It is a simple problem without a simple solution:

• Single embryo transfer success rates are lower than when 2 are transferred
• Couples want a baby (or twins) ASAP, and they don’t want to pay for multiple IVF attempts
• They fear failing to become pregnant more than they fear the risks from a twin pregnancy

This dilemma is often due to the fact that the large majority of patients in the US are self-pay for all costs associated with IVF. In the US the average cost of IVF is about $10,000 (for monitoring and procedures) and about $3500 for the medications. With these high costs, couples will often push for at least two embryos for transfer – even if the female partner is young.

Guidelines from the American Society for Reproductive Medicine (ASRM) were established many years ago for the maximum number of embryos to transfer (see table below). These guidelines take into consideration the age of the female and other criteria that help predict risks for having a multiple pregnancy.

ASRM guidelines have been modified over the years – with the recommended maximum number for transfer being reduced each time. I believe that the ASRM guidelines on the maximum number of embryos for transfer are excellent.

See PDF document with ASRM transfer guidelines

Currently the guidelines suggest a maximum of 1 to 2 embryos to be transferred for a female partner under 35 years old if the transfer is being done on day 2 or 3 – and a maximum of one embryo to be transferred for that age group if the transfer is being done on day 5. These maximum numbers are for patients considered to have a “favorable prognosis”.

When female age is over 35, the maximum number of embryos allowed increases. Everyone knows about the Octomom mess – a situation where a physician went way overboard – with a patient that was just as far out there…

Favorable prognosis would be couples having their first IVF attempt, good embryo morphology scoring, left over embryos available for freezing, or a previous successful IVF cycle. The guidelines allow transfer of additional embryos for patients that have a less favorable prognosis.

When single embryo transfer is performed, blastocyst embryo transfer on day 5 after fertilization appears to be the best method. Embryos that have continued developing normally to the 5th day have a higher chance of implanting than do day 3 embryos (on the average).

• Learn more about blastocyst transfer and multiple pregnancies
• Learn about day 5 blastocyst embryo grading

A common dilemma that comes up regarding the number of embryos to transfer is seen in couples that have had an unsuccessful IVF cycle. They come back to talk to their doctor about what to do in order to have a successful outcome after IVF has failed. If these patients have transferred 2 embryos with the failed cycle – it is fairly common that they ask – “can we transfer 3 if we try IVF again at your clinic?”

If the female partner is less than 35 years old this would be a violation of the guidelines which suggest that the maximum number to transfer should be 2 – regardless of whether it is being done on day 3 or day 5 – even in the “less favorable” prognosis situations.

So if the infertility specialist says that it would not be a good idea to transfer more than 2 embryos, sometimes the patient responds with; “My friend went to another clinic and she’s younger than me. They transferred 3 embryos and she has beautiful baby now. So why won’t you let us transfer 3 embryos if we understand and accept the risks?”

The consumer of fertility services may be putting their entire life savings on the line with this treatment. Because of that, they sometimes feel strongly that they should be able to take the risk of a multiple pregnancy if they choose to. When it comes to deciding on how many embryos to transfer – how much say should the couple have, and how much say should the doctor have?

The reality of a competitive marketplace is that patients will take their money to the clinic they believe will serve them best. Sometimes that will be a clinic that is willing to transfer more embryos because they’re afraid that if they are limited to 2 (for example) that they will fail and never have a family because that doctor was too conservative.

Some IVF centers operate in a geographic area that does not have much competition from other clinics. I think it is much easier to set strict guidelines on the maximum number of embryos that can be transferred in such an environment – as opposed to an environment such as the Chicago area (and many others) where there are 15 or more IVF programs patients can choose from.

In some countries in Europe there are laws restricting the maximum number of embryos that can be transferred with in vitro fertilization. In the US there are not laws like this. One difference in those European countries is that usually the government is paying for IVF. If the government pays for it, then perhaps it is reasonable for them to restrict the maximum number of embryos for transfer. Apparently, those governments believe it is important to put a limit on the number of embryos transferred in order to minimize multiple pregnancies and the complications that can occur.

However when the infertile couple is paying the ticket, it may not be reasonable for government to regulate the number of embryos transferred. There are about 14 states in the US that have some level of health insurance mandate for infertility treatment coverage. The rest of the states in the US have no mandate – and there generally is very little health insurance coverage for fertility treatments in those states.

In Illinois, some couples have insurance coverage for IVF and many do not – even though there is officially a mandate for health insurance to cover IVF on the books. The state has allowed loopholes – so many companies do not provide the coverage that was written into the law.

I find that couples with good health insurance coverage for in vitro fertilization tend to be more conservative on average with the number of embryos that they ask to have transferred as compared to patients that are paying completely out of pocket. Couples paying on their own tend to be more aggressive and transfer higher numbers of embryos. This is not surprising. Patients often say; “We want to try to get more bang for our buck”.

Fertility treatment costs can be substantial, particularly with the too common scenario where the health insurance does not cover any of the costs.

Pros of single embryo transfer – SET:

• Greatly reduces risks for having multiple pregnancy (in rare cases the embryo splits and there are identical twins)
• Single pregnancies have lower risks for complications such as premature birth, etc.

Cons of single embryo transfer:

• Single embryo transfer success rates are lower than when more are transferred (from 1 “fresh cycle”)
• Therefore, potentially higher financial costs for continued treatments

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

Mail | Web | Google+ | More Posts

• In June of 2008, Nadya Suleman was a single, unemployed mother of 6 children
• According to reports, she was receiving some “public assistance”
• All six of her children were reportedly conceived through in vitro fertilization
• All 6 kids were under 7 years old, including 2 year old twins

Then, she does IVF again

• In June of 2008, her IVF doctor transferred 6 frozen-thawed embryos to her uterus.
• Apparently, all six embryos survived – and 2 split into identical twins – so she ended up with eight fetuses growing in her uterus.
• Nadya declined having a fetal reduction procedure. Reduction can be done to selectively reduce the number of fetuses.
• The vast majority octuplet pregnancies would be expected to result in death of all fetuses after a severely premature birth.
• In her case the pregnancy progressed to viability. All 8 babies were born (prematurely) in January of 2009.
• This is apparently only the second living set of octuplets ever born in the United States.

Public debate rages

• Is she a fit mother?
• Should the fertility specialist have been willing to treat her at all?
• How many embryos should the doctor have transferred to her uterus?
• Should a physician that transfers that many embryos to a 33-year-old be sanctioned – or even lose his medical license?
• Why doesn’t the government pass laws to control fertility doctors?

Violation of guidelines of the American Society for Reproductive Medicine, ASRM

Her fertility physician has been identified as Dr. Michael Kamrava who practices in Beverly Hills California. The American Society for Reproductive Medicine is reportedly investigating Dr. Kamrava related to violating its guidelines on the maximum number of embryos to transfer. Although there are guidelines, there are not any laws in the US regulating the maximum number of embryos transferred.

The ASRM guidelines in place when Nadya Suleman had her IVF procedure said that the maximum number of embryos to be transferred to a woman under 35 years of age should be 1 or 2 depending on the specific medical issues. There was some wiggle room in the guidelines. Since they were frozen embryos, a max of 3 for transfer might also have been considered appropriate.

Comments from a fertility specialist

• Physicians, including fertility specialists cannot play god and judge who will be a “fit enough parent” to have fertility treatments.
• Patients undergoing fertility treatment desperately want children and can face huge financial burdens.

The costs of IVF treatment are substantial and although sometimes medical insurance in the US will cover fertility treatment and IVF, more often it does not. Therefore, patients often pressure fertility specialists to transfer more embryos with the hope that they will be more likely to be pregnant.

The ASRM guidelines on the maximum to transfer are appropriate. However, patients are sometimes unhappy about limitations on the number of embryos for transfer – particularly couples with financial difficulties due to IVF costs. For example, some couples will put a second mortgage on their house, max out credit cards, and borrow from parents.

As IVF success rates have increased over the years, the average number of embryos transferred to the uterus has declined. Some cases are now even having single embryo transfers (SET) by choice. This has become a more viable option with utilization of blastocyst embryo transfer which can result in better embryo quality and more control of multiple pregnancy risk.

However, although I have substantially increased the time spent discussing risks of multiple births (including twins), our rate of single embryo transfer is still low. Patients rarely accept single embryo transfer – even after hearing about increased risks with twins. Infertile couples fear failing to become pregnant at all more than they fear the risks to the babies from multiple pregnancies.

When will there be laws regulating the number of IVF embryos that can be transferred?

I think it unlikely that our government will pass laws regulating how many embryos can be transferred unless they also mandate insurance coverage for IVF treatments in order to relieve the financial burden for couples with fertility problems.

Conclusions

• The ASRM guidelines on the maximum number for transfer should be closely followed (whenever possible)
• In a case such as this, a maximum of 2 embryos should be transferred
• 6 embryos should never be transferred to a 33 year old woman – no matter what she says about accepting risks.

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

Mail | Web | Google+ | More Posts