BOSTON – For many couples undergoing in vitro fertilization, the desire to rapidly complete a family apparently outweighs concerns over medical risks and the lure of cash savings, according to Dr. Fady I. Sharara.
Despite being offered free gonadotropins (Menopur) for one cycle and a free year of freezing and storage of all extra blastocysts, 48% of couples who were paying out of pocket opted for multiple- rather than single-embryo transfer, and 23.5% of those who had at least one reproductive cycle covered by insurance also refused the free offer, said Dr. Sharara, a reproductive endocrinologist and infertility specialist in group practice in Reston.
The medication alone could cost as much as $6,000, with freezing adding another $1,800 or so and storage, approximately $750, Dr. Sharara said in an interview.
The patients made the decision to proceed with multiples despite being informed about the higher risk of maternal, fetal, and perinatal problems.
Dr. Fady I. Sharara
"Twins are associated with significant morbidities: early delivery, cerebral palsy, mental retardation if they’re delivered very early, diabetes in the mom, and hypertension, so [there are] a lot of issues, and I tell my patients that twins are not twice the fun," he said.
"We were not meant to bear litters," he added.
New mothers of twins are more susceptible to postpartum depression, especially if they do not have help at home, and parents of twins have been shown in at least one study (Obstet. Gynecol. 2011;117:892-7) to be slightly but significantly more likely to get divorced than parents of singletons.
"One is hard enough; two at the same time is a killer for a lot of people. Some marriages don’t survive this," he said at the conjoint meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine.
Dr. Sharara offered patients – all women under age 38 who were proceeding with assisted reproductive technology (ART) – the chance to participate in the study. The free drugs and services were offered without regard to the patient’s insurance coverage or to her ovarian reserve status.
Of 48 couples offered a single-embryo transfer, 18 refused to take part in the trial. Of those who had double-embryo transfer, the ongoing pregnancy rate (approximately 10 weeks’ duration) was 80%, compared with 58.3% for the women who had single-embryo transfer, a difference that was not significant. Dr. Sharara noted, however, that two additional patients who had single-embryo transfer are now pregnant, and he estimated that the updated ongoing pregnancy rate for singletons will be about 60%-65%.
In all, 7 of the 18 women who opted for dual-embryo transfer are pregnant with twins, whereas none of the single-embryo pregnancies have resulted in twins. In a series of 500 single-embryo transfers at his center, the rate of twin pregnancies was 1.5%.
Dr. Sharara noted that some of the women offered single-embryo transfer did not meet the ASRM definitions for good-prognosis patients, including women aged 35 years and older who had a failed prior reproductive cycle, one ovary, prior uterine surgery, or diminished ovarian reserve.
One of the hardest parts of his job, he said, is getting the message through.
"When I sit down and talk to patients about the risks of having twins, they don’t want to hear it," Dr. Sharara said.
The study was supported by Ferring Pharmaceuticals. Dr. Sharara disclosed receiving grants from the company.