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Fertility, IVF and Egg Donation
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
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
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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