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How to prevent multiple multiplesFrom: Mark Jutras (mjutras@gate.net)Sat Nov 29 12:17:48 1997
No one who is not regularly involved in REI can understand the frustratiosn involved with offering substandard treatment to the majority of ones patients. Most of us live in states were infertility is not accepted as a legitamate disease and is not appropriately covered by insurance. What most likely happened in this case of septuplets is that they had a woman that would not respond appropriately to gonadotrophins. We see many patients who at low doses do not respond to the drugs and when a dose is found that produces a response the response is always excesive. Ideally, these patients should go to IVF were the number of embryos transfered can be limited. That is what is done in modern countries but not in the US. You do cancel these cycles when they first occur and restart with another approach. But this just cannot work all the time. Who is going to pay for these high risk births? The same people who should have paid for the appropriate medical care in the first place. Insurance executives see these cases and say that is why they do not want to become involved with this business. It is because they are not involved that this happens. If they would provide appropriate coverage then they could also set the limitations. But, if you no playee the game, you no makeee the rules! The only quadruplets I have had in 11 years of IVF was in a patient who was given only one cycle of IVF by her insurance company. She wanted 5 back since she wanted to maximize her chances and could not afford even a frozen embryo cycle on her own. We wanted 2 or 3. The compromise was 4 if she was agreeable to reduction of quads. She had the reduction and has two healthy babies. IVF is in the stages of its final break out to acheive the ultimate goal of reliable delivery rates with transfers limited to 2 embryos. Most of the good programs in the country have been stuck at the 35 to 40 percent delivery rate per transfer for 3 or 4 years (women under 35). Our program has done this with an average of less than 4 embryos. There are now reports of lab modifications that have increase the delivery rates to 60% with less than 3 embryos and that program is now experimenting with the 2 max limit. I left out the over 35 women for two reasons. First, their rates are a little lower (low 30s for me). Second, couples shouldn't have to save until there almost 40 to do IVF. Additionally, it shouln't take till there 37 or older to convence there GYN to refer. I am hoping that business sense will prevail. If we can give a >50% delivery rate with no risk of triplets (we have had an occasional identical set of twins in our program) then I think we can use this, and the threat of doing what the patient wants (transfering 3,4,5 or more) to blackmail the insurance companies into doing what is right. Most infertility surgery is useless and a waste of money. Most medical therapy for male infertility is useless. Most inseminations are useless. IVF works and it works well!! We need the Ob/GYNs to be informed. It does not help when the local news stattion cons you into making an uneducated comment on the subject of mulitples. The local Obs (Orlando) are complaining to me that they have seen there number of deliveries cut in half in the last 5 years (to many residency slots but that's another argument). Work with me and I can provide another 20 pregnancies a month with no trouble. What do you get paid better for, 12 clomid cycles (still see this happening here) or one delivery?
-- Mark Jutras, MD Reproductive Medicine and Fertility Center Orlando, FL mjutras@gate.net
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