The Taiwanese Society for Reproductive Medicine (TSRM) recently announced new clinical guidelines recommending that the number of embryos implanted during fertility treatments be limited to a maximum of two.
Current regulations on artificial insemination allow for the placement of up to five embryos, while directives from the Department of Health’s Bureau for Health Promotion recommended only four.
A physician and former chairman of the Taiwan Association of Obstetrics and Gynecology, Lee Maw-sheng (李茂盛), has pointed out that, prior to the TSRM’s announcement, certain clinics were placing more than 10 embryos during such procedures. He added that he had also done so in the past, and on one occasion all 10 took, obliging the patient to go through three selective abortion operations to address the multiple pregnancy. Even then the woman gave birth to twins.
What are the pros and cons of adjusting the practice of implanting 10 or more embryos down to the current limit of four and further lowering that number to two?
About three years ago, the Taichung District Court ordered a specialist in that city to pay compensation of NT$510,000 (US17,000) to a surrogate mother because the specialist’s artificial insemination procedure had left the woman pregnant with eight embryos. This multiple pregnancy led to severe vomiting and high blood pressure in the patient, who ultimately had to go through six reduction abortion operations, resulting in a uterine infection and caused a miscarriage, which almost killed her. In addition, it is unlikely that she would be able to get pregnant again.
Artificial insemination is a competitive field, worth billions of New Taiwan dollars, and is rife with all kinds of methods to increase fertility, a wide range of prices, confidentiality surrounding the number of embryo implants a woman has, promises of pregnancy and live birth rates, and the initial euphoria of success often ending in disappointment from an early miscarriage.
Infertility clinics worldwide are looking into new ways to increase the success rate for test-tube babies, directing efforts at controlling lab conditions or improving placement techniques, each claiming that they are more successful than the other. The reality is that there is very little to distinguish one specialist from another in terms of success rates, and members of the public have no means to make informed choices on which practitioner to use.
The private artificial insemination market in Taiwan is essentially a small, exclusive club of infertility experts, all of whom claim they can create life, but who remain tight-lipped when it comes to the problem of having to carry out selective abortions in the event of multiple pregnancies occuring. Nor are they entirely transparent about the realities of the process, not mentioning the multiple pregnancies that can occur, which expose women to health risks, or of the possibility of premature births.
Taiwanese fertility specialists have often been criticized for claiming impressive success rates while failing to observe the conventions followed in other countries, which limit the number of embryos implanted during the procedure to two.
With a younger generation of doctors, the TSRM has moved beyond such outdated ideas, hence these latest clinical guidelines, which can be seen as a form of reproductive justice for women.
According to a report on assisted reproduction by the International Federation of Fertility Societies, Taiwan is the only nation out of 107 countries that allows its doctors, in the absence of clinical guidelines to substantiate the existing laws and regulations, to implant five embryos. Therefore, a consistent 40 percent of artificial insemination procedures in Taiwan result in multiple births, something the TSRM deems unacceptable.
It is only natural for childless couples paying for artificial insemination to embrace multiple embryo placements if this will increase their chances of a successful pregnancy, Lee said. If the government is footing the bill, the Bureau for Health Promotion can demand that the number of implants be restricted, but if the couple is paying for the treatment on the private market, it is unlikely that the number of embryos can be limited to two, he added.
Chen Hsin-fu (陳信孚), a doctor at National Taiwan University, believes that multiple embryo placement is misguided.
There are too many concomitant risks: The heightened risk of having to conduct selective reduction abortions, the dangers of multiple pregnancies and the long-term burden on the national health insurance due to problems such as the provision of care for prematurely born children or those with conditions such as cerebral palsy, undeveloped lungs or eye problems.
The issue is not whether national health insurance should cover artificial insemination. Money is already being spent on the entirely avoidable side-effects of the current government policy on embryo placement restrictions.
Reform is never easy and the new guidelines have come not a minute too soon, but it is always prudent to err on the side of caution.
Chiang Sheng is an attending physician in the Department of Obstetrics and Gynecology at Mackay Memorial Hospital.
Translated by Paul Cooper