Infertility, Public Health, and Private Choices

Infertility is an increasingly common problem for many couples in the U.S, but infertility treatments are creating new problems, according to a report released last week by the CDC. In 2005, the most recent year with statistics available, assisted reproductive technologies (ARTs) such as in vitro fertilization had a 35% success rate (i.e., 35% of treatments resulted in a live birth). Forty-nine percent of these births were multiples (twins, triplets, or higher).

These ART-conceived multiple births may be a personal triumph but they are a public health disaster. Why? The chances of infant and maternal health problems increase with multiples, particularly those conceived with ARTs. Triplets and higher multiples conceived with ARTs, for example, have a 95% chance of having a low birthweight, according to the CDC. In 2005, although 13% of all infants were preterm, 42% of ART-conceived infants were preterm.

The public health cost of ART preterm births was approximately $1 billion in 2005, or an average of $51,600 per infant, the report stated. One percent of all U.S. infants born in 2005 were conceived with ARTs.

In the report “Assisted Reproductive Technology Surveillance – United States, 2005,” the CDC analyzed data from 89% of the 475 medical centers that treat fertility problems with assisted reproductive technologies.

The report stated that many ART medical centers are working to avoid multiple births in favor of singleton births by implanting fewer embryos at a time, but others are bowing to patient and marketing pressures to increase their success rate by implanting numerous embryos at once.

Successful fertility treatments themselves increase the number of children who are as genetically vulnerable as their parents were to infertility problems as adults. Successful treatments therefore create a new generation of customers for infertility clinics, and, barring medical advances in ARTs, fresh public health costs in the future.

There are alternatives. For a couple unable to conceive, adoption can help them build a family – a choice that helps both individuals and society. Considering the public health cost of ARTs and the dismal failures of the U.S. foster care system, it is in the government’s best interest to take two steps: regulate the use of multiple embryos in ART, and promote and streamline the domestic adoption process.

Addendum - July 17, 2008

Preterm birth can also have long-term consequences on an infant. Today, the New England Journal of Medicine published an article about the "Long-Term Medical and Social Consequences of Preterm Birth" among preterm infants followed to adulthood in Norway. Among this group, there was a significantly increased risk for cerebral palsy, mental retardation, and dependence upon disability payments as adults if they were born at 23 to 27 weeks. The abstract concluded that "the risks of medical and social disabilities in adulthood increased with decreasing gestational age at birth."

Art and Medicine

Since the American Academy of Orthopaedic Surgeons (AAOS) is celebrating its 75^th anniversary this year, the AAOS had a special display of art by patients and surgeons at its annual conference earlier this month in San Francisco. I first noticed the exhibit, called eMotion Pictures: An Exhibition of Orthopaedics in Art, as I was hurrying into Moscone West to catch a session I was covering on the third floor.

In the press room, I picked up a book the AAOS had put together describing the artwork, and I paged through it in my few quiet moments. By the end of the week, I had passed by the large bridge-shaped sculpture “Bone Rainbow” many times, although I did not initially notice that the bridge’s crossbars were made of bronze femurs. The artist, Ruth Cozen Snyder, had been injured in a car accident, and said in her artist’s statement that creating art had helped her cope with and recover from her injuries. Much of the patient art I saw and read about tried to make sense of, and rise above, the pain and disability that many patients faced.

My favorite piece was a painting by an orthopoaedic surgeon, called “Nothing About You Without You.” In the painting, a patient with a cast on his right foot and a sombrero hiding his face straddles a chair next to a vivid orange wall, the colors and clothing reminiscent of Central or South America. I was struck by the description of the work by the artist, S. Terry Canale, MD, who said that “with an increasingly diverse patient population, [orthopaedic surgeons] need to become more culturally competent, treating patients of all cultures with respect and practicing patient-centered care.”

The Journal of the American Medical Association always features artwork on its cover, as an antidote perhaps to the technical articles inside. At the AAOS conference, it was refreshing to see such striking artwork as I ducked in and out of PowerPoint presentations featuring sutured knees, diseased hips, and MRSA infection statistics. It was a reminder that there are human beings on either side of the scalpel.