Hum. Reprod. Advance Access published December 10, 2013 Human Reproduction, Vol.0, No.0 pp. 1 –2, 2013
LETTER TO THE EDITOR
What ‘misguided campaign’ against single embryo transfer?
Funding Salary support through the Center for Human Reproduction – New York.
Conflict of interest None to declare in reference to here discussed topics.
References Bissonnette F, Phillips SJ, Gunby J, Holzer H, Mahutte N, St-Michel P, Kadoch IJ. Working to eliminate multiple pregnancies: a success story in Quebec. Reprod Biomed Online 2011;23:500– 504. Gleicher N. Eliminating multiple pregnancies: an appropriate target for government intervention? Reprod Biomed Online 2011;23:403– 406. Gleicher N. The irrational attraction of elective-single embryo transfer (eSET). Hum Reprod 2013a;28:294 – 297. Gleicher N. Clinician to clinician: for some IVF patients, twins are the best outcome. Cont Ob/Gyne 2013b;58:40 – 46. Gleicher N, Barad D. The relative myth of single embryo transfer. Hum Reprod 2006;21:1337 – 1344. Gleicher N, Barad D. Arguments against elective single-embryo transfer. Expert Rev Obstet Gynecol 2008;3:481– 486. Gleicher N, Barad DH. Twin pregnancy, contrary to consensus is a desirable outcome in infertility. Fertil Steril 2009;91:2426 – 2431.
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Sir, A recent manuscript by Stillman et al. (2013) incorrectly accuses us of ‘a misguided campaign against the goal of SET and singleton birth in assisted reproduction (ART)’. They do so citing our repeatedly published opinion in various medical journals (including Human Reproduction; Gleicher and Barad, 2006, 2008, 2009, 2013; Gleicher, 2011, 2013a,b) that the currently almost indiscriminately propagated drive toward single embryo transfer (SET) is misguided. Our opinion has, indeed, received attention from prominent organizations, such as the March of Dimes and Hastings Institute, both of which are intensely interested in the subject (a report on the subject from both institutions is imminent), and as witnessed by acceptance of above-noted manuscripts by prominent journals. It is based on (i) proponents of SET incorrectly utilizing maternal and neonatal statistical outcome data, and, therefore, incorrectly claiming increased risks and costs for twin in comparison to singleton deliveries; and (ii) on proponents of SET not only ignoring the right of patients toward self-determination when minimizing as ‘uneducated’ their desire for twin pregnancies (again demonstrated by Stillman et al.), but also their willingness to assume educated risks to improve pregnancy chances, demonstrated by Scotland et al. (2007) and Sharara (2013), two important references conveniently overlooked by Stillman et al. To accuse us of a ‘campaign’, a word usually associated with advertisement or political election efforts, appears in this context semantically incorrect and uncollegial in response to scientifically presented opinions. These authors’ biases further reveal themselves by accusing us of mounting this alleged campaign against ‘the goal of SET and singleton birth in ART’. In contrast to Stillman et al. and other proponents of SET, we, however, never had specific ‘goals’; we simply exercised our right to free expression of what we consider to represent scientifically wellsupported opinions. We, indeed, would argue that setting a ‘goal’, and then trying to produce evidence in support, is not an appropriate scientific approach. Wishing that 1 + 1 remains 1 does not make it so. Stillman et al. can, indeed, argue until the end of all days that comparing one twin pregnancy with one singleton pregnancy is statistically valid; it is not! Space restrictions in a Letter to the Editor, unfortunately, do not permit a point-by-point rebuttal. We, however, urge readers to make up their own minds by reading our above referenced papers on the subject. We especially recommend our most recent publication (Gleicher, 2013b), submitted at the invitation of an editor-in-chief who, as a perinatologist, strongly believes that twin pregnancies should be avoided. This paper not only addresses all relevant issues raised by Stillman et al. but also discusses the important results of a first (Swedish) study, which compared outcomes of one twin pregnancy with two consecutive
singleton pregnancies (Sazonova et al., 2013), and is incorrectly cited by Stillman et al. We, therefore, stand by our published conclusions. Stillman et al. do, though, raise an interesting point in favor of SET, which we addressed only peripherally in the past. They suggest that agreeing to mandatory SET in return for government-reimbursed coverage of ART costs should be viewed as further validation of SET. Colleagues have, indeed, made such ‘Faustian bargains’ in Belgium, in other European countries, and in a Canadian province. In the USA, the ‘business partners’ are usually not governments but private insurance companies in states with insurance mandates. Colleagues in Quebec reported such a bargain as a medical and economic ‘success’ (Bissonnette et al., 2011). In analyzing their reported data, we, however, came to very different conclusions because the province lost, overall, approximately one-third of IVF newborns and their life-long earning power (Gleicher, 2011). The last available U.S. Clinical Summary Report suggests that the ART program for which Dr Stillman carries responsibility performed SET in only 32.0% of women under age 35 years and only in 3.8% of women at ages 38–40 years (Society for Assisted Reproductive Technology, 2011). These data, therefore, suggest a degree of divergence between the author’s, at times, rhetorical exuberance for SET and routine clinical practice. This, however, serves to his and his center’s credit, as a more forceful introduction of SET, unquestionably, would lead to the unintended and unpreventable consequence of lower pregnancy rates without compensatory benefits for his reputable center’s patients.
2 Gleicher N, Barad DH. Mistaken advocacy against twin pregnancies following IVF. J Assist Reprod Genet 2013;30:575 – 579. Sazonova A, Ka¨llen K, Thurin-Kjellberg A, Wennerholm UB, Bergh C. Neonatal and maternal outcomes comparing women undergoing two in vitro fertilization (IVF) singleton pregnancies and women undergoing one IVF twin pregnancy. Fertil Steril 2013;99:731 – 737. Scotland GS, McNamee P, Peddle VL, Bjattacharya S. Safety, versus success in elective single embryo transfer: women’s preferences for outcomes of in vitro fertilization. BJOG 2007;114:977 – 983. Sharara FI. Despite significant financial incentives many couples still decline elective single embryo transfers (eSET). Feril Steril 2013;100: S145. Society for Assisted Reproductive Technology. SART National Summary of IVF Success Rates. 2011, https://www.sartcorsonline.com/rptCSR_
Letter to the Editor
PublicMultYear.aspx?ClinicPKID=2329 (5 November 2013, date last accessed). Stillman RJ, Richter KS, Jones HW Jr. Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction. Hum Reprod 2013;28:2599 – 2607.
N. Gleicher*, V.A. Kushnir and D.H. Barad The Center for Human Reproduction – New York, 21 East 69th Street, New York, NY 10021, USA *Correspondence address. E-mail:
[email protected] doi:10.1093/humrep/det444
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