Too Many Twins,Triplets,Quadruplets,and So on: A Call for New Priorities

See Katz M.A. , “Federal Trade Commission Staff Concerns with Assisted Reproductive Technology Advertising,” Fertility and Sterility, 64 (1995): 10–12; Katz M. , “The Role of a Federal Regulatory Agency,” Women's Health Issues, 7 (1997): 192–96.

See Fertility Clinic Success Rate and Certification Act of 1992, 42 U.S.C. §§ 263a-1 et seq. (2003). See also Lawrence L.D. Rosenwaks Z. , “Implications of the Fertility Clinic Success Rate and Certification Act of 1992,” Fertility and Sterility, 59 (1993): 288–90.

See Kelleher S. Christensen K. , “Records Show UCI Egg Misuse,” Orange County Register, May 19, 1995, at 1; Gianelli D.M. , “Fraud Scandal Closes California Fertility Clinic,” American Medical News, June 19, 1995, at 1.

See Jonsen A.R. , “Assisted Reproduction: A Process Ripe for Regulation? A Conference of the National Advisory Board on Ethics in Reproduction,” Women's Health Issues, 6 (1996): 117–21; Cohen C.B. , “Unmanaged Care: The Need to Regulate New Reproductive Technologies in the United States,” Bioethics, 11 (1997): 348–65.

See Centers for Disease Control and Prevention, “Contribution of Assisted Reproductive Technology and Ovulation-Inducing Drugs to Triplet and Higher-Order Multiple Births—United States, 1980–1997,” Morbidity and Mortality Weekly Report, 49, no. 24 (June 23, 2000): 535–38.

See Martin J.A. , “Births: Final Data for 2000,” National Vital Statistics Reports, 50, no. 5 (February 12, 2002): 1–102, at 19.

The data presented in Figure 1 is derived from the following: Centers for Disease Control and Prevention, supra note 5, at 537; Centers for Disease Control and Prevention, “Triplet Births: Trends and Outcomes, 1971–94,” Vital and Health Statistics, series 21, no. 55 (January 1997): 1–20, at 13; Guyer B. , “Annual Summary of Vital Statistics — 1997,” Pediatrics, 102 (1998): 1333–49, at 1338; Martin , supra note 6.

See Centers for Disease Control and Prevention, supra note 5, at 536. Cf. Wilcox L.S. , “Assisted Reproductive Technologies: Estimates of Their Contribution to Multiple Births and Newborn Hospital Days in the United States,” Fertility and Sterility, 65 (1996): 361–66.

See Guzick D.S. , “Efficacy of Superovulation and Intrauterine Insemination in the Treatment of Infertility,” N. Engl. J. Med., 340 (1999): 177–83; American Society for Reproductive Medicine, Induction of Ovarian Follicle Development and Ovulation with Exogenous Gonadotropins, Practice Committee Report (1998), available at <http://www.asrm.com/Media/Practice/ovulation.html>.

See Centers for Disease Control and Prevention, supra note 5, at 536.

See Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine, “Assisted Reproductive Technology in the United States: 1999 Results Generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry,” Fertility and Sterility, 78 (2002): 918–31.

See Alexander G.R. , “What Are the Fetal Growth Patterns of Singletons, Twins, and Triplets in the United States?,” Clinical Obstetrics and Gynecology, 41 (1998): 115–25.

See id. at 117.

See Collins M.S. Bleyl J.A. , “Seventy-One Quadruplet Pregnancies: Management and Outcome,” American Journal of Obstetrics and Gynecology, 162 (1990): 1384–92.

See Albrecht J.L. Tomich P.G. , “The Maternal and Neonatal Outcome of Triplet Gestations,” American Journal of Obstetrics and Gynecology, 174 (1996): 1551–56; American Society for Reproductive Medicine, Multiple Pregnancy Associated with Infertility Therapy, Practice Committee Report (2000), available at <http://www.asrm.org/Media/Practice/multiples.pdf>; Seoud M.A.-F. , “Outcome of Twin, Triplet, and Quadruplet In Vitro Fertilization Pregnancies: The Norfolk Experience,” Fertility and Sterility, 57 (1992): 825–34; Lipitz S. , “High-Order Multifetal Gestation — Management and Outcome,” Obstetrics and Gynecology, 16 (1990): 215–18.

See Lieberman B. , “An Embryo Too Many?,” Human Reproduction, 13 (1998): 2664–66.

See Doyle P.E. , “Congenital Malformations in Twins in England and Wales,” Journal of Epidemiology and Community Health, 45 (1990): 43–48.

See American Society for Reproductive Medicine, supra note 15; Lipitz , supra note 15.

See Peterson B. , “Twins, Triplets, and Cerebral Palsy in Births in Western Australia in the 1980's,” British Medical Journal, 307 (1993): 1239–43. See also Pharoah P.O.D. Cooke T. , “Cerebral Palsy and Multiple Births,” Archives of Disease in Childhood, 75 (1996): F174–77.

See Addor V. , “Impact of Infertility Treatment on the Health of Newborns,” Fertility and Sterility, 69 (1998): 210–15.

See Wilcox , supra note 8.

See Luke B. Keith L.G. , “The Contribution of Singletons, Twins and Triplets to Low Birth Weight, Infant Mortality and Handicap in the United States,” The Journal of Reproductive Medicine, 37 (1992): 661–66.

See id. at 663.

See Albrecht Tomich , supra note 15; Seoud , supra note 15.

See American Society for Reproductive Medicine, supra note 15; Collins Bleyl , supra note 14.

See Albrecht Tomich , supra note 15; American Society for Reproductive Medicine, supra note 15; MacLennan A.H. , “Multiple Gestation: Clinical Characteristics and Management,” in Creasy R.K. Resnik R. , eds., Maternal-Fetal Medicine: Principles and Practice (Philadelphia: WB. Saunders Company, 1994): 589–601; ESHRE (European Society of Human Reproduction and Embryology) Capri Workshop Group, “Multiple Gestation Pregnancy,” Human Reproduction, 15 (2000): 1856–64; American College of Obstetricians and Gynecologists, “Special Problems of Multiple Gestation,” International Journal of Gynecology & Obstetrics, 64 (1999): 323–33; Senat M.-V. , “How Does Multiple Pregnancy Affect Maternal Mortality and Morbidity?,” Clinical Obstetrics and Gynecology, 41 (1998): 79–83; Doyle P. , “The Outcome of Multiple Pregnancy,” Human Reproduction, 11, suppl. 4(1996): 110–17.

See Albrecht Tomich , supra note 15; American Society for Reproductive Medicine, supra note 15; Collins Bleyl , supra note 14; Senat , supra note 26; American College of Obstetricians and Gynecologists, supra note 26.

See Albrecht Tomich , supra note 15; Collins Bleyl , supra note 14.

See Garel M. , “Psychological Consequences of Having Triplets: A 4-Year Follow-up Study,” Fertility and Sterility, 67 (1997): 1162–65.

See Merenkov K.E. , “Psychiatric Considerations After the Birth of Multiples,” in Keith L.G. , eds., Multiple Pregnancy: Epidemiology, Gestation, and Perinatal Outcome (New York: Parthenon Publishing Group, 1995): 573–81; Robin M. , “Maternal Reactions to the Birth of Triplets,” Acta Geneticae Medicae Gemellologiae, 40 (1991): 41–51; Garel M. Blondel B. , “Assessment at 1 Year of the Psychological Consequences of Having Triplets,” Human Reproduction, 7 (1992): 729–32.

See Thorpe K. , “Does a Twin Pregnancy Have a Greater Impact on Physical and Emotional Well-Being than a Singleton Pregnancy?,” Birth, 22 (1995): 148–52; MacLennan , supra note 26; ESHRE Capri Workshop Group, supra note 26; Olivennes F. , “Double Trouble: Yes a Twin Pregnancy Is an Adverse Outcome,” Human Reproduction, 15 (2000): 1663–65.

See Thorpe K. , “Comparison of Prevalence of Depression in Mothers of Twins and Mothers of Singletons,” British Medical Journal, 302 (1991): 875–78.

See Callahan T.L. , “The Economic Impact of Multiple-Gestation Pregnancies and the Contribution of Assisted-Reproduction Techniques to Their Incidence,” N. Engl. J. Med., 331 (1994): 244–49.

See Goldfarb J. , “Attitudes of In Vitro Fertilization and Intrauterine Insemination Couples Toward Multiple Gestation Pregnancy and Multifetal Pregnancy Reduction,” Fertility and Sterility, 65 (1996): 815–20; Leiblum S.R. , “Attitudes Toward Multiple Births and Pregnancy Concerns in Infertile and Non-Infertile Women,” Journal of Psychosomatic Obstetrics and Gynecology, 11 (1990): 197–210; Gleicher N. , “The Desire for Multiple Births in Couples with Infertility Problems Contradicts Present Practice Patterns,” Human Reproduction, 10 (1995): 1079–84.

See Leiblum , supra note 34.

See Collins J.A. , “A Couple with Infertility,” JAMA, 274 (1995): 1159–64.

An example of a physician advocating giving priority to the autonomy of the couple in ovarian stimulation is Hershlag A. , “Multifetal Prophylaxis — A Reality?,” Fertility and Sterility, 72 (1999): 973–74.

See Aronson D.D. , “Getting Out of the Corner,” Fertility and Sterility, 70 (1998): 623–24.

See Fertility Clinic Success Rate and Certification Act of 1992, 42 U.S.C. §§ 263a-1 et seq. (2003).

See Schulman J.D. , “What's Your Success Rate? Dr. X Comes to America,” Human Reproduction, 11 (1996): 697–99.

See Gleicher , supra note 34.

See Faber K. , “IVF in the US: Multiple Gestation, Economic Competition, and the Necessity of Excess,” Human Reproduction, 12 (1997): 1614–16.

See Evans M.I. , “What Are the Ethical and Technical Problems Associated with Multifetal Pregnancy Reduction?,” Clinical Obstetrics and Gynecology, 41 (1998): 47–54. See also Berkowitz R.L. , “The Current Status of Multifetal Pregnancy Reduction,” American Journal of Obstetrics and Gynecology, 174 (1996): 1265–72.

See Gleicher , supra note 34.

See Bergh C. , “Obstetric Outcome and Psychological Follow-Up of Pregnancies After Embryo Reduction,” Human Reproduction, 14 (1999): 2170–75; Garel M. , “Psychological Reactions After Multifetal Pregnancy Reduction: A 2-Year Follow-Up Study,” Human Reproduction, 12 (1997): 617–22; Schreiner-Engel P. , “First-Trimester Multifetal Pregnancy Reduction: Acute and Persistent Psychologic Reactions,” American Journal of Obstetrics and Gynecology, 172 (1995): 541–47; McKinney M. , “The Psychological Effects of Multifetal Pregnancy Reduction,” Fertility and Sterility, 64 (1995): 51–61.

See McKinney , supra note 45.

Frankfurter D. , “Insurance Mandates for IVF Coverage Effectively Lower Multiple Births per Embryo Transfer,” Fertility and Sterility, 70, suppl. 1 (1998): S49.

Kurth A. , “Reproductive and Sexual Health Benefits in Private Health Insurance Plans in Washington State,” Family Planning Perspectives, 33 (2001): 153–60, 179.

See Hughes E.G. Giacomini M. , “Funding In Vitro Fertilization Treatment for Persistent Subfertility: The Pain and the Politics,” Fertility and Sterility, 76 (2001): 431–42.

See Resolve (National Infertility Association), Insurance Coverage—State Laws, at <http://www.resolve.org/main/national/advocacy/insurance/index.jsp?name=advocacy&tag=insurance> (last visited May 31, 2003).

Bragdon v. Abbott , 524 U.S. 624 (1998). This case involved an HIV-positive patient who was seeking dental care, not reproductive assistance. The Supreme Court has not directly addressed the issue of insurance for infertility treatment.

See Gleicher N. , “Strategies to Improve Insurance Coverage for Infertility Services,” Fertility and Sterility, 70 (1998): 1006–08.

Coleman C.H. DeBuono B.A. , “Developing Public Policy on Assisted Reproductive Technologies: Reflections on the Work of the New York State Task Force on Life and the Law,” Fertility and Sterility, 73 (2000): 21–23.

See Griffin M. Panak W.F. , “The Economic Cost of Infertility-Related Services: An Examination of the Massachusetts Infertility Insurance Mandate,” Fertility and Sterility, 70 (1998): 22–29; Stovall D.W. , “The Cost of Infertility Evaluation and Therapy: Findings of a Self-Insured University Healthcare Plan,” Fertility and Sterility, 72 (1999): 778–84; Van Voorhis B.J. , “Cost-Effective Treatment of the Infertile Couple,” Fertility and Sterility, 70 (1998): 995–1005.

See Jensen G.A. Morrisey M.A. , “Employer-Sponsored Health Insurance and Mandated Benefit Laws,” The Milbank Quarterly, 77 (1999): 425–59, at 448–49, 454.

See Gleicher , supra note 52, at 1006. Some state and local chapters of Resolve have reported the demise of bills aimed at mandating insurance coverage for infertility. See Resolve of Wisconsin, Letter to Representative Obey (April 26, 1999), at <http://www.resolvewi.org/daveobeylet.html>; Resolve of Pittsburgh, Advocacy, at <http://www.resolveofpgh.org/advocacy/> (last visited June 15, 2003).

See Gleicher , supra note 52, at 1006.

See, e.g., Family Building Act of 2001, H.R. 389, 107th Cong. (2001); Fair Access to Infertility Treatment and Hope Act of 2001, S. 874, 107th Cong. (2001); Medicare Infertility Coverage Act of 2003, H.R. 969, 108th Cong. (2003).

In a district court case that applied the rule laid down in Bragdon, the court held that an employer's refusal to provide infertility insurance did not violate the ADA. Rochelle Saks brought action against her employer, Franklin Covey Co., following the denial of her claim for IVF. The court held that the defendant's failure to provide coverage for IVF was not a violation of the ADA because the same insurance coverage was offered to all employees,' whether fertile or infertile. See Saks v. Franklin Covey Co., 117 F. Supp. 2d 318 (S.D.N.Y. 2000). See also Roche J.B. , “After Bragdon v. Abbott: Why Legislation Is Still Needed to Mandate Infertility Insurance,” Boston University Public Interest Law Journal, 11 (2002): 215–28.

See Gleicher N. , “Reducing the Risk of High-Order Multiple Pregnancy After Ovarian Stimulation with Gonadotropins,” N. Engl. J. Med., 343 (2000): 2–7; Balash J. , “Late Low-Dose Pure Follicle Stimulating Hormone for Ovarian Stimulation in Intra-Uterine Insemination Cycles,” Human Reproduction, 9 (1994): 1863–66.

See De Geyter C. , “Experience with Transvaginal Ultrasound-Guided Aspiration of Supernumerary Follicles for the Prevention of Multiple Pregnancies After Ovulation Induction and Intrauterine Insemination,” Fertility and Sterility, 65 (1996): 1163–68; Albano C. , “Avoidance of Multiple Pregnancies After Ovulation Induction by Supernumerary Preovulatory Follicular Reduction,” Fertility and Sterility, 76 (2001): 820–22.

See Lessing J.B. , “Avoidance of Cancellation of Potential Hyperstimulation Cycles by Conversion to In Vitro Fertilization-Embryo Transfer,” Fertility and Sterility, 56 (1991): 75–78; ESHRE Capri Workshop Group, supra note 26.

See Jones H.W. Jr. Cohen J. , “IFFS Surveillance 01,” Fertility and Sterility, 76 (2001): S1–S36.

Human Fertilisation and Embryology Authority, Code of Practice, 5th ed. (London: Human Fertilisation and Embryology Authority, March 2001): § 9.18, available at <http://www.hfea.gov.uk/Downloads/CodeOfPractice/CodeOfPractice2001.pdf>.

See Templeton A. Morris J.K. , “Reducing the Risk of Multiple Births by Transfer of Two Embryos After In Vitro Fertilization,” N. Engl. J. Med., 339 (1998): 573–77.

See Human Fertilization and Embryology Authority, Press Release, HFEA Reduces Maximum Number of Embryos Transferred in Single IVF Treatment from Three to Two (August 8, 2001), available at <http://www.hfea.gov.uk/forMedia/archived/08082001.htm>.

See Grifo J. , “We Are Due for a Correction … and We Are Working to Achieve One,” Fertility and Sterility, 75 (2001): 14.

See American Society for Reproductive Medicine, Guidelines on Number of Embryos to Transfer, Practice Committee Report (1999), available at <http://www.asrm.org/Media/Practice/NoEmbryosTransferred.pdf>.

See ISLAT (Institute for Science, Law, and Technology) Working Group, “ART into Science: Regulation of Fertility Techniques,” Science, 281 (1998): 651–52; Jones H.W. Jr. Schnorr J.A. , “Multiple Pregnancies: A Call for Action,” Fertility and Sterility, 75 (2001): 11–13.

See Grifo , supra note 67.

See Levene M.I. , “Higher Multiple Births and the Modern Management of Infertility in Britain,” British Journal of Obstetrics and Gynaecology, 99 (1992): 607–13; Worcester S. , “Educate Women Early About Fetal Reduction,” Ob. Gyn. News, May 15, 1999, at 18.

See Alikani M. Wiemer K. , “Embryo Number for Transfer Should Not Be Strictly Regulated,” Fertility and Sterility, 68 (1997): 782–83; Bustillo M. , “Imposing Limits on the Number of Oocytes and Embryos Transferred: Is It Necessary/Wise or Naughty/Nice?,” Human Reproduction, 12 (1997): 1616–17.

My thanks to an anonymous reviewer for putting forward these objections.

See Strong C. , Ethics in Reproductive and Perinatal Medicine: A New Framework (New Haven: Yale University Press, 1997): At 91–92.

See Bayles M.D. , “Harm to the Unconceived,” Philosophy and Public Affairs, 5 (1976): 292–304; Feinberg J. , Harm to Others (New York: Oxford University Press, 1984): At 99; Steinbock B. McClamrock R. , “When Is Birth Unfair to the Child?,” Hastings Center Report, 24, no. 6 (1994): 15–21.

Strong , supra note 74, at 92–93.

Feinberg J. , “The Child's Right to an Open Future,” in Aiken W. LaFollette H. , eds., Whose Child? Children's Rights, Parental Authority, and State Power (Totowa, New Jersey: Littlefield, Adams & Co., 1980): At 124–53; Davis D.S. , “Genetic Dilemmas and the Child's Right to an Open Future,” Hastings Center Report, 27, no. 2 (1997): 7–15.

The right to a decent minimal opportunity for development raises a number of issues that are beyond the scope of this article: How severe must the handicap be before the right is violated? How can it be claimed that the child is wronged when the alternative — nonexistence — is not preferable from the child's perspective? For a discussion of these issues, see Strong , supra note 74, at 90–95.

See Dresser R. , “Regulating Assisted Reproduction,” Hastings Center Report, 30, no. 6 (2000): 26–27.

See Strong C. , “Octuplets and Ethics,” Fertility and Sterility, 72 (1999): 970–72; Hershlag , supra note 37; Strong C. , “To the Editor,” Fertility and Sterility, 73 (2000): 1266–67.

See Gardner D.K. , “Culture and Transfer of Human Blastocysts Increases Implantation Rates and Reduces the Need for Multiple Embryo Transfers,” Fertility and Sterility, 69 (1998): 84–88; Gardner D.K. , “A Prospective Randomized Trial of Blastocyst Culture and Transfer in In Vitro Fertilization,” Human Reproduction, 13 (1998): 3434–40.

This option was suggested by the New York State Task Force on Life and the Law, Assisted Reproductive Technologies: Analysis and Recommendations for Public Policy (New York: New York State Task Force on Life and the Law, 1998). See Coleman DeBuono , supra note 53, at 21.

This proposal has been put forward by De Jonge C.J. Wolf D.P. , “Embryo Number for Transfer Should Be Regulated,” Fertility and Sterility, 68 (1997): 784–86.

This approach has been advocated by Jones H. W. Jr. , “The Time Has Come,” Fertility and Sterility, 65 (1996): 1090–92. Although Jones presented this option as a form of professional self-regulation, it seems more plausible to regard it as a type of government control because of its licensing function.

This option is recommended by the ISLAT Working Group, supra note 69.

A requirement not to destroy preembryos or use them for research would not appear to interfere with the procreative freedom of couples, and therefore it presumably would not be subject to a constitutional challenge as an interference with the right to privacy.

Of course, my view that the risk of such restrictions occurring counts as a disadvantage is normative. Those who believe that preembryos are persons and that such restrictions would be appropriate might regard the possibility of their occurring as an advantage. My disagreement with them is at bottom a dispute over the moral standing of preembryos. A presentation of the arguments against the view that preembryos are persons would take us beyond the scope of this paper. The reader is referred to my discussion of these arguments in other works. See Strong , supra note 74, at 41–62; Strong C. , “The Moral Status of Preembryos, Embryos, Fetuses, and Infants,” Journal of Medicine and Philosophy, 22 (1997): 457–78.

De Jonge Wolf , supra note 83, at 785.