Is a Blanket Elective Single Embryo Transfer Policy Defensible?

Abstract

For the purpose of reducing maternal and neonatal morbidity, elective single transfer (eSET) in in vitro fertilization (IVF) was first proposed in 1999. The purpose of this review is to summarize recent oral debate between a proponent and an opponent of expanded eSET utilization in an attempt to determine whether a blanket eSET policy, as is increasingly considered, is defensible. While eSET is preferable when possible, and agreed upon by provider and patient, selective double embryo transfer (DET) must be seriously entertained if deemed more appropriate or is desired by the patient. Patient autonomy, let alone prolonged infertility and advancing age, demand nothing less. Importantly, IVF-generated twins represent only 15.7% of the national twin birth rate in the United States. Non-IVF fertility treatments have been identified as the main cause of all multiple births for quite some time. However, educational and regulatory efforts over the last decade, paradoxically, have exclusively only been directed at the practice of IVF, although IVF patient populations are rapidly aging. It is difficult to understand why non-IVF fertility treatments, usually applied to younger women, have so far escaped attention. This debate on eSET utilization in association with IVF may contribute to a redirection of priorities.

Transfer of 2 Embryos Using a Double-Embryo Transfer Protocol Versus 2 Sequential Single-Embryo Transfers: The Impact on Multiple Pregnancy

“…Despite discussions of the advantages and pitfalls of eSET in the literature, 24,29,30 we propose, based on our findings, that the eSET policy should be promoted for couples with a good prognosis. The eSET policy maintains the accumulated clinical pregnancy rates, avoids multiple pregnancies, and consequently avoids the maternal and neonatal complications and indirect costs of treatment such as obstetrics, in which spending is reduced.…”

“…27,28 Finally, the indirect cost of IVF treatment considering the obstetric outcomes could not be evaluated in this study because the patients who became pregnant were not followed in the IVF clinic, and thus, data could not be obtained. Despite discussions of the advantages and pitfalls of eSET in the literature, 24,29,30 we propose, based on our findings, that the eSET policy should be promoted for couples with a good prognosis. The eSET policy maintains the accumulated clinical pregnancy rates, avoids multiple pregnancies, and consequently avoids the maternal and neonatal complications and indirect costs of treatment such as obstetrics, in which spending is reduced.…”

“…This difference can be attributed to the fact that the decision-making process regarding the number of embryos transferred in the United States and LA is the shared responsibility of the couple and their doctor. 8 While eSET is preferable when possible and agreed upon by the doctor and couple, the transfer of a higher number of embryos is entertained if desired by the patient, 24 and the DET remains the most common practice worldwide.…”

Worldwide decline of IVF birth rates and its probable causes

“…Recently extensively reviewed (Adashi and Gleicher, 2017), we here do not intend to address controversies surrounding eSET. That eSET, in comparison to double embryo transfer, reduces clinical pregnancy rates is well established (McLernon et al ., 2010).…”

Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain

“…This is reflected in the statistical report of 2017 of the Spanish Society of Fertility on assisted reproductive technologies [ 20 ]; 60.3% of the transfers were of two embryos that, in 23.5%, resulted in multiple gestation, although since 2015, the embryo transfer policy is to increase the number of unique transfers. This is largely explained by the pressure that health professionals receive on behalf of patients requesting double transfers as they are considered more profitable in terms of their socioeconomic and work context [ 21 , 22 ].…”