Thursday, October 2, 2014

Upcoming Frozen Embryo Transfer #4: Do I Transfer 1, 2 or 3????


I have a son via FET. I have now had three cycles of FET total. The first did not work, the second we got my son, and this last one worked- however I had a miscarriage at 6.5 weeks pregnant. I now have 4 embryos left frozen and am starting my next IVF cycle. They are frozen in vials of 2 each. I am so concerned if only one survives: do I only implant only one and pray it works, or do I thaw the last two we have and implant all 3? I obviously want the ultimate outcome: a pregnancy. 
My doctor is NO help when I ask what he recommends.  I am scared to only implant one.  Yet I am scared to use all of them in this one last attempt we have.  Is only implanting one pointless? Can you give me a recommendation on what is best if this situation were to happen on the day of transfer? The transfer is only a couple weeks away so I am so nervous.
Thank-you so much.
S. from Illinois. Nervous mom!!!!!!!


Hello S. from the U.S. (Illinois),

Since you haven't given me your age, I can't give you specific recommendations but will have to answer your question in more general terms.  Also, another significant piece that would help answer the question is whether your embryos were frozen on day#3 (cleaved) or day#5 (blastocyst).

We always consider age when counseling patients on the number to transfer because this affects the quality of the embryos and therefore their chances of implantation.  Of course, the younger you are, the higher your chances of implantation and pregnancy per embryo.  Because the technology has gotten so much better over the years, pregnancy rates have gone up and we have realized a problem; namely, an increase in multiples, especially those over twins.  As a consequence, every IVF Physician is wary of putting to many back for fear of getting too many in return.  As a result, the American Society for Reproductive medicine and the Society for Assisted reproduction, its subgroup, have produced recommendations or guidelines for transfer.  these of course are dependent on the age and the stage of development.  Their recommendations are as follows:

 Cleaved embryos:   
                             35    35-37    38-40  40 years old
   Favorable         1-2       2         3        5+
   Unfavorable        2        3         4        5+


   Favorable          1        2         2        3
   Unfavorable      2        2         3        3

I have my patient sign a counseling for that they have been informed regarding these guidelines and either choose to follow them or choose a different number.  I do let my patients decide within reason.  Because you have gotten pregnant with these embryos before, that would be an additional piece of information making me more cautious.

So here's the decision.  Unless you are over 35, I would recommend no more than 2 if they are blastocysts.  If these are cleaved embryos, then I would recommend 2-3.  But, the risk is of getting multiple implantations leading to at least twins.  With blastocysts and transferring 2, my twin rate is 56%.  With cleaved and transferring 3, my twin rate is 35%.  Are you willing to take the risk of having twins?  The pregnancy is harder and there is an increased risk of fetal loss.  If you are not willing to take the risk of twins then you would only transfer 1 no matter what stage.  If you are not willing to take the risk of triplets, then you would not transfer more than 2.  I do not recommend triplets.  The fetal loss rate can be as high as 50%.  The down side of transferring less than 2 is a decrease in pregnancy rates per cycle, but not necessarily over all.  It make take more attempts to get pregnant doing single embryo transfer.

I hope this gives you the information you needed to help with the decision.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.



  1. Hello Doctor, This is my 1st IVF. I had 3 embryos transfered (3 days old, grade B, 8 cells, all 3 of them) I did a HPT 9dp3dt and got a negative. I called my GP( I didn't call d IVF doc because he is against HPT and I can only wait for the blood test after 14days) my GP said it was too early. Now I have decided to have another HPT tomorrow ( 13 days after transfer) do you think whatever it shows tomorrow is the truth? I am yet to have any implantation spotting, only cramps every now and then. I am so anxious doctor, I want to test tomorrow morning. Martha from Nigeria

    1. Hello. Your GP is correct. It is probably too early for a HPT to detect the pregnancy. That is because the HPT has a threshold level that the bHCG needs to reach in order to be positive. I blood test done at this time would be positive, however. I don't think you need to wait until 14 days post transfer. I usually test and 8 and 10 days post transfer for D#3 embryos and 6 and 8 days post transfer for D#5 embryos.

  2. Dr. Ramirez, your posts have given me so much strength, specially since I am going through my first ivf at the age of 41. I am based in Belgium and had a 3 day transfer , 2 embryo ( 1 was 8 cells, the second 6 cells), on the 19 th of December. I had started on 200 mg vaginal progesterone ( 3 times a day) on the 17 th do December and was asked to continue the same. I started slight bleeding on the 26 th of December and it got heavier by the 27 th and so I went to the hospital. My beta was 19.2 and the gynaec asked me to continue with the progesterone. By Monday the bleeding was period like and continuous, so they asked me to stop the progesterone. The bleeding had started lessening by Monday evening. I did another blood test on the 30 th of December( yesterday).To our pleasant surprise the beta was 121 and the nurse asked me to go back on progesterone, so I did take 2 vaginal progesterone yesterday and so far 2 today. I feel that when I take the progesterone, the bleeding gets more. I have an appointment with the doctor on Friday 2 nd January. They have asked me to continue with 600 mg progesterone. While I am ecstatic that the pregnancy is positive, I am anxious that nothing should go wrong. I would like to add that while I have some aches, I do not have any cramping. I have gone through all your blog post on bleeding after transfer, however would like to hear from you if you have any advice. Thanks so much in advance. Suzy

    1. I have found that vaginal progesterone causes vaginal bleeding. The probable cause is erosion of the cervical lining and not bleeding from inside the uterus, although it is no clearly known. I would recommend that you go back on the progesterone to help support the pregnancy and ask to use injectable progesterone as a substitute for the vaginal. It is more painful and tedious, but it should stop the bleeding. The alternative would be using HCG injections but that will interfere with following the bHCG's accurately. Congratulations!

  3. Dr. Ramirez, thanks so much for your quick response. I will talk to my doctor on Friday. Thanks again. Suzy

  4. Hi Dr. Here is a little background information on me. I'm 36, had a successful IVF at at age 34 with a day 5 embryo. We are now trying a FET. We did one cycle 2 months ago with 1 day 5 frozen embryo and it was unsuccessful. We tried again ~6 weeks later but the cycle was cancelled bc my lining wasn't thick enough. This time we are trying a natural FET with use of tamoxifen. I am now on day 14 of my cycle and according an ultrasound this morning, my lining is a little over 4 (4.3 I think) and my follicle isn't ready to ovulate. I will go back in 2 days for another check up. My question to you is what to expect from a natural FET, are my number today normal? we will be transferring both remaining day 5 embryos bc they were frozen together and we don't want to risk a thaw/ re freeze if we only transfer 1. Thanks.



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