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Fertility, IVF and Egg Donation
by Dr. Mohamad Irani on Apr.02, 2019, under Chromosomal Abnormalities in Eggs, Embryo implantation, IVF success rates, Miscarriage, Number of IVF Embryos to Transfer, Preimplantation Genetic Screening, Single Embryo Transfer
It has been an exciting time for the field of Reproductive Medicine, which has witnessed major advances over the last three decades. For instance, the recent evolution in Preimplantation Genetic Testing for aneuploidy (PGT-A, formerly called Preimplantation Genetic Screening [PGS]), has provided an important tool to enhance embryo selection and subsequently elective single embryo transfer (eSET).
Advancements of Preimplantation Genetic Testing for Aneuploidy (PGT-A)
Embryo biopsy on Day 3 has been suggested to adversely affect the implantation potential of the embryo. Hence, the majority of IVF laboratories have switched to blastocyst biopsy on Day 5 or 6. Evidence supports that the improvements in the biopsy technique, and the removal of approximately 4-5 cells from the trophectoderm (precursors to the placenta) on Day 5, when performed by expert embryologists, may not negatively impact the reproductive potential of the embryo.
Furthermore, enhancements to genetic testing, which currently analyzes all chromosomes compared to the initial platform that analyzed only a limited number of chromosomes, have significantly improved the accuracy of the test.
Clinical Benefits of PGT-A
This technology has significantly decreased miscarriage rates and increased the implantation rate per transfer. The high implantation potential of embryos determined to be euploid by PGT-A has contributed to the increased adoption of elective single embryo transfer, (eSET). This has subsequently reduced the incidence of multiple gestations, and all associated maternal and fetal complications.
Despite its critical advantages, PGT-A comes with some risks and may not be the best option for all patients; therefore, personalization of care is key to success. All patients should understand the pros and cons of each procedure in order to make informed decisions.
In my practice, I help patients understand the advanced reproductive technologies that offer them their best chance of achieving a healthy baby.
Why do we recommend elective single embryo transfer?
By: Michelle Catenacci, MD
Many couples that come to us have had a long and difficult journey with their infertility. When discussing treatment options, we discuss the risk of twins or high order multiples (triplets or more) that exist with the different available fertility treatment options.
However, to many that are trying to conceive, multiples are thought of as a blessing and not a risk. “The more the better”, and, “Two for the price of one”, are common replies that we get from couples when discussing twins. It can be difficult to convey that there is more risk involved with twins compared to a singleton pregnancy and that it is safest for both mom and baby to have one baby at a time.
Recent changes in recommendations
Recently, the Society of Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) issued new guidelines and recommendations for the number of embryos to transfer in order to encourage physicians to increase use of elective single embryo transfer (eSET).
With an elective single embryo transfer, a single embryo is selected from a larger group of embryos to be transferred. Excess embryos can be cryopreserved for future attempts at pregnancy. In general, it is recommended that patients with a high chance for success should strongly consider having eSET. Those patients include younger women (37 and under), women with normal embryos after preimplantation genetic testing for aneuploidy (PGT-A), and women using donor eggs.
Transferring one embryo at a time will not decrease the “cumulative” pregnancy rates for that IVF cycle – when looking at overall pregnancy chances with both the fresh transfer cycle and also any subsequent frozen transfer cycles. Single embryo transfer will, however, significantly decrease the overall risk of twins. For example, at our clinic, we see approximately 65% live birth with eSET for embryos that have been screened for aneuploidy using PGS (also called PGT-A). The risk of identical twins is under 1% in this situation. If we transfer two embryos, the pregnancy rate is about 90%, but the rate of twins is 65% with a 1% risk of triplets. At AFCC we try to encourage patients to transfer just one PGT-A embryo in hopes of helping them have a healthier single pregnancy.
There are increased rates of complications with twin pregnancies. Some of these risks are for the mother herself. Maternal complications that are increased in twin or higher order multiples include preeclampsia, gestational diabetes, worsening anemia and severe nausea and vomiting in early pregnancy. There is also an increased risk of abnormal placental attachment which can cause bleeding and other complications during pregnancy or at delivery.
Women pregnant with multiples are more likely to have a cesarean section for delivery. For the babies, there are significantly increased rates of preterm labor and delivery, small for gestational age babies and growth restriction. At times delivery will occur near or just before the gestational age of possible viability leading to death or long-term complications for one or both twins. The risk of cerebral palsy in twins is more than four times higher compared to a singletons. Twin babies are also more likely to be stillborn or die in the first month after birth as compared to single babies.
Our goal is to provide safe and high-quality care to our patients. When we recommend eSET we are striving to give the best possible outcome for the patient and their unborn child. When planning to move forward with IVF or egg donation it is important to know the current practices the fertility program you are working with, and their overall success and experience with eSET. For patients that have a high chance of success, transfer of a single embryo should be seriously considered even though the initial pregnancy rate from transferring two embryos is higher than if we transfer one.
Single embryo transfer is an up-and-coming more commonly utilized procedure in the field of in vitro fertilization in recent years. There has been a push for several years to reduce the number of multiple pregnancies by reducing the number of embryos transferred with IVF. However, the push to do elective single embryo transfer is opposed by most couples that do IVF in the US.
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.
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
Welcome to the
Advanced Fertility Center of Chicago
Richard Sherbahn, MD is a Board Certified Reproductive Endocrinology and Infertility specialist.
Dr. Sherbahn founded the Advanced Fertility Center of Chicago in 1997.
He will post regularly about fertility issues.
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