial in the same issue, Dr. Avner Hershlag of the New York University School of Medicine in Manhasset,
New York, agrees that something needs to be done, but disagrees with Strong on the solution. Hershlag points out that
requiring patients to agree ahead of time to take steps to reduce the number of fetuses may be tantamount to coercion.

Instead, Hershlag explains, doctors need to work with insurance companies and legislators to expand coverage of
infertility treatment so that patients would not feel so desperate and take chances on multiple births due limited
insurance coverage for infertility treatment.

He notes that while more money would then be spent on infertility treatment, a lot less would be spent on caring for
high-risk multifetal pregnancies, fetal reductions, and the care of premature infants.

Both Strong and Hershlag agree on one thing -- if insurance companies were to cover more infertility treatment,
couples would be willing to reduce the number of eggs treated with each procedure, and the chances of grand multifetal
pregnancies would be reduced.

SOURCE: Fertility and Sterility 1999;72:970-972, 973-974.