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Double trouble: Should double embryo transfer be banned?

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Abstract

What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children (not yet born) in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy.

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Notes

  1. Other forms of ART (for example, controlled ovarian stimulation without IVF) are also associated with increased rates of multiple birth [6]. In this article, we focus on issues related to IVF, however, the central arguments potentially also apply to regulation of other forms of ART.

  2. The American Society for Reproductive Medicine has issued guidelines recommending restriction on the number of embryos transferred depending on the mother’s age [9], but those recommendations do not have the force of law.

  3. Human Fertilisation and Embryology Authority (HFEA) regulations in the UK require clinics to set out policies that will reduce their multiple birth rate to 10 % [10]. This has led some clinics to adopt policies that effectively mandate SET for younger women [11].

  4. We frame our discussion in terms of restriction of liberty (rather than, say, protection of interests) because this is the direct policy question being debated: whether double embryo transfers should be legally limited. (As noted below, the default in the past has been to allow transfer of greater number of embryos). While this emphasizes the issue of autonomy at the outset, we do not mean to dismiss other issues relevant to policy such as prevention of harm. As we will argue, a central question is whether the harms (to woman, child or others) attributable to DET are sufficiently weighty that double embryo transfer should not be permitted.

  5. If DET should be banned (at least for some women), a fortiori, transfer of larger number of embryos should also be prohibited. However, if the arguments in favour of limiting DET do not succeed, there is a further question about multiple (>2) embryo transfer.

  6. For this reason, even countries with policies that limit DET may permit it in older women.

  7. Although, in the general population, twins have higher cerebral palsy rates, IVF twins may be less affected. Identical twins who share a placenta or amniotic sac have a substantially higher rate of complications (and neurological morbidity) [21]. However, twins arising from DET are dizygotic (non-identical) and consequently have fewer complications.

  8. One way of reducing complications from multiple pregnancies associated with IVF has been to employ multifetal pregnancy reduction, with selective termination performed to reduce pregnancies to singletons or twins. However, complication rates in reduced pregnancies remain higher than non-reduced pregnancies (of the same number) [22]. There are potential neurological complications in the remaining fetus/fetuses [23].

  9. A speculum will be inserted into the woman’s vagina, and a catheter passed through the cervix. The only difference between SET and DET is whether one or two 0.1 mm embryos are inserted into the uterus.

  10. We do not mean to suggest that this right is absolute. It is, rather, a pro tanto right—one that has significant strength, but can be overridden under certain circumstances. The next sections will discuss whether such circumstances obtain in the case of DET.

  11. There may be some cases of justified paternalistic restriction on inserting property into one’s body, as in the case of self-mutilation or severe self-harm (such as swallowing a sharp object one owns). But those exceptions arise only when the action involves highly likely and very substantial harm; the relative risks of multiple pregnancy, while non-negligible, hardly rise to that level.

  12. US courts have sometimes regarded stored embryos as having a status intermediate between property and persons. More recent decisions typically have granted couples disposition over their embryos equivalent to that given to transferrable property, subject to contract law [41].

  13. There is an interesting contrast between Sweden’s attitude to SET (mandatory except in exceptional circumstances) [7] and caesarean section on demand (discouraged but permitted) [45].

  14. The subscript notation A2 here indicates a child born as part of a twin gestation.

  15. A1 indicates a child born as part of a singleton pregnancy

  16. In some circumstances, the non-identity problem might mean that neither A2 nor B2 are harmed. If multiple embryo transfer were to lead to a sufficiently severe neurological disability in A2, it might be thought to be identity-changing, such that the disabled child A2 is different from the non-disabled singleton A1 who might have existed. As noted, the harms attributable to DET are not likely to be of this severity. One unique feature of the harm in DET is that, in almost all circumstances, neither twin will ever be in a position to complain about being harmed from being a twin—since they will never know whether they were embryo A (destined to exist in both cases) or embryo B. At best, they would know that they had a 50 % chance of having been harmed from being transferred as a twin.

  17. If further SET cycles were undertaken after a successful pregnancy, embryos other than B and C would be used to maintain non-identity.

  18. ITDET has not (to our knowledge) been performed in humans, and it is unknown whether it would be associated with harms to the children thus conceived. Such harms would need to be taken into account were ITDET to be explored as a way to address possible harms of DET. (Artificial twinning has been used successfully in several other species [51]).

  19. In the environmental damage case, future people live much worse lives than the (different) people who would have lived had the environment not been damaged. This seems impersonally bad.

  20. Such views are often taken to lead to a counter-intuitive or ‘repugnant’ conclusion that it is generally better to bring more and more people into existence, even if each additional person only has a life barely worth living. However, this population ethic need not be endorsed here: we can merely make the negative claim that such a benefit means one should not interfere with reproductive choices, without endorsing the positive claim that such a benefit implies it is better to maximize reproduction.

  21. As noted earlier, the additional physical, financial, and psychological burden of additional IVF treatment cycles leads at least some women to prefer DET over repeat SET.

  22. Using figures from Scotland et al. [27], in young women, cost per live-born child with DET is £22,341.70, compared with £24,647.60 (calculated from Scotland et al. Table 1—60 children per 100 cycles DET, 45 children per 100 cycles repeated SET1).

  23. There are differences between natural reproduction and artificial reproduction that make it easier for governments to limit artificial reproduction than the natural form. Further, limits to natural reproduction might be thought to threaten rights (for example, to privacy) that are not at stake, or less at stake, when discussing numbers of embryos transferred. However, as we argued earlier, women’s negative right against state interference in reproductive decision making includes whether to undergo DET. Infertile women are already at a disadvantage (struggling with infertility) and may be spending significant resources to alleviate it. Restricting their reproductive rights only serves to disadvantage them further. Furthermore, countries like Sweden and Turkey not only do not restrict natural reproduction, they have adopted a range of policies to positively promote childbirth [61, 62]. It would appear hypocritical to restrict access to DET on the basis of concerns about overpopulation, while at the same time to be positively promoting reproduction by other means. Finally, population growth attributable to artificial reproduction constitutes only a tiny proportion of global population increase. The world population has increased by approximately 3 billion since 1978, while, as noted, there have been 5 million births from IVF (approximately 0.17 % of global population growth). Restrictions on IVF are likely, therefore, to be highly inefficient means of curbing population growth.

  24. This estimate incorporates future earnings and tax. However, even if this is ignored and only health costs are assessed, given the approximate cost of $17,000 for one cycle of PGD, it would appear to be clearly cost effective to perform PGD or prenatal diagnosis over live birth.

  25. Most parents in this situation would be likely to choose pre-implantation genetic diagnosis. However, it is possible that some parents (for example, with a strong religious objection to disposal of viable embryos) would choose to avoid PGD.

  26. As noted, DET is potentially cheaper than SET in the long-run. However, if only health related costs are to be included, patients might be required to pay $3600 for a DET rather than a SET cycle. This is approximately half the full cost of an IVF treatment cycle in the UK [32].

  27. Only 1 % of three or four embryo transfer cycles performed in the UK between 2003-2007 resulted in live-birth of three babies. This compares with approximately 7 % of two-embryo transfer cycles resulting in twin-live-birth [18]. Correspondingly, the economic benefit from additional tax-paying members of society is likely to be small. In the same study, the adjusted odds ratio of live birth with DET compared with SET was 1.65 (confidence interval 1.54–1.77), while the odds ratio of live birth with three embryo transfer (compared with SET) was 1.62 [18].

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  1. Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK

    Dominic Wilkinson, G. Owen Schaefer & Julian Savulescu

  2. Repromed, Adelaide, SA, Australia

    Kelton Tremellen

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Wilkinson, D., Schaefer, G.O., Tremellen, K. et al. Double trouble: Should double embryo transfer be banned?. Theor Med Bioeth 36, 121–139 (2015). https://doi.org/10.1007/s11017-015-9324-x

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