How many do I put back?

On the INCIID bulletin board I am often asked to comment on how many embryos to transfer. It amazes me that anyone would value the opinion of the cyber-RE over their actual RE. This decision is too important to just gloss over and give it only a passing thought. Transfer too many and we have to deal with twins…or worse. Transfer too few and the next thing you know the patient is requesting records to zip off to the RE down the street. How easy things would be if the government mandated single embryo transfer…but although that works in countries with comprehensive government supported healthcare, it seems unlikely to occur in the USA. I am not a big fan of twins and would be only too happy to never have another twin pregnancy come out of our clinic, but when patients reach the point of embryo transfer they are willing to risk a lot to get that positive beta…even a multiple pregnancy.

So here is today’s Question of the Day from the book 100 Questions and Answers about Infertility that was written on my laptop that is currently sitting in a pawn shop in PG County waiting for the police to recover it (turns out you actually cannot buy stolen good legally…even if you get a receipt!).

54. How do I decide how many embryos to transfer?

Determining the number of embryos to transfer in an IVF cycle is a crucial decision that requires careful discussion between the patient / couple and the physician. The goal of every
treatment cycle should be the delivery of a full-term, healthy, singleton baby. Although transferring more than one embryo will increase the pregnancy rate, at some point transferring additional embryos merely serves to increase the multiple pregnancy rate without altering the overall pregnancy rate.

Several European countries have eliminated all discussion of how many embryos to transfer by mandating that all patients undergo only single-embryo transfers. Whereas elective (or mandatory) single-embryo transfer has been promoted heavily throughout Europe, it has not yet received widespread acceptance in the United States. One of the major disadvantages of single-embryo transfer is that it leads to a decreased IVF pregnancy rate from the fresh cycle. Proponents of single-embryo transfer claim that the potential reduction in the overall pregnancy rate is well worth the marked reduction in the twin pregnancy rate.

Twin pregnancies can be problematic because they are associated with higher rates of preterm labor and preterm delivery. Some couples, however, may desire twins or at least regard them as a neutral outcome. This view is especially prevalent among patients who are paying for the treatment themselves (rather than it being covered by insurance) and regard twins as a “two for the price of one” outcome. As noted in Question 53, the greatest risk to the health of children following IVF is the complications related to prematurity associated with multiple births. Despite the risks associated with multiple pregnancy, couples still tell us every day that they would “love to have twins.”

The ASRM has published guidelines for making the decision of how many embryos to transfer (see Table 4). Patients who fall into the excellent prognosis category should transfer only one or two embryos, whereas those with an exceedingly poor prognosis—because of the woman’s age or multiple failed IVFs, for example—may undergo embryo transfer of five or more embryos. The most problematic decisions concern those patients who fall between these two extremes. Couples who are paying out of pocket for IVF will often pressure their RE to be more aggressive in terms of the number of embryos transferred. Of course, the expense involved in caring for premature infants is many times greater than the cost of all of the fertility procedures used to initiate those pregnancies.

The financial costs are merely one part of the picture, as caring for patients with preterm labor or premature infants is also associated with a variety of emotional, psychological, and physical costs. If multiple pregnancies occur, a multifetal selective reduction procedure can be considered. This procedure is performed at approximately 10 weeks of pregnancy and involves injecting a salt solution into one or more of the gestational sacs. The overall pregnancy loss rate following this procedure is usually less than 5%. In patients who wish to avoid a triplet gestation (but who will not consider selective reduction), it is best to limit the number of embryos transferred to one or two.