Blastocyst how many to transfer

Who makes those decisions? Doctors used to make all the calls: this is the way we do it. Patients were accepting. Lately, it seems that the patient gets whatever she wants. Healthcare costs are increasing hugely because of the attitude: we can do it.

We get paid to do it. But no one asks should we do it. These attitudes may also be changing over time. Physicians face questions of whether they should make these decisions on their own or in conjunction with other professionals. Providers differ, too, in whether they consult with a Quality Assurance QA or other type of committee.

A physician in a private practice said:. If anything looks exceptional, we bring it to QA for all of us to discuss. Our patients sign a consent form about how many embryos to transfer.

We treat our patients. We are very proud of American pregnancy rates, but we need to get our twin and triplet rates down. The type of clinic can shape these decision-making processes.

Providers who work within academic medical contexts or hospitals can face additional implicit and explicit pressures:. My hospital had a meeting of the medical executive directors with people, and they had me talk with a maternal-fetal specialist about the impact of IVF on the hospital. I thought it was going to be a lynching.

From a cost point of view, you want to have singletons because the complications otherwise are difficult. I have patients who lose twins at 23 weeks.

Some complicated twin pregnancies are in bed for six months. I have competitors in my region with pretty terrible records: triplets, quads. Hospital environments, in which physicians periodically have to present their work to others outside assisted reproductive technology, can thus act as a form of oversight or social control. The fact that relatively high rates of both twin and higher-order multiple births continue poses critical questions concerning the need for possible additional guidelines, or for regulations.

Competing potential risks and benefits of such additional policies need to be weighed against each other. These clinicians opposed rules rather than guidelines , or stricter mandates that would diminish their autonomy — stressing that clinical judgment can play an important role in these decisions. Yet even though providers may not all follow certain guidelines, they tended to oppose more stringent approaches, feeling that current guidelines, rather than tighter regulations, suffice:.

The question becomes: What exactly is a guideline? Should doctors be punished for not adhering? Should there be rules, rather than guidelines? Yet, while preferring suggested guidelines — rather than regulations — this doctor nonetheless queries their scope, meaning and implications. A broad continuum exists of levels and types of guidelines, based on several characteristics e.

Providers may feel that changes to the reporting policies are needed, but will be elusive due to the complex federal bureaucratic structures and processes involved. While changes in reporting requirements may have helped decrease the rates of births of three or more infants at a time, reduction in the frequency of twins may be harder:.

Because that has to be the incentive. They are very interested, but there is that conflict. They have to push it through. Physicians may therefore also be somewhat ambivalent about maximizing individual patient versus broader public health benefits. These clinicians generally favour increasing professional self-regulatory mechanisms first, before initiating government regulations:. SART wants to set up guidelines for very stringent monitoring of clinic performance, and ask clinics with poor performance to change, taking steps from there.

It should start with self-regulation. There have been improvements over time. The threat of government regulation, if models of professional self-regulation fail, could potentially enhance adherence, though it has not yet proven sufficient. To reduce the incidences of twins and other multiple births, other government policies, concerning insurance coverage, may also then be needed:.

I see the result of twins and triplets, and the maternal complications for ovarian stimulation — people hospitalized during an IVF cycle.

But patients and doctors are willing to do it, and try to transfer more, and not be so cautious, because the patient is paying for it.

These data, the first to explore several critical aspects of how providers view and make decisions about how many embryos to transfer, highlight how professional recommendations and guidelines in this area can contain flexibility and ambiguities, and lack enforcement, raising challenges, tensions and dilemmas that providers and patients therefore confront.

Though the previous prior literature has focused largely on limitations in insurance coverage as contributing to high rates of twins, the present data suggest how other, non-economic factors — social, psychological, cognitive, medical, logistical and professional — can play critical roles as well. Though, as found in Denmark, patients may still prefer twins, even in countries that provide insurance, the present data probe how providers and patients then confront and respond to ensuing tensions, given professional recommendations favouring SET.

The present data also suggest possible strategies that have not been previously reported for addressing these problems, and several directions for future research. Specifically, eight findings that have not been presented in the literature have key implications for future research, practice, education and guidelines. Secondly, while Jungheim et al. These data extend and build substantially on prior findings that the median length of time of consulting about these issues with providers was 5 min Kalra et al.

The present data add considerably to the past literature, in suggesting that providers differ considerably in what they actually say, how thoroughly they discuss these issues; whether they communicate the risks involved, and if so which risks, how effectively and when e.

These data suggest that providers may not fully explain or convey these risks, and may even minimize them; and that patients may also then minimize these dangers, or feel that these odds do not apply to them. Thirdly, while recommendations in certain countries e. These data suggest that patients may seek rationalizations for why these risks will not apply to them: for example because they exercise and are healthy. Patients in other areas of medicine commonly minimize or deny possible risks to themselves Rabinowitz and Peirson, , and do so here, too.

Physicians must obtain informed consent, and patients thus need to understand the risks and benefits involved, but the present data suggest that that may not always occur. While Jungheim found that most clinics deviated from guidelines, due to patient requests, the current data suggest that patient requests themselves may vary widely in how informed and firm they are. Therefore, the present data suggest clinicians should not always simply follow patient requests, but instead should ascertain how fully informed and strong these requests are.

Guidelines should, arguably, also specify that providers should carefully discuss specific relevant details with patients e. Studies in other areas of medicine show that patients may benefit most from being told not either absolute or relative rates alone, but rather both, along with proportions e. These data also suggest, for the first time, several reasons for these perceptions of the data as insufficient.

For any one patient, the odds of success with twins are relatively good i. Rather, paediatricians, not reproductive endocrinology and infertility REI specialists, are responsible for, and have experienced difficulties in, treating harmful outcomes that twins face, for example in the NICU. The risks may thus be easy for REI specialists and prospective patients to discount. The costs generated by these risks also accrue not to these REI specialists, but to society and the eventual parents.

Fifthly, these data suggest that providers may at times transfer additional embryos due to their own competing motives and pressures — desires, in many countries, to increase their reported rates of success. Physicians may therefore not always adequately communicate these dangers to patients, and may be biased in arguing that patient autonomy should readily trump all other considerations. Sixthly, these data suggest that physicians may be over prioritizing patient autonomy and ignoring or undervaluing other ethical considerations — the rights of the unborn child, beneficence toward these future offspring, non-maleficence and social justice.

In focusing on patient autonomy, physicians may be downplaying their ethical responsibilities concerning the future child, public health burdens to society as a whole and the need to avoid harm to the mother and future children.

Arguably, at a certain point, wider social and public health costs and risks to the mother and future offspring may at times outweigh the autonomy of an individual patient. Dilemmas surface of precisely how much obligation providers have to follow these other principles; yet clinicians should at least seriously consider these other ethical concerns, especially given both potential patient misunderstandings of risks, and possibilities of physicians having conflicting motives.

Seventhly, while research has indicated that providers may differ in how many embryos they transfer, the present data suggest that clinicians also vary in how they make these decisions: whether they do so informally or formally through an ethics or QA committee that may include not only assisted reproductive technology providers.

These data suggest, too, that providers vary in these decisions due to several factors, such as the type of institution in which they work, and their own personal or professional experiences and perceptions of the persuasiveness of the risk data. Providers and patients may see SET as having advantages over DET, but perceive DET as having advantages over no child — thus focusing only on the outcome to have a baby rather than on the risks as well.

These findings have several important implications for further practice, policy, education and research. Though a few commentators have suggested increasing insurance coverage, doing so poses challenges: for example, the cost of providing sufficient infertility care to everyone who wants it may be prohibitive. Rather, these data suggest that several other approaches e. Governments can thus forcefully limit numbers of embryos transferred as part of payments.

In contrast, in many other countries, where IVF is reimbursed much less or not at all, recommendations to limit the numbers of embryos transferred face additional hurdles, and may have considerably less success.

Hence, countries can vary widely in use of SET due to the presence of a single insurance payer. Given competing economic and political priorities that can impede the adoption of such policies, pursuing other potential ways to increase SET use is thus critical.

In only 11 of 27 EU countries was public access to data from individual clinics available in Kupka et al. Increasing public access to individual clinic data, and requiring reporting by clinics may therefore be helpful as well. In many countries, current reporting requirements disincentivize providers from transferring fewer embryos. For instance, between and , the proportion of cycles that US IVF programmess failed to report increased from 3.

Of these clinics, 3. The researchers analysing these data therefore found lessened transparency of reporting, and recommended prospective reporting of each initiated cycle by all clinics. Williams et al. Proponents of SET have emphasized the need for increased insurance coverage for assisted reproductive technology and improved education of patients Kissin et al.

Such alterations in reporting requirements will likely encounter resistance Gleicher, , but the present data add further support to efforts to expand reporting in these ways, highlighting how current reporting is limited, fuels misunderstanding and may be self-serving. Moreover, SART, for instance, currently cautions viewers of its reports that the data should not be used for comparing clinics. These findings also underscore needs to enhance professional, patient and public education about the risks of twins and other multiple births.

Yet many patients will still then end up with twins, while other prospective parents remain childless. Clinicians, especially if they are transferring extra embryos, should proceed with care, and rigorously ensure that patients fully grasp these risks. The data also suggest a need to develop decision-making tools for patients, to help them grasp the relative risks, benefits and costs to them. Given ongoing media reports of celebrities and others having twins, education of journalists about the risks involved can also be beneficial.

These data suggest several avenues for future research. The present data underscore the need to examine exactly what risks providers convey to patients; how much time clinicians spend doing so, and how effectively; how often patients seeking DET minimize the risks; how often providers using DET feel the risk data about twins are insufficiently compelling; what they feel the risks in fact are; what odds they feel would be compelling enough to switch to SET; and how they weigh these risks against other considerations.

Some providers have begun to use SET with single blastocyst transfer after pre-implantation genetic screening. However, data are lacking on how frequently providers in various countries are adopting this practice.

Moreover, for the reasons described here, many patients will presumably still prefer to have twins, rather than singletons. These data have several potential limitations. The sample size is sufficient for qualitative research designed to elucidate the issues and themes that emerge; however, future studies using larger samples are needed to analyse statistically how various groups may differ e.

In fact, the BEST trial in showed that the likelihood of success with a single embryo transfer is equivalent to that of a double embryo transfer Therefore, a single embryo transfer should strongly be considered for all patients before transfer of multiple embryos. All patients considering transfer of multiple embryos should have a conversation with their doctor regarding their optimal plan of care and the additional risk of having twins or a higher order multiple pregnancy.

She is a board-certified Obstetrician Gynecologist. Nazem completed her residency in Obstetrics and Gynecology at the New York University School of Medicine, where she was elected administrative chief resident and graduated with the Robert F. Porges Honor Resident Award, for outstanding performance. Who should consider an elective single embryo transfer eSET?

While such pregnancies can be a good thing when no problems arise, multiple pregnancies even twins increase the obstetric complications. Therefore, the goal of most infertility experts is to obtain singleton pregnancies. To this end, some experts have advocated the transfer of only one embryo at a time for many patients, a practice known as single embryo transfer, or SET.

In general, SET results in a decreased chance of achieving a pregnancy per embryo transfer as compared to the transfer of two or more embryos, but it also greatly decreases pregnancy risks by avoiding multiples. At Fertility Associates of Memphis, patients believed to have an excellent chance at achieving pregnancy with favorable predictors good embryo quality, non smoker, normal BMI, previous successful pregnancy, etc.

For patients with more complicated clinical situations, more embryos for transfer may be recommended. Ultimately, the decision on how many embryos to transfer is one made thoughtfully by the patient and physician. In the distant past, some clinics would transfer up to four day-three embryos and hoped for the best. Blastocysts allow for more informed choices and better control over outcomes. While a study suggested blastocyst transfers increased the risk of premature birth and heavier babies, that risk was small.

The routine approach to day-five transfers will continue. For the latest fertility news, tips and updates, like us on Facebook and follow us on Twitter. Am very concerned did blastocyst tranfer and had an accident same day.

I am 27 years. I had egg retrieval which only 7 eggs were retrieved ,5 fertilized,had only 3 embryos on day 2,about to get a call from the embriologist on day I got 2 embroys transferred 15 days back , one got implanted and other was not, What will happen to the failed embryo.?

I had 6 eggs collected and 5 fertilised 4 made day 5 blastosist. Hi I am in my 3 IVF try now. I har only 1 embryo fertilized and transfer.

And to Say is my day 8 after dag 5 embry transfer. And the test was negative. Has anyone had any experience to share… please.? I am a latter lost! Im nearly 38yrs.. Hello ladies.. It took 2 months for me to recover. I just pray the one survives and i get to carry my baby. I have been waiting for too long and in my country Zimbabwe you are shunned by family if you are married and dont have a child.

Please pray for me, i am emotionally and financially drained. Hi Mai Nat.. My story is same as yours..

My embryo transfer will happen in some where in january.. Tell me what happened after your transfer.. Were you successful mai nati, am also local to u. I had my 1st IVF fail this year and it was heartbreaking. Will soon go for my fet, so terrified. Hello, I have a frozen 4DD blastocyst. The lab uses the Gardner grading system. It was frozen as it had developed further from an early blastocyst to 4DD from day 5 to day 6. Is it worth trying to use it? It seems it is not worth spending more money on this as the chances are so remote.

What do you think? Do you freeze 4DDs? Thank you. Hi everyone. One embryo was a grade 4CD and the other an EB1 — so both very poor quality. Had anyone had a positive from low grade embryos? We are both 30 very low sperm count long story short. We had 1 transferred and 3 frozen……. So happy I also had transferred one day 5 blastocyst.. Did you find out at your 6 week ultrasound that you were pregnant with twins?

What was your HCG level? My HCG is only at at 12 days after transfer. Hi, this is my first IVF cycle i am 39, I had an etopic a few years back in my last tube which was removed a few months ago to prepare for IVF.. I had egg collection yesterday, they retrieved 22 eggs.. I was advised yesterday to do a frozen cycle instead of a fresh one to prepare my womb.. I received a call today 7 have fertilized so I will be doing blastocyst at day 5 to be frozen if of course they survive I am aware I may not get any after day I am receiving 2 embryo transfer if all goes well, pls pray for me!

Hi Marie, hope all is going well. We selected to have 1 5 day blastocyst transfer and just hoped for the best as we only had 3 viable eggs. I transferred 2 blastocyst when I was 26 yrs.

I had a singleton, normal pregnancy and my beautiful DD is almost 6yrs old and healthy! Hi, I just want to give hope to all you wonderful people who see this page. In at age 44, I had 2 fresh cycle blastocysts transferred. At 6 weeks of pregnancy one foetus died I thought all was lost in the bleed , but I was put on double progesterone for a few days till the blood loss stopped and a scan revealed our healthy day.

She is now 19 months of age and perfection itself! I have this month returned to my clinic had my last 2 frozen embryos transferred we had 4 in our original cycle. Both were great quality 1AA and 2BB and survived the thaw.