CHR-New York/Illinois, 60 E. Delaware Place, Suite 1400, Chicago, IL 60611, USA
1 To whom correspondence should be addressed. e-mail: chrjournal{at}aol.com
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Key words: aetiology/assisted reproductive technologies/health problems/singleton pregnancies
A recent article that appeared in Human Reproduction by Lambert (Lambert, 2002) expressed opinions which mandate a rebuttal. He, of course, is correct in arguing that reproductive technologies must be applied responsibly and with the highest regard for human dignity. Yet, unfortunately, his arguments go beyond a universally acceptable message.
Lambert implies in his piece that practitioners of reproductive technologies, in a historical sense, have acted "irresponsibly". Indeed, in one big indictment of the profession, he accuses everyone who ever participated in the advancement of assisted reproductive technologies (ART), starting with Edwards and Steptoes monumental initial achievement (Edwards et al., 1980), of unethical behaviour and, in doing so, greatly overshoots all reasonableness.
Quotes such as "The birth of a healthy child, which should be the most important indicator of successful infertility treatment, has been neglected", imply a complete disregard for outcome after ART have been applied. As if we, the practitioners in the field, simply did not care about the results of our efforts, as long as what?...the cash register was working?
This carries valid concerns into the realm of almost unimaginable risk. At least on this side of the Atlantic, the term neglect represents legal consequences of major significance. Indeed, neglect can be equated with instant legal liability. Is this really what Lambert intended to communicate? If he did, he is, of course, categorically wrong. If he did not, he is guilty of the [sic!] negligent use of the English language.
Misguided in the choice of words, Lambert also demonstrates his own individualistic understanding of the history of ART and, in doing so, once again, creates a potential of immense legal liability. He does so by applying todays knowledge retroactively to a time when much less was known. It seems so obvious today that the transfer of multiple embryos increases the risk of multiple births. However, only a little more than a decade ago, it was not! Lambert overlooks the fact that, not too long ago, our primary concern was not the risk of multiple births, but our ability to achieve pregnancy at all, utilizing ART (Toner, 2002). To view selectively the development of ART through the retrospectoscope and accuse practitioners of neglect during the early years, simply because they did not know then what we know today, is simply not acceptable. Infertility treatment, of course, is still causing too many multiple births and this is by no means only the consequence of ART. Indeed, one can make the point that the developments in ART have finally given us tools to achieve high pregnancy rates without a significant risk for multiple births or, at least high-order multiples. As we pointed out a number of years ago, a large majority of high order multiple births are not the consequence of ART, but occur following ovulation induction cycles, which have represented standard practice for decades (Gleicher et al., 2000
).
Lambert has failed to recognize that only the diligent step-by-step progress in ART over the last 20 years has finally given us an alternative treatment to standard ovulation induction, in which we have a final decision about which multiple risks we are willing to accept. As we have demonstrated, even the most conservative approach to ovulation induction will still result in an unacceptably high risk of high order multiples (Gleicher et al., 2000).
Lambert also fails to acknowledge the unique nature of how progress in ART has been achieved. Adjustments to new practice patterns in medicine are chronically slow (Lomas et al., 1989). Yet, no other field in medicine has integrated new knowledge quicker into daily routine practice than our field. And no other field has done so with more concern for the patient!
It is, therefore, painful to read in Lamberts piece that "gynaecologists are treating their patients efficiently, but not always safely". Such statements are not only untrue, but outright inflammatory. Every medical treatment, of course, carries risks. The safety record of ART is, however, probably unmatched anywhere in medicine. Where else has treatment success been so universal, has loss of life been so minimal and has impact on quality of life and universal happiness been so extensive?
One, therefore, comes to wonder where all of this hostility is coming from? Instead of criticising the field, we should celebrate its success and its unique contributions to the happiness of mankind. At a time when, due to controversies on stem cells and human cloning, reproductive sciences are viewed with a degree of suspicion, we should advertise our unique contributions. Indeed, this appears a unique time to point out to the public how reproductive technologies have created new choices for everyone. Sterile men can become fathers through ICSI. Postmenopausal women can experience motherhood through egg- or embryo donation.
And isnt choice one of the most basic human rights?
In a lengthy dissertation on human rights, Lambert fails to mention even once the patients right to choose. Dont patients have the right to choose different risk levels, based on their own, private circumstances and desires? Isnt it patronizing to assume that well educated adults are incapable of making such decisions in a personal and responsible way?
A large majority of infertile women, if given the choice, would prefer a twin pregnancy over a singleton (Gleicher et al., 1995). Should this surprise, considering the fact that the patient may have attempted pregnancy for years? While the medical safety case for single embryo transfer is irrefutable, as so vehemently argued by Lambert, how about the right of the educated patient to choose a risk level she is comfortable with in creating her family? Is this not a basic human right?
How completely out of touch with clinical (and ethical) reality Lambert is in his comments is best documented by the statement that (based on the Declaration of Helsinki) "on the basis of these principles, the transfer of multiple IVF embryos should have not even reached phase I in clinical trials, much less should it have become a widely accepted medical practice".
Without multiple embryo transfers, IVF would not have survived early application, because no pregnancies would have been achieved, and as a result ART would not have existed today and hundreds of thousands of babies would not have been born.
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References |
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Gleicher, N., Campbell, D., Chan C., Karande, V., Rao, R., Balin, M. and Pratt, D. (1995) The desire for multiple births in couples with infertility problems contradicts present practice patterns. Hum. Reprod., 10, 10791084.[Abstract]
Gleicher, N., Oleske, D.M., Tur-Kaspa, I., Vidali, A. and Karande, V. (2000) Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins. N. Engl. J. Med., 1, 27.[CrossRef]
Lambert, R.D. (2002) Safety issues in assisted reproductive technology. The children of assisted reproduction confront the responsible conduct of assisted reproductive technologies. Hum. Reprod., 17, 30113015.
Lomas, J., Anderson, G.M., Domnick-Pierre, K., Vayda, E., Enkin, M.W. and Hannah, W.J. (1989) Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N. Engl. J. Med., 321, 13061311.[Abstract]
Toner, J.P. (2002) Progress we can be proud of: U.S. trends in assisted reproduction over the first 20 years. Fertil. Steril., 78, 943950.[CrossRef][ISI][Medline]
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