Ethical Obligation for Restricting the Number of Embryos Transferred to Women: Combating the Multiple-birth Epidemic from In Vitro Fertilization

Bradley J. Van Voorhis, M.D.; Ginny L. Ryan, M.D., M.A.


Semin Reprod Med. 2010;28(4):287-294. 

In This Article

Abstract and Introduction


In vitro fertilization (IVF) is an increasingly effective and popular means of achieving pregnancy for infertile women, but contributes to a growing incidence of risky twin pregnancies. Despite studies demonstrating cost-effective means to achieve IVF pregnancy while strictly limiting the number of embryos transferred, multiple-embryo transfer remains the most common practice in the United States, and twin pregnancies continue to increase. IVF providers resist restricting these practices, arguing that this is counter to principles of procreative liberty, patient and professional autonomy, and free-market economics. We counter that physicians have a professional fiduciary responsibility to weigh issues of nonmaleficence to patients and just use of health care resources with patient desires. With oversight from professional organizations, providers should follow strict but medically appropriate restrictions on embryo transfer practices and work toward safer means of optimizing IVF outcomes than multiple-embryo transfer.


In the early years of in vitro fertilization (IVF), this infertility treatment was highly inefficient and necessitated the transfer of multiple embryos to achieve any pregnancies. Over time, embryo implantation and pregnancy rates have increased markedly, in part due to improved embryo culture and selection techniques. This has led to a rapid expansion in the acceptable indications for IVF treatment and in the numbers of patients treated. Although the average number of embryos transferred has decreased over the years as the implantation rate per embryo has improved, it is still very common practice to transfer more than one embryo. Thus IVF treatment is still plagued by high multiple-gestation rates.

Although higher-order multiple-gestation (triplets and greater) rates have declined in recent years, twinning rates after IVF have remained consistently high in U.S. IVF programs.[1] Although there is widespread agreement that the high-order multiple gestations are a problem that must be addressed, there is disagreement over the need to reduce the twinning rate. In this article, we will describe the scope of the problem of twin and high-order multiple gestations, including long-term complications, as well as potential solutions to the problem. One of these solutions involves implementing more strict regulations on the number of embryos that will be transferred after IVF, with the goal being an optimization of singleton pregnancy rates. The main focus of this article is on the ethical issues that arise when contemplating and implementing such a restriction—issues that challenge us to reconsider our responsibilities to our patients, our profession, and our communities.


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