How Many Embryos Should You Transfer? eSET and In Vitro Fertilization
Medical Contribution By Dr. Robert Stillman
Fertility treatments can be complex and often require patients to make many decisions along the way. One of the toughest questions for patients undergoing IVF & Donor Egg treatment is "how many embryos should I transfer?" This is an important question and we understand the reasons why patients might struggle for the right answer.
For starters, some patients might actually want twins! The idea of building a family with only one round of treatment sounds enticing. Another reason is that patients want to optimize their chances of success. Nobody wants a cycle to fail and transferring more than one embryo seems like the logical way to increase the chance of success. Lastly, fertility treatment is expensive and the idea of having to find the funds to repeat a treatment cycle can seem overwhelming.
The goal at Shady Grove Fertility is to help patients achieve a pregnancy and deliver one healthy baby at a time. The medical team at Shady Grove Fertility has taken on the mission of educating patients about the risks that can occur with a multiple pregnancy and encouraging the use of elective Single Embryo Transfer (eSET) in patients with a good prognosis for pregnancy. The progressive adoption of eSET over the past few years has led to a substantial decrease in the rates of multiple pregnancy among women using their own eggs as well as women using donor eggs without any decrease in pregnancy rates.
What is elective single embryo transfer (eSET)?
ESET is elective Single Embryo Transfer, a process by which one good quality blastocyst (or day 5) embryo is transferred back to the patient. The embryos that survive to the blastocyst stage of development are more likely to be strong and healthy. Blastocyst embryos have a much higher chance of implanting than 4 cell (day 2) or 8 cell (day 3) embryos, therefore fewer embryos are required to achieve a pregnancy.
"When you choose eSET, you are giving yourself the best possible chance for a safe pregnancy and a healthy baby," explains Robert Stillman, MD, Shady Grove Fertility’s Medical Director. "Now we can confidently tell an increasing proportion of our patients that they won't be sacrificing their chances of pregnancy in order to achieve that peace of mind."
And it’s catching on. Since its inception in 2002, the number of patients choosing elective Single Embryo Transfers has increased each year. In 2010, nearly 20% of all IVF patients and 41% of donor egg patients elected to transfer a single embryo which resulted in a 61% clinical pregnancy rate for IVF and 62% pregnancy rate for donor egg.
Patients are educated about their options for embryo transfer and eSET throughout their cycle. When a patient arrives at Shady Grove Fertility for their embryo transfer, they will be prepared for a discussion with the doctor regarding how many embryos they want to transfer. Together, they will review data such as the chart below which shows how out of 678 IVF eSET transfers, 98.3% resulted in a singleton pregnancy and only 1.7% resulted in a twin pregnancy (since any embryo can split to form an identical twin). There were zero (0) triplet pregnancies.
When two blastocyst embryos were transferred (Double Embryo Transfer) in 1,038 IVF cases, 54.8% resulted in singleton pregnancies and 42.5% resulted in twin pregnancies and an additional 2.7% resulted in triplet pregnancies! Most striking is that the pregnancy rate per embryo transfer in both cases remained the same at about 61%. The results are very similar in donor egg cases as well at 62% - 64%.
Is eSET right for me?
One size does not fit all for the number of embryos transferred. All treatment at Shady Grove Fertility is an individualized process designed to give the best outcome for each couple.
“Not everyone’s embryos will reach a day 5 blastocyst stage,” explains Dr. Stillman. In these cases, a day 3 transfer may occur. A number of these patients have two (or rarely more) embryos recommended for transfer. About half of the embryo transfers at Shady Grove Fertility are currently day 3 and half day 5 or day 6.
Many patients undergoing a day 3 embryo transfer still have very good pregnancy success rates but may end up transferring more than one embryo. If a patient is able to proceed with a day 5 transfer, it may be recommended to transfer only one embryo to reduce the high likelihood of a multiple pregnancy.
Reducing risks of in vitro fertilization (IVF)
While some couples needing fertility treatment may see it as a way to increase the chances of having more than one child, there are risks for the mother associated with a multiple pregnancy.
"We don't just want to help you get pregnant, we want to help you have a healthy baby that becomes a healthy child," says Dr. Stillman. "In our field, as well as in obstetrics and pediatrics, there is a great awareness of the risks inherent in a multiple pregnancy - even twins - for both the mother and baby but often patients are not aware of these risks."
Since 2005, when the eSET initiative became commonplace at Shady Grove Fertility, pregnancy rates continue to rise while the rate of twins continues to decline.
SGFC Financial Programs Support Single Embryo Transfers
It has been shown that patients who have insurance coverage for IVF or Donor Egg transfer fewer embryos per cycle since their fears of being unsuccessful and having to pay for another cycle are lessened. When insurance is not available, Shady Grove Fertility's financial programs can help minimize the psychological and economic pressures on patients.
For instance, in the Shared Risk 100% Refund Plan, for one fixed fee, patients may attempt up to six fresh cycles of IVF or Donor Egg. If the treatments do not result in a delivery, the patients will receive a 100% refund of the fee. Since Shared Risk also includes the cost for cryopreservation of embryos and any subsequent Frozen Embryo Transfer cycles, patients in the Shared Risk Program are more likely to transfer a single embryo because all is not riding on the one cycle. Armed with the knowledge that additional cycles may be attempted with no additional cost relieves pressure from the "number of embryos to transfer" decision.
Another newer financial option, the Multi-Cycle Discount Program, provides patients with two fresh IVF cycles, cryopreservation and storage, and unlimited Frozen Embryo Transfers for one flat fee. Much like Shared Risk, the Multi-Cycle program minimizes a patient’s financial risk by fixing the cost of treatment and offering more than one chance at a successful pregnancy for a discounted rate, thus providing additional confidence in transferring just one embryo.
And for those not in the Shared Risk or Multi-Cycle program, Shady Grove Fertility offers a discount on cryopreservation of embryos if they choose eSET.
"Even insurance plans that don't cover the costs of fertility treatment are starting to understand the benefits of eSET," says Dr. Stillman. "They have recognized the fact that they pay more for the maternal, neonatal intensive, and long-term care complications of affected infants from multiple pregnancies than they would pay for the costs of infertility therapy."
He adds, "Even though some companies won't cover the full IVF cycle yet, some have begun programs that offer to pay for a subsequent Frozen Embryo Transfer cycle if the patient chooses eSET."
Recent IVF Success Rates Support the Use of eSET
Based on our most recent eSET data, patients can feel confident knowing that pregnancy rates will not be compromised if eSET is recommended. "We are proud that we have had such a pronounced increase in the number of patients choosing eSET and that we have been able to keep the pregnancy rates so high. We know this means more safe pregnancies and more healthy babies," Dr. Stillman says.