- BIOETHICS FORUM ESSAY
The Octuplets: An Insurance Story
By now, you’ve probably heard all about the California octuplets: born via in vitro fertilization to an unemployed single mom who already had six IVF kids, born at birth weights varying from one pound eight ounces to three pounds six ounces, requiring hundreds of thousands of dollars worth of NICU care. Editorial writers and some bioethicists are using the births to justify a call for strict regulation on the number of embryos that can be transferred to a uterus in a single cycle. The California Medical Board is launching an investigation into whether the multiple transfers violated standard of care.
Fertility clinicians are defensively pointing out that guidelines from the American Society for Reproductive Medicine (ASRM) already recommend single embryo transfers for healthy, younger patients, and limit transfers for older and less healthy patients, depending up their conditions. These clinicians also point out that the number of multiple births from IVF in the United States has declined significantly in recent years. Finally, some commentators have argued that the fertility clinicians do not bear sole responsibility for the multiple births in the octuplet case: the mother was offered selective reduction when her multiple pregnancy was first detected, and she declined.
So, there you have it: another classic insurance story.
Permit me to explain. In the United Kingdom, Belgium, and the Scandinavian nations, for example, the number of transfers permissible in IVF pregnancies has been sharply limited, either by state regulation or by professional standard-setting that appears to have more bite than the ASRM standards do here. But in those countries, too, the IVF process, including transfer attempts, is covered by national health insurance. If the physician transfers only a single embryo into the woman’s uterus and there is no implantation, he simply has another go—at no additional expense to the infertile couple.
A few states in this country have similar regulations: they mandate private insurance coverage for IVF, and then either make limits on the number of embryos transferred a condition of insurability, or require IVF providers to comply with the ASRM guidelines. But only 15 states require insurance coverage of any kind for infertility, and many of those either sharply limit coverage for IVF or exclude it entirely.
The result is predictable, given the high cost of IVF. If they can only afford, or their insurance will only cover, a single cycle, many couples—and their clinicians—feel that the best odds of achieving pregnancy involve multiple transfers. Like fertile couples, couples who’ve had trouble with infertility often want more than one child—and there, too, the economics favor shooting for twins in a single cycle, rather than paying for two cycles of singleton births. That’s undoubtedly an important part of why 53 percent of American women undergoing IVF treatments in 2005 transferred three or more embryos. And the predictable consequence of multiple transfers, even given the availability of selective reduction, is multiple birth. The octuplet story is just an extreme version of a much more common story, and that common story has its roots in the problem of insurance coverage.
What’s more, the same story can be told about ovarian stimulation, another cause of multiple births. Lack of insurance coverage may bias couples to go forward with fertilization even in the presence of multiple eggs, because they don’t want to have to pay for, or can’t afford, another attempt.
Of course, the absence of IVF insurance doesn’t explain the whole of the multiple-birth phenomenon. Some clinicians may view multiple transfers as a way to enhance their success rates. Some couples’ desire for twins isn’t driven by the economics of IVF treatment. And some women may be strongly motivated to limit the number of times they go through any invasive fertility procedure. But the fact remains: without insurance coverage, strict regulations capping the number of embryos transferred in a cycle will severely limit the reproductive options of couples who can’t afford multiple attempts at pregnancy. With insurance coverage, such regulations would not be nearly so burdensome.
And that’s why the octuplets story is another classic insurance story.