Therefore, those patients could benefit from repeated oriented pelvic ultrasound examinations to shorten the time to diagnosis and to avoid the use of laparoscopy. To paraphrase the great French surgeon Henri Mondor (1885–1962), we propose that his dictum be applied to heterotopic pregnancy after ART: When presented with a woman who has had IVF and ET, think about heterotopic pregnancy. When we always think about it, we’re still not thinking about it enough. Lionel Reyftmann, M.D. Herve´ Dechaud, M.D., Ph.D. Bernard Hedon, M.D. Department of Reproductive Medicine and Biology, University Hospital, Arnaud de Villeneuve, Doyen G. Giraud, Montpellier, France April 17, 2007
REFERENCE 1. Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2007;87:417. e9–15.
doi:10.1016/j.fertnstert.2007.07.013 Reply of the Author: I would like to thank Dr. Reyftmann and colleagues for their interest in our article ‘‘Heterotopic pregnancy: two cases and a comparative review’’ (1). I do appreciate their kind words and comments. As they point out, when considering gestations after assisted reproduction treatment, the suspicion level for heterotopic pregnancies should be higher. However, it is of note that, even with a high index of suspicion, the diagnosis of heterotopic pregnancy is not easy. The data reported in our article suggest that transvaginal ultrasound may not be a reliable tool in diagnosing an ectopic pregnancy with concomitant ovarian hyperstimulation syndrome. As stated in the article (1), the dictum ‘‘think ectopic’’ signifies the difficulty of achieving the correct diagnosis of ectopic pregnancy. However, when an intrauterine pregnancy is diagnosed, it does not immediately indicate a heterotopic pregnancy. The proposed dictum of Reyftmann and colleagues to think ‘‘continuously’’ of heterotopic gestation in women after assisted reproduction pregnancies may shorten the diagnosis interval, but, in our opinion, delays in diagnosis will still occur. Gorka Barrenetxea, Ph. D. Obstetrics and Gynecology of Universidad del Paıs Vasco/Euskal Herriko Unibertsitatea Center for Reproductive Medicine and Infertility Quiro´n Bilbao, Bilbao, Spain June 10, 2007 760
Letters to the Editor
REFERENCE 1. Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2007;87:417.e9–15.
doi:10.1016/j.fertnstert.2007.07.014 Variables affecting the decision for numbers of embryos transferred To the Editor: The article by Newton et al. (1) attempts to determine factors that may impact a patient’s decision to undergo single embryo transfer (SET). In this study, the authors interviewed patients regarding their satisfaction with and attitudes toward the number of embryos transferred immediately after their embryo transfer (ET). Although the results were certainly interesting, significant weaknesses of this study were the post hoc application of risk assessment and the hypothetical nature of the clinical scenario. The authors found that when patients received accurate information regarding the risks of twin gestation both partners had a decreased desire for twins. Yet there were no patients who underwent a voluntary SET in the study. Unknown are the precise factors important to couples immediately before ET. It is plausible that patient valuations are different prospectively compared with retrospectively. The present study does not provide information on how the actual ET number was determined. Was it physician recommendation? What specific counseling did the patients receive before ET? Although these questions may be beyond the scope of the report, they remain important to understanding the decision-making process. It is likely that, in clinical practice, physician influence is greater than reported post hoc. Studies involving patients undergoing other invasive procedures have demonstrated that patients rely heavily on the recommendations of their physicians (2). Why would assisted reproduction treatment be any different? A study by Blennborn et al. (3) examined the factors influencing decisions to undergo SET and found that greater than 75% of patients reported that their physician’s advice was important to very important (3). That study was performed in Sweden, where conceivably SET has been more favorably received by clinicians, which may in part explain the 41.2% incidence of SET among the study population. The Newton study has addressed matters paramount to patients’ assessment of risk: understanding how patients analyze, interpret, and use data in the context of their clinical condition and how physicians may influence patient decisions. A thorough awareness of patients’ biases and priorities remains of principal import to addressing difficult issues in assisted reproduction such as SET. Moreover, I would submit that physicians’ attitudes do impact patients’ decisions related to SET to a far greater extent than previously reported. Finally, there undoubtedly remain other contributing factors that effect patients’ valuations that require prospective Vol. 88, No. 3, September 2007
exploration to more completely understand, notably why the risks associated with multiple ET are seemingly ignored. Eric D. Levens, M.D. Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland April 23, 2007 REFERENCES 1. Newton CR, McBride J, Feyles V, Tekpetey F, Power S. Factors affecting patients’ attitudes toward single- and multiple-embryo transfer. Fertil Steril 2007;87:269–78. 2. Mazur DJ, Hickam DH, Mazur MD, Mazur MD. The role of doctor’s opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures? Health Expect 2005;8:97–102. 3. Blennborn M, Nilsson S, Hillervik C, Hellberg D. The couple’s decisionmaking in IVF: one or two embryos at transfer? Hum Reprod 2005;20: 1292–7.
doi:10.1016/j.fertnstert.2007.07.007 Reply of the Authors: We thank Dr. Levens for his interest in our work and appreciate the opportunity to clarify certain issues related to patient’s attitudes toward embryo transfer (ET) reported in our study (1). Our research attempted to identify possible factors that might influence patients’ decision making concerning single and multiple ET. In our report, we emphasized that patients were interviewed after ET and that no effort was made to influence actual transfer choices. Therefore, it was not surprising (as Dr. Levens correctly notes) that no patients in the study actually chose single ET. We think that this simply highlights the current resistance to this option among North American patients. Our study was exploratory in nature and not an intervention. We wished to examine how the patients’ own initial beliefs, values, and attitudes had shaped their views of transfer and whether and how the presentation of risk information affects these attitudes. Whether a change in attitudes leads to a change in behavior (a different transfer decision) is a very important but separate question. It is possible that patient responses to risk information might be different in some ways if presented before rather than after transfer. However, it seems more likely that actual transfer decisions (the gold standard) are likely influenced by added factors besides the patients’ own beliefs and values, (i.e., the physician’s beliefs and values). On a related note, Dr. Levens also requests clarification about how the actual ET number was determined. In our program, probably like many others, there is an ongoing discussion between patients and physician, both before the cycle and immediately before ET. The standard recommendation is to transfer two embryos when women are under age 35. Patients receive risk information, but not in the detail and Fertility and Sterility
to the degree that they received in our study. We completely agree that physician influence is significant and that patients might underreport this influence. Although we did not report this, immediately after transfer, 51% of women in our study rated the physician’s influence as ‘‘large’’ or ‘‘very large.’’ However, 71% women also rated their own influence as similarly large. Clearly, many women believed that the decision was a shared one, and as we reported, when they felt this way, they were more satisfied with transfer decisions. It is entirely possible that the physician’s influence is underestimated because (lacking information) many patients hold views congruent with those of their physician. This raises the important question of whether we need to make greater use of decision aids to assist in vitro fertilization patients with their transfer decisions (2). This would empower patients to make more informed decisions, and possibly to make different choices. Christopher Newton, Ph.D. Joanna McBride, M.A. Valter Feyles, M.D. Francis Tekpetey, Ph.D. Stephen Power, M.D., Ph.D. Reproductive Endocrinology and Infertility, University Hospital, London Health Sciences Centre, London, Ontario, Canada May 30, 2007 REFERENCES 1. Newton CR, McBride J, Feyles V, Tekpetey F, Power S. Factors affecting patients’ attitudes towards single and multiple embryo transfer. Fertil Steril 2007;87:269–78. 2. O’Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003;2:CD001431.
doi:10.1016/j.fertnstert.2007.07.008
Genetic and epigenetic risks of ART To the Editor: In the workshop report (1) published in Fertility Sterility, one important risk associated with assisted reproductive technology (ART) seems to be of less concern but may be of great relevance with regards to genetic counseling. The possible vertical transmission of male infertility, specifically by intracytoplasmic sperm injection (ICSI), also should be considered a genetic risk linked to ART, one that should be disclosed and discussed with parents to be. Male infertility has become a major health problem as 40% to 50% men of reproductive age present qualitative or quantitative abnormalities in sperm production (2). Numerous studies have confirmed the concept of a genetic basis for male infertility, and genetic causes are now estimated to account for more than 10% of severe male infertilities (3). 761