Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction

Abstract

Much recent progress has been made by assisted reproductive technology (ART) professionals toward minimizing the incidence of multiple pregnancy following ART treatment. While a healthy singleton birth is widely considered to be the ideal outcome of such treatment, a vocal minority continues a campaign to advocate the benefits of multiple embryo transfer as treatment and twin pregnancy as outcome for most ART patients. Proponents of twinning argue four points: that patients prefer twins, that multiple embryo transfer maximizes success rates, that the costs per infant are lower with twins and that one twin pregnancy and birth is associated with no higher risk than two consecutive singleton pregnancies and births. We find fault with the reasoning and data behind each of these tenets. First, we respect the principle of patient autonomy to choose the number of embryos for transfer but counter that it has been shown that better patient education reduces their desire for twins. In addition, reasonable and evidentially supported limits may be placed on autonomy in exchange for public or private insurance coverage for ART treatment, and counterbalancing ethical principles to autonomy exist, especially beneficence (doing good) and non-maleficence (doing no harm). Second, comparisons between success rates following single-embryo transfer (SET) and double-embryo transfers favor double-embryo transfers only when embryo utilization is not comparable; cumulative pregnancy and birth rates that take into account utilization of cryopreserved embryos (and the additional cryopreserved embryo available with single fresh embryo transfer) consistently demonstrate no advantage to double-embryo transfer. Third, while comparisons of costs are system dependent and not easy to assess, several independent studies all suggest that short-term costs per child (through the neonatal period alone) are lower with transfers of one rather than two embryos. And, finally, abundant evidence conclusively demonstrates that the risks to both mother and especially to children are substantially greater with one twin birth compared with two singleton births. Thus, the arguments used by some to promote multiple embryo transfer and twinning are not supported by the facts. They should not detract from efforts to further promote SET and thus reduce ART-associated multiple pregnancy and its inherent risks.

Embryo quality is the main factor affecting cumulative live birth rate after elective single embryo transfer in fresh stimulation cycles

“…The rate is highest in Finland (45.1%) [2]. Previous studies have confirmed that the cumulative pregnancy and live birth rates (cLBR) evaluating the outcome of ovum pick-up (OPU) and all following FETs indicate the real efficiency of ART and should be used when compared with other transfer policies [3,4]. eSET, combined with an effective cryopreservation programme, has been shown to result in a high cumulative pregnancy rate (44-62%) per oocyte retrieval [5][6][7][8].…”

“One for Sorrow, Two for Joy?”: American embryo transfer guideline recommendations, practices, and outcomes for gestational surrogate patients

“…Multiple-birth pregnancies often produce pregnancy and delivery complications [33][34][35], require longer post-delivery hospital stays [36], and may contribute to family adjustment problems [37].…”

“…[107] Privileging twin IVF births has long been recognized as a positive ART outcome by patients and clinicians [37,[77][78][79][80]. The risks posed by a twin pregnancy compared to two singleton births are contested [35,108,109]. The Söderström-Anttila et al's systematic review of surrogate pregnancy outcomes concludes that surrogates experience similar levels of hypertensive disorders and placental complications as other IVF patients even though they are likely to be younger [95].…”

Double trouble: Should double embryo transfer be banned?

“…Clearly, it is vital for women undergoing IVF to be aware of the relevant risks and benefits for themselves as well as the potential harms to others [42]. One obvious and uncontroversial policy would be to adequately educate and inform women about these risks and benefits.…”

“…Robert Stillman, writing recently in defense of SET, noted 'The potential children, those at greatest risk of the complications associated with multiple pregnancy, are unable to advocate for themselves. It is the professional and ethical responsibility of the physician-led clinical team … to advocate on their behalf' [42].…”