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A Risk–Benefit Discussion of Single-embryo Transfer
However, this is not always the case. A significant number of patients information on predicting success is found in the article by Rosenwaks
drop out because of the huge physical and psychological burden of IVF (see pages 5–8).
treatment. In our experience, the drop-out rate is around 40% after each
cycle of IVF (see Table 2). This high drop-out rate is a very real Many reproductive professionals recognize that embryo quality is
phenomenon and occurs even when IVF treatment is significantly more important than a woman’s age in determining whether she
subsidized, as a number of European studies into the subject have should receive SET or DET. Generally, embryos are considered of
demonstrated.
15,16
Physicians have to regard patients who drop out of good quality (grade) if they contain regular-sized blastomeres and
treatment as a failure of the treatment rather than the patient’s own little or no fragmentation. As the fragmentation rate increases, the
choice, and must attempt to address the problem accordingly. Pregnancy implantation rate drops off. This is most marked in older women. One
rates are hugely important in this scenario. study showed that in women under 35 years of age a fragmentation rate
of 26–35% reduced implantation rate to 80% and a fragmentation rate
Cost-effectiveness of 36–50% reduced it to just over 60%; for women aged 40 years and
The economic costs of multiple pregnancies include the service charges older the figures were around 39 and 21%, respectively (Scott,
to establish the pregnancy and see it through to delivery and any unpublished data).
neonatal services, but should also take into account the life-long
consequences of the birth of a healthy child versus that of a child with Results from a recent Finnish study suggest that embryo quality rather
disabilities. The evaluation of cost-effectiveness is therefore neither than a woman’s age should determine whether one or two embryos are
straightforward nor without controversy. Proponents of SET have transferred.
19
It was found that infertile women between the ages of 36
suggested that its practice is cost-effective,
9
although a complete analysis and 39 years with good-quality embryos had similar conception success
has never been performed. to younger women when a single embryo was transferred. A significant
area of research has to be the assessment of embryonic, and therefore
Costs also vary greatly with geography: in Europe, for example, IVF is reproductive, competence. Better markers of embryo quality will be
significantly cheaper than in the US. Cost-effectiveness also involves the crucial if we are to move toward more SETs.
value that an individual assigns to achieving pregnancy as soon as
possible. Europe has a lower per-cycle pregnancy rate than the US, Conclusion
suggesting that on average European women have to wait longer for The arguments for and against SET continue and each side has respected
pregnancy success. proponents and opponents. SET may be suitable for some infertile
couples, but not all. In certain medical indications SET is wholly sensible
Relevant available cost data are limited; therefore, using this argument in (prior uterine surgery or pre-term labor, for example). Additionally, if the
support of SET is at this point in time misleading. patient has appropriate medical history (less than 35 years of age, normal
ovarian function, and no previous IVF failures), one might say she is
Selection an ideal candidate for SET. However, few patients fit neatly into these
Patient selection is the most important factor in predicting success with two categories.
ART. Female age is inversely proportional to IVF success rates due to
increased ovarian gonadotropin resistance and deteriorating egg quality The goal of all reproductive practitioners is to help patients to deliver
as women get older. There are ways to identify those least likely to be healthy babies. If the goal is not achieved because too many unsuccessful
successful with IVF prior to cycle initiation. The most useful test to IVF cycles caused patients to run out of funds or cease treatment because
identify poor responders is taking follicle-stimulating hormone (FSH) and of the psychological burden, then we have failed. Individualized patient
estradiol levels at day three. If these levels are <10mlU/ml and <70pg/ml, care has to be paramount, and that may come with single-embryo,
respectively, the patient generally has an excellent prognosis.
17,18
More double-embryo, and, occasionally, multiple-embryo transfer. ■
1. Centers for Disease Control and Prevention, Assisted Reproductive 8. Menezo YJ, Sakkas D, Monozygotic twinning: is it related to Society of Human reproduction and Emryology (ESHRE), Assisted
Technology Success Rates, 2004. Available at: apoptosis in the embryo?, Hum Reprod, 2002;17(1):247–8. reproductive technology in Europe. 2000. Results generated from
http://www.cdc.gov/ART/ART2004/download.htm 9. Bergh C, Single embryo transfer: a mini review, Hum Reprod, European registers by ESHRE, Hum Reprod, 2004;19(3):490–503.
2. Society for Assisted Reproductive Technology and the Practice 2005;20:323–7. 15. Land JA, Courtar DA, Evers JL, Patient dropout in an assisted
Committee of the American Society for Reproductive Medicine. 10. Evans MI, Berkowitz RL, Wapner RJ, et al., Improvement in reproductive technology program: implications for pregnancy
Guidelines on number of embryos transferred, Fertil Steril, outcomes of multifetal pregnancy reduction with increased rates, Fertil Steril, 1997;68:278–81.
2006;86(Suppl. 4):S51–52. experience, Am J Obstet Gynecol, 2001;184:97–103. 16. Roest J, van Heusden AM, Zeilmaker GH, Verhoeff A, Cumulative
3. Bulmer MG, The Biology of Twinning in Man, Oxford: Clarendon 11. Templeton A, Morris JK, Reducing the risk of multiple births by pregnancy rates and selective drop-out of patients in in vitro
Press, 1970. transfer of two embryos after in vitro fertilization, N Engl J Med, fertilization treatment, Hum Reprod, 1998;13:339–41.
4. Derom C, Vlietnick R, Derom R, et al., Increased monozygotic 1998;339:573–7. 17. Fanchin R, de Ziegler D, Olivennes F, et al., Exogenous follicle
twinning rate after ovulation induction, Lancet, 1987;1(8544): 12. Thurin A, Hausken J, Hillensjo T, et al., Elective single embryo stimulating hormone ovarian reserve test (EFORT): a simple and
1236–8. transfer versus double embryo transfer in in vitro fertilization, reliable screening test for detecting ‘poor responders’ in in-vitro
5. Edwards RG, Mettler L, Walters DE, Identical twins and in vitro N Engl J Med, 2004;351:2392–2402. fertilization, Hum Reprod, 1994;9:1607–11.
fertilization, J In Vitro Fert Embryo Transf, 1986;3(2):114–17. 13. Van Montfoordt APA, Fiddelers AAA, Janssen M, et al., In 18. Hansen LM, Batzer FR, Gutmann JN, et al., Evaluating ovarian
6. Alikani M, Cekleniak N, Walters F, et al., Monozygotic twinning unselected patients, elective single embryo transfer prevents all reserve: follicle stimulating hormone and oestradiol variability
following assisted conception: an analysis of 81 consecutive cases, multiples, but results in significantly lower pregnancy rates during cycle days 2–5, Hum Reprod, 1996;11:486–9.
Hum Reprod, 2003;18(9):1937–43. compared with double embryo transfer: a randomized controlled 19. Veleva Z, Vilska S, Hyden-Granskog C, et al., Elective single
7. Behr B, Fisch J, Racowsky C, et al., Blastocyst-ET and Monozygotic trial, Hum Reprod, 2006;21:338–43. embryo transfer in women aged 36–39 years, Hum Reprod,
Twinning, JARG, 2000;17(6):349–51. 14. The European IVF-monitoring programme (EIM) for the European 2006;21:2098–2102.
FERTILITY TREATMENT REVIEW 29
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