Dr. Meldrum published an article in the May Fertility and Sterility journal urging IVF programs to consider the overall psychological stress of going through IVF, including the resulting pregnancy and care of the offspring. He entitled it “Lightening the burden of care in ART.”
First, efforts to have a smoothly operating program from the first answered phone call all the way through to billing should be aimed toward keeping stress as low as possible for the couple. In his March review, he pointed out the extensive evidence that stress reduces outcomes and contributes to dropping out of further care, and proposed that constriction of blood flow to the ovary may be the most logical mechanism of the effect of stress on IVF success.
The first relatively new source of stress he discussed is genetic screening prior to IVF. There is a limited panel of tests such as for cystic fibrosis mutations that multiple bodies overseeing our specialty recommend. However, many programs have adopted a much more extensive screening panel looking for carriers of mutations with lesser impact. The problem is that finding an abnormality adds significant stress on the couple, wondering if the husband will also be a carrier and therefore giving a chance the offspring could have the disease, having to decide whether relatives should be tested and on and on. The small benefit is undeniable, but is it causing more harm than good when the couple’s primary goal is IVF success? We and many other programs are not convinced and recommend only the panel advised by supervising organizations.
The second source of stress he discussed is when a genetic laboratory uses newer, more sophisticated techniques to call an embryo biopsy mosaic (containing both normal and abnormal cells) rather than simply normal or abnormal. Calling up to 30% of a couple’s embryos “possibly abnormal” adds a large amount of stress and we do not yet have enough good information to say what is the benefit (excluding those from transfer or reducing their rank until after failures using other embryos) versus harm (discarding or delaying transfer of an embryo that will result in a success), and from published reports there have been several normal offspring resulting from embryos so designated. Other studies have shown there is major self-correction that occurs, with the abnormal cells falling behind and mainly relegated to the placenta. For the time being our program has decided to not request the newer and incompletely studied analysis.
The third and most important source of stress is multiple pregnancies. It is hard to believe, for couples who have gone through so much together, but the chance of divorce is higher with parents of IVF twins. The stresses involved with the increased complications during pregnancy and for the offspring together with the logistics, loss of sleep and financial issues with twins, are overwhelming for many couples. That is why our program has led the way in counseling our patients to have transfer of their embryos one at a time in most instances. With the excellent freezing techniques we now use (vitrification), the overall success will be the same. It is far better to have IVF babies one at a time. For certain mothers, such as those who are non-white or obese, pregnancy complications, including premature birth with the offspring at increased risk of not surviving or being impaired is much higher, making transfer of a single embryo imperative.
Our constant goal should be to lighten the burden of ART care whenever possible.