How many embryos should i have transferred

As a result, the American Society for Reproductive Medicine ASRM and Society for Assisted Reproductive Technology SART revised their recommendations regarding the number of embryos to transfer in in an effort to promote singleton gestations and reduce the number of multiple pregnancies.

The ASRM recommendations are based on embryo quality, which accounts for several characteristics:. Embryo Developmental Stage: embryos on day 3 of development cleavage stage or embryos on day 5 of development blastocyst stage.

Euploid Embryo: an embryo with a normal chromosomal complement based on pre-implantation genetic testing for aneuploidy PGT-A. Favorable Prognosis: a patient with a euploid embryo or one or more high quality embryos based on appearance or a patient with a history of a live birth from an IVF cycle. The ASRM recommends that all patients, regardless of age, who have a euploid embryo have an eSET because PGT-A has been shown to increase the likelihood of implantation and live birth while reducing the chance of miscarriage.

Many couples perceive twins as an optimal goal obtained from an IVF cycle. While such pregnancies can be a good thing when no problems arise, multiple pregnancies even twins increase the obstetric complications. Therefore, the goal of most infertility experts is to obtain singleton pregnancies.

To this end, some experts have advocated the transfer of only one embryo at a time for many patients, a practice known as single embryo transfer, or SET. In general, SET results in a decreased chance of achieving a pregnancy per embryo transfer as compared to the transfer of two or more embryos, but it also greatly decreases pregnancy risks by avoiding multiples. At Fertility Associates of Memphis, patients believed to have an excellent chance at achieving pregnancy with favorable predictors good embryo quality, non smoker, normal BMI, previous successful pregnancy, etc.

For patients with more complicated clinical situations, more embryos for transfer may be recommended. We are very proud of American pregnancy rates, but we need to get our twin and triplet rates down. The type of clinic can shape these decision-making processes.

Providers who work within academic medical contexts or hospitals can face additional implicit and explicit pressures:. My hospital had a meeting of the medical executive directors with people, and they had me talk with a maternal-fetal specialist about the impact of IVF on the hospital. I thought it was going to be a lynching. From a cost point of view, you want to have singletons because the complications otherwise are difficult.

I have patients who lose twins at 23 weeks. Some complicated twin pregnancies are in bed for six months. I have competitors in my region with pretty terrible records: triplets, quads. Hospital environments, in which physicians periodically have to present their work to others outside assisted reproductive technology, can thus act as a form of oversight or social control.

The fact that relatively high rates of both twin and higher-order multiple births continue poses critical questions concerning the need for possible additional guidelines, or for regulations. Competing potential risks and benefits of such additional policies need to be weighed against each other. These clinicians opposed rules rather than guidelines , or stricter mandates that would diminish their autonomy — stressing that clinical judgment can play an important role in these decisions.

Yet even though providers may not all follow certain guidelines, they tended to oppose more stringent approaches, feeling that current guidelines, rather than tighter regulations, suffice:. The question becomes: What exactly is a guideline? Should doctors be punished for not adhering?

Should there be rules, rather than guidelines? Yet, while preferring suggested guidelines — rather than regulations — this doctor nonetheless queries their scope, meaning and implications.

A broad continuum exists of levels and types of guidelines, based on several characteristics e. Providers may feel that changes to the reporting policies are needed, but will be elusive due to the complex federal bureaucratic structures and processes involved. While changes in reporting requirements may have helped decrease the rates of births of three or more infants at a time, reduction in the frequency of twins may be harder:.

Because that has to be the incentive. They are very interested, but there is that conflict. They have to push it through. Physicians may therefore also be somewhat ambivalent about maximizing individual patient versus broader public health benefits.

These clinicians generally favour increasing professional self-regulatory mechanisms first, before initiating government regulations:. SART wants to set up guidelines for very stringent monitoring of clinic performance, and ask clinics with poor performance to change, taking steps from there.

It should start with self-regulation. There have been improvements over time. The threat of government regulation, if models of professional self-regulation fail, could potentially enhance adherence, though it has not yet proven sufficient.

To reduce the incidences of twins and other multiple births, other government policies, concerning insurance coverage, may also then be needed:. I see the result of twins and triplets, and the maternal complications for ovarian stimulation — people hospitalized during an IVF cycle. But patients and doctors are willing to do it, and try to transfer more, and not be so cautious, because the patient is paying for it. These data, the first to explore several critical aspects of how providers view and make decisions about how many embryos to transfer, highlight how professional recommendations and guidelines in this area can contain flexibility and ambiguities, and lack enforcement, raising challenges, tensions and dilemmas that providers and patients therefore confront.

Though the previous prior literature has focused largely on limitations in insurance coverage as contributing to high rates of twins, the present data suggest how other, non-economic factors — social, psychological, cognitive, medical, logistical and professional — can play critical roles as well.

Though, as found in Denmark, patients may still prefer twins, even in countries that provide insurance, the present data probe how providers and patients then confront and respond to ensuing tensions, given professional recommendations favouring SET. The present data also suggest possible strategies that have not been previously reported for addressing these problems, and several directions for future research. Specifically, eight findings that have not been presented in the literature have key implications for future research, practice, education and guidelines.

Secondly, while Jungheim et al. These data extend and build substantially on prior findings that the median length of time of consulting about these issues with providers was 5 min Kalra et al. The present data add considerably to the past literature, in suggesting that providers differ considerably in what they actually say, how thoroughly they discuss these issues; whether they communicate the risks involved, and if so which risks, how effectively and when e.

These data suggest that providers may not fully explain or convey these risks, and may even minimize them; and that patients may also then minimize these dangers, or feel that these odds do not apply to them. Thirdly, while recommendations in certain countries e. These data suggest that patients may seek rationalizations for why these risks will not apply to them: for example because they exercise and are healthy.

Patients in other areas of medicine commonly minimize or deny possible risks to themselves Rabinowitz and Peirson, , and do so here, too. Physicians must obtain informed consent, and patients thus need to understand the risks and benefits involved, but the present data suggest that that may not always occur. While Jungheim found that most clinics deviated from guidelines, due to patient requests, the current data suggest that patient requests themselves may vary widely in how informed and firm they are.

Therefore, the present data suggest clinicians should not always simply follow patient requests, but instead should ascertain how fully informed and strong these requests are.

Guidelines should, arguably, also specify that providers should carefully discuss specific relevant details with patients e. Studies in other areas of medicine show that patients may benefit most from being told not either absolute or relative rates alone, but rather both, along with proportions e. These data also suggest, for the first time, several reasons for these perceptions of the data as insufficient. For any one patient, the odds of success with twins are relatively good i.

Rather, paediatricians, not reproductive endocrinology and infertility REI specialists, are responsible for, and have experienced difficulties in, treating harmful outcomes that twins face, for example in the NICU.

The risks may thus be easy for REI specialists and prospective patients to discount. The costs generated by these risks also accrue not to these REI specialists, but to society and the eventual parents. Fifthly, these data suggest that providers may at times transfer additional embryos due to their own competing motives and pressures — desires, in many countries, to increase their reported rates of success. Physicians may therefore not always adequately communicate these dangers to patients, and may be biased in arguing that patient autonomy should readily trump all other considerations.

Sixthly, these data suggest that physicians may be over prioritizing patient autonomy and ignoring or undervaluing other ethical considerations — the rights of the unborn child, beneficence toward these future offspring, non-maleficence and social justice.

In focusing on patient autonomy, physicians may be downplaying their ethical responsibilities concerning the future child, public health burdens to society as a whole and the need to avoid harm to the mother and future children. Arguably, at a certain point, wider social and public health costs and risks to the mother and future offspring may at times outweigh the autonomy of an individual patient.

Dilemmas surface of precisely how much obligation providers have to follow these other principles; yet clinicians should at least seriously consider these other ethical concerns, especially given both potential patient misunderstandings of risks, and possibilities of physicians having conflicting motives.

Seventhly, while research has indicated that providers may differ in how many embryos they transfer, the present data suggest that clinicians also vary in how they make these decisions: whether they do so informally or formally through an ethics or QA committee that may include not only assisted reproductive technology providers.

These data suggest, too, that providers vary in these decisions due to several factors, such as the type of institution in which they work, and their own personal or professional experiences and perceptions of the persuasiveness of the risk data.

Providers and patients may see SET as having advantages over DET, but perceive DET as having advantages over no child — thus focusing only on the outcome to have a baby rather than on the risks as well. These findings have several important implications for further practice, policy, education and research. Though a few commentators have suggested increasing insurance coverage, doing so poses challenges: for example, the cost of providing sufficient infertility care to everyone who wants it may be prohibitive.

Rather, these data suggest that several other approaches e. Governments can thus forcefully limit numbers of embryos transferred as part of payments. In contrast, in many other countries, where IVF is reimbursed much less or not at all, recommendations to limit the numbers of embryos transferred face additional hurdles, and may have considerably less success.

Hence, countries can vary widely in use of SET due to the presence of a single insurance payer. Given competing economic and political priorities that can impede the adoption of such policies, pursuing other potential ways to increase SET use is thus critical.

In only 11 of 27 EU countries was public access to data from individual clinics available in Kupka et al. Increasing public access to individual clinic data, and requiring reporting by clinics may therefore be helpful as well. In many countries, current reporting requirements disincentivize providers from transferring fewer embryos.

For instance, between and , the proportion of cycles that US IVF programmess failed to report increased from 3. Of these clinics, 3. The researchers analysing these data therefore found lessened transparency of reporting, and recommended prospective reporting of each initiated cycle by all clinics. Williams et al. Proponents of SET have emphasized the need for increased insurance coverage for assisted reproductive technology and improved education of patients Kissin et al.

Such alterations in reporting requirements will likely encounter resistance Gleicher, , but the present data add further support to efforts to expand reporting in these ways, highlighting how current reporting is limited, fuels misunderstanding and may be self-serving. Moreover, SART, for instance, currently cautions viewers of its reports that the data should not be used for comparing clinics. These findings also underscore needs to enhance professional, patient and public education about the risks of twins and other multiple births.

Yet many patients will still then end up with twins, while other prospective parents remain childless. Clinicians, especially if they are transferring extra embryos, should proceed with care, and rigorously ensure that patients fully grasp these risks.

The data also suggest a need to develop decision-making tools for patients, to help them grasp the relative risks, benefits and costs to them. Given ongoing media reports of celebrities and others having twins, education of journalists about the risks involved can also be beneficial. These data suggest several avenues for future research. The present data underscore the need to examine exactly what risks providers convey to patients; how much time clinicians spend doing so, and how effectively; how often patients seeking DET minimize the risks; how often providers using DET feel the risk data about twins are insufficiently compelling; what they feel the risks in fact are; what odds they feel would be compelling enough to switch to SET; and how they weigh these risks against other considerations.

Some providers have begun to use SET with single blastocyst transfer after pre-implantation genetic screening. However, data are lacking on how frequently providers in various countries are adopting this practice. Moreover, for the reasons described here, many patients will presumably still prefer to have twins, rather than singletons.

These data have several potential limitations. The sample size is sufficient for qualitative research designed to elucidate the issues and themes that emerge; however, future studies using larger samples are needed to analyse statistically how various groups may differ e. However, future studies can measure the rates at which these phenomena occur in larger samples in multiple countries. As the first data to probe these issues, inter-rater reliability was not calculated statistically; however, future studies, using larger samples can do so.

Moreover, these data appear to have a certain face validity, illuminating challenges that many patients and providers confront.

These interviewees worked in the USA; yet extensive literature searches indicate a lack of data addressing these questions in other countries, and arguably, similar challenges and tensions exist in many other countries as well.

These interviews were also conducted at one point in time. Yet, enrolment of physicians and other providers is also difficult. Healthcare providers are increasingly difficult to recruit for surveys, as indicated by response rates declining over time Cho et al.

In summary, these data, the first to explore several critical aspects of decisions concerning how many embryos physicians should transfer following IVF, have vital implications for future practice, research, policy and education. He has conducted research on several ethical and policy issues concerning assisted reproductive technology, genetics and other areas; and has authored or co-authored over peer-reviewed scientific articles and eight books.

He has received several awards for his work, including fellowships from the Guggenheim Foundation, Rockefeller Foundation and others. Declaration: The author reports no financial or commercial conflicts of interest. What challenges do you face in your work as an assisted reproductive technology provider? Have you faced challenges concerning the number of embryos to transfer to a patient? If so, when? However, ASRM does not ask all patients receive single-embryo transfer because in many cases multiple-embryo transfer has benefits.

When a patient elects to transfer multiple embryos in a transfer, there is a higher likelihood that transfer will lead to a live birth than if she has one embryo transferred.

This can shorten the time often by a few months and lower cost often by a few thousand dollars needed to have a child. Thus neither approach reliably lowers the number of cycles needed to have a child. When women include more embryos in a transfer, the likelihood that transfer will work increases. Another important caveat is that it appears when a single, PGT-approved embryo is transferred, the live birth rates per transfer are similar to that when two, non-PGT tested embryos are transferred.

As you'll see below, it's best practice to transfer only one PGT-approved embryo per transfer. All the same, the comparable Live Birth Rates are striking, especially in context of the lower twin rate and lower percentage of deliveries that end up in the NICU.

Patients who elect to transfer a single embryo have additional embryos to transfer if the first transfer fails. And yes, the twin rate was far lower. There can be many interpretations of this data.

Our interpretation is that when there is a finite number of available embryos e. Many single-embryo transfers fail and another question is whether on the next transfer one, or multiple, embryos should be transferred. Unfortunately there is little data on the subject and you should confer with your doctor if they have a strategy for this circumstance and the logic or data to support it.

For myriad reasons, your clinic may insist upon transferring embryos that have only been grown to Day 3 , not to Day 5 or 6. Day 3 embryos are less developed, and generally speaking, have a lower-likelihood to lead to a live birth and thus multiple births.

The American Society of Reproductive Medicine ASRM believes transferring multiple Day 3 embryos is of lower risk from a multiple-birth perspective than transferring multiple Day 5 or 6 embryos. Thus, keep in mind the nature of the embryos you are transferring when determining how many to transfer. Should you, or your doctor, choose to exceed the suggested limit, we urge you to be clear with your reasoning and consider the additional medical risk and financial risk, which we cover next you are taking.