SELECTIVE EMBRYO REDUCTION

A Discussion of the Pros and Cons of Selective Embryo Reduction After In-vitro Fertilization Kayla Vadney 00787819

Submitted in partial fulfillment of the requirements in the course NURS330: Nursing Care of the Childbearing Family Old Dominion University NORFOLK, VIRGINIA Spring, 2013

SELECTIVE EMBRYO REDUCTION

A Discussion of the Pros and Cons of Selective Embryo Reduction After In-vitro Fertilization Infertility has been a major struggle for some couples since the emergence of human existence. Furthermore, the emotional suffering and societal persecution associated with the inability to conceive a child is well known and documented. There are many accepted interpretations of infertility, however it is most commonly defined as an inability to conceive after 12 months of unprotected intercourse (Paul-Simon, 2011). Fortunately within the last few decades, medicine has advanced to allow couples the opportunity to create a family of which, under natural circumstances, would not otherwise be possible. One of the ways this is achievable is by means of in-vitro fertilization (IVF), in which an ovum is fertilized with sperm outside of the female body and implanted in the uterus at a later time. Although IVF is considered a breakthrough in technology and medicine, it does pose the potential for many concerns, one of which is multiple embryo pregnancy. When more than one embryo successfully implants in a womans uterus, that woman, along with her family and her physician, must then make the ethical and moral decision of whether or not to selectively reduce the number of embryos she will attempt to bring to term. The controversy of selective reduction after IVF was initially caused by the fact that IVF technology has emerged only recently and therefore there is not a pre-established and commonly accepted ethical code of which to follow. Some researchers are concerned with the health risks of carrying multiple embryos to term, while others have very distinct and strong moral and ethical opinions about removing embryos after they have already been implanted. According to PaulSimon (2011) and Rosenthal (2009), the decision to selectively reduce after initial implantation should never arise because there should never be a situation in which so many embryos are implanted that it becomes necessary to remove one or more. Additionally, both researchers argue

SELECTIVE EMBRYO REDUCTION

further that no more than two embryos should ever be implanted for any one treatment of IVF so that the need to selectively reduce is diminished (Paul-Simon, 2011; Rosenthal, 2009). However, in many documented cases, such as the Suleman octuplets, as many as six or more embryos are initially implanted to increase the chances of successful implantation (Rosenthal, 2009). Regardless, the purpose of this discussion is ultimately to explore the advantages and disadvantages of performing selective embryo reduction after IVF once multiple fertilized and perfectly healthy and viable embryos have already been successfully implanted and to identify the audience of which this information may benefit most. Audience The target audience for this discussion is two-fold. First and foremost, this analysis intends to address registered nurses and other healthcare professionals working with patients who plan to receive or who have already received IVF. These professionals would be interested in the topic of selective embryo reduction because they attend to both the negative and positive effects it can have on a woman and her family. It is important that they take time to acknowledge the controversy of this decision and that many factors need to be considered. They would also benefit from addressing their own feelings and opinions regarding embryonic reduction to assist them in providing less judgmental and more holistic care. Another group who is an intended audience for this discussion includes the women and families who are interested in, plan to receive, or have already participated in IVF treatment. This group would be interested in the information covered in the succeeding sections because it is imperative that they be thoroughly informed of the ethical choices they may have to make during their treatment plan and they also need to have information from both sides of this controversy to be able to make informed and responsible decisions and become active participants in their care. This discussion intends to

SELECTIVE EMBRYO REDUCTION

address both of these parties because in real-life scenarios they will both be working together to make the best decisions regarding selective reduction for everyone involved. Advantages of Selective Reduction There are numerous reasons that women and families decide to reduce the number of embryos that have successfully been implanted after IVF. One of the most common explanations is the overwhelming emotional burden multiple children can impose on a family (Paul-Simon, 2011). For example, caring for two or more children of the same age may have the tendency to inflict certain thoughts in the woman or couple such as that they may not have enough love, patience, or hands to go around. These anticipated emotions have the potential to directly increase the already present caregiver strain that accompanies any parent with even just one newborn. Another reason usually associated with choosing selective reduction is the undeniably stressful financial burden of raising several children at a time (Paul-Simon, 2011). Providing for one newborn can be financially draining in and of itself, let alone buying diapers and formula for three, four, five or more infants. Another significant influence for choosing selective reduction over carrying multiple embryos to term is the fear of societal ostracizing that, as of late, accompanies families with more than an acceptable number of children, such as Nadia Suleman, more commonly known as Octo-mom (Rosenthal, 2009) and other media and television celebrity families. The last most commonly reported rationale for choosing selective reduction is the the simple lack of desire to have multiple children (Paul-Simon, 2011). Some families only desire one child and selective reduction is a reasonable option for them after IVF treatment. Although the aforementioned reasons are relevant rationales for choosing selective reduction, perhaps the most significant advantage is the decrease in probability of serious health

SELECTIVE EMBRYO REDUCTION

complications. It has come to be thoroughly understood that multiple embryo pregnancies pose significant health risks to both the mother and the babies, and this risk increases exponentially as the number of embryos increases (Rosenthal, 2009; Paul-Simon, 2011). The intention of selective embryo reduction is to reduce the embryos to a safe number and thereby prevent the occurrence these potential risks. Some of the maternal complications which may arise with a multiple embryo pregnancy include any of the many different hypertensive disorders which may lead to eclampsia if left untreated, gestational diabetes which can cause the development of diabetes mellitus type II, and hemorrhaging during or after delivery which if uncontrolled will contribute to maternal death. In addition to maternal complications, multiple embryo pregnancies can significantly harm the embryos themselves. For example, according to Paul-Simon (2011), every documented set of living multiples of four or more were born significantly under normal weight and the reduction to a single embryo is associated with increased birthweight. Another potential and very common complication with multiples is preterm delivery (Paul-Simon, 2009). Depending on how preterm the infants are born, this complication poses the risk of several subsequent developmental insufficiencies such as an underdeveloped brain, heart or lungs which may lead to lifelong struggles or death (Paul-Simon, 2009). According to Rosenthal, even twins can facilitate considerable complications and the birth of a single infant through the implantation of a single embryo after IVF is most ideal (2009). Therefore there is sufficient evidence to conclude that the less embryos that are attempted to be carried to term, the less potential for significant health complications for both mother and baby and by extension the less associated emotional and financial stress on the family. Disadvantages of Selective Reduction

SELECTIVE EMBRYO REDUCTION

Although it may be fair to argue that carrying more than one infant to term after IVF treatment poses several physical, emotional and financial risks to the mother, infants and family, there are considerable disadvantages that need to be considered. First and foremost, the process of reducing the number of embryos in a womans uterus is a medical procedure in and of itself and any medical procedure has the potential for certain complications. For example, according to an article by McClimans (2010), electively reducing the number of embryos can contribute to the loss of the pregnancy in its entirety. For women and families who have tried unsuccessfully for several years or more who have finally achieved a successful pregnancy, the risk of losing all the embryos may not outweigh the benefits of carrying only one or two babies versus three or more. Furthermore, according to a 2010 article by McClimans, it is not ethically preferable to perform selective reduction as a preventative measure and until there are clear and evident threats to the mother or embryo(s), no intervention should be implemented at all. Other rationales for refusing selective reduction may stem from the overwhelming controversy associated with perspectives of the Pro-choice stand. Ruse and Schwarzwalder, two researchers from the Family Research Council, argue scientifically that life begins at conception without regard to religious or cultural influences (2011). According to Ruse and Schwarzwalder (2011), when a human sperm penetrates a human ovum, a new human cell is created. This cell is composed of human DNA, which holds the blueprints that will guide the growth and development of the being, which is based off hereditary material contributed by the ovum and sperm. These two researchers conclude that a human zygote, which will grow into an embryo, is biologically alive because it meets the four criteria of life: it grows from one cell to many; these cells metabolize; the being reacts to stimuli; and it carries genetic and hereditary material needed for future reproduction (Ruse and Schwarzwalder, 2011).

SELECTIVE EMBRYO REDUCTION

Building off of this argument, another reason to refuse selective reduction after IVF would be the societal rejection associated with the commonly held belief that embryos are alive and the removal of them from the uterus resulting in embryonic death is essentially murder (Ruse and Schwarzwalder, 2011). The stress that this may impose on a woman and her family may be enough to make the choice to carry all implanted embryos as far as possible. Furthermore, elective disposal of embryos not only carries the potential for societal repercussions of wasting viable embryos, but personally inflicted emotional stresses, as well (McClimans, 2010). Without regard to religion, the sheer idea that an individual has caused selfish harm to a live being is enough of a moral and ethical distress. Consequently, there is substantial support to reinforce the argument that several disadvantages exist in regard to the implementation of selective embryo reduction. Conclusion In summary, there are several advantages and disadvantages of selective embryonic reduction after IVF treatment, of which both have substantial published research to support either decision. Although it is true that attempting to carry more than three embryos to term poses significant health, financial, emotional and societal risks to a woman, the embryos, and her family, there are substantial physical, societal and emotional risks with selective reduction as well. The purpose of this discussion was to explore these pros and cons in an effort to assist individuals in making an informed, logical and responsible decision. Ultimately, it is the personal choice of the individual woman whether or not to selective reduce once multiple embryos have successfully implanted and it is the responsibility of registered nurses and other healthcare professionals to relay this and any additional information that families may need in order to make this decision.

SELECTIVE EMBRYO REDUCTION

References McClimans, L. (2010). Elective twin reductions: Evidence and ethics. Bioethics, 24(6), 295-303. doi: 10.1111/j.1467-8519.2008.01704.x Paul-Simon, A. (2011). Infertility and multiples. Newborn and Infant Nursing Reviews, 11(4), 180-184. doi: 10.1053/j.nainr.2011.09.007 Rosenthal, M.S. (2009). The Suleman octuplet case: An analysis of multiple ethical issues. Womens Health Issues, 20(1), 260-265. doi: 10.1016/j.whi.2010.04.0 01 Ruse, C.C., & Schwarzwalder, R. (2011). The best pro-life arguments for secular audiences. Retrieved from http: //downloads.frc.org/EF/EF11J30.pdf

SELECTIVE EMBRYO REDUCTION

Honor Pledge "I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community, it is my responsibility to turn in all suspected violators of the Honor Code. I will report to a hearing if summoned." Signed (electronically): Kayla Marie Vadney Date: 4/29/13