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

Question:

Hello,

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!!!!!!!

Answer:

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+

 Blastocyst         

   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

www.montereybayivf.com 

Monterey, California, U.S.A.

 

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions

Question:

Hello again, this is S. with some follow-up questions from my earlier email.

Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!

Answer:

Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Elective Single Embryo Transfer - Notes from this year's ASRM meeting

At the annual American Society for Reproductive Medicine meeting one of the many courses I attended was one entitled "Elective Single Embryo Transfer". Perhaps no issue in assisted reproductive technologies (ART) is as controversial as the selection of the optimal number of embryos for transfer. Single Embryo Transfer or SET is a method being heavily promoted by the fertility specialists to reduce the incidence of a multiple getstation. Of course, the recent New York Times article about twins that were born with severe deficits was a source for discussion ("The Trouble With Twin Births" Oct. 11, 2009 Opinion").

Indeed, in current years the number of triplets resulting from ART has diminished; but the number of twins has not declined. The most recent guideline published by SART indicates that the number of embryos to transfer in women age 35 and under is 1 - 2 embryos for "favorable prognosis patients and 2 for all others".

The panel consisted of two Physicians and a PhD Embryologist. Both Physicians came from states where IVF is a mandated benefit, so their patients don't pay out of pocket. They presented their data and arguments for proposals to enact a SET policy on good prognosis patients under 38 years old. They condemned all multiple gestations, including twins, because of the increased costs of the medical care.

The main data they showed to support their argument was that cumulative pregnancy rates (PR) (fresh transfer plus frozen attempts) were the same as PR from transferrring 2 embryos (DET) in one cycle. Transferring SET had a lower PR than transferring DET in a single cycle if you did not add the frozens. Because IVF was mandated, the extra cycles were at no extra cost. The other point that they made was that if the patient failed in the 1st cycle, they transferred 2 (DET) embryos in the subsequent cycle. So in essence, in order to achieve the same PR as the DET in 1 cycle, they had to transfer 3 embryos over two or more cycles.

Their final point was that as reproductive specialists and physicians, we are bound to an ethic of "do no harm" and having a multiple gestation is "harm" as explained in the NY Times article. They professed that we should choose for our patients to transfer only one embryo and not let the emotions and "desperation" of patients to choose more than one embryo for a higher PR.

Personally, I too strive for a singleton pregnancy for all my patients. That is the ultimate goal. I am in favor of SET if the PR per cycle is equivalent to DET. We, ASRM, SART and reproductive specialists, are trying to move toward SET as the gold standard. But, we are not there yet! And, when patients have to pay for their cycles, as they do in California, I believe that we also have an obligation to them, as the consumer, to give patients the highest chances of success for the least cost. A "cumulative PR", especially when more than one embryos is transferred in subsequent cycles, with a higher twin PR, is NOT equivalent. This is a fudge of statistic and not truthful counseling.

Also, one has to remember that the NY Times article is an anecdote about a specific couple and should not be interpreted as the "majority" or "usual" outcome of patients or twins. It is absolutely not. With the advances in Obstetrics and Perinatology, most twins deliver at term and do fine, and have no deficits. We should therefore not fear twin gestations. A NY Times article such as the one recently published, is biased and sensationalized, and not based on scientific evidence. Triplets or more is a different story, however, and should strongly be avoided.

In addition, we Do Not have the knowledge or ability to choose the ideal embryo at this time. It is still a best guess. We choose based on external characteristics "best looking" but that doesn't guarentee a perfect internal structure. Many of us have had terrible looking embryos turn into pregnancies and beautiful children. So in fact, although we think we know best for the patient, we may not be doing the best for patients if we limit their choices.

So, I think that DET may still be the best for the patient at this time, in order to give patients the highest chances for success per cycle with a small twin risk and even smaller twin deficit risk. I don't think that patients should be forced into SET but should be honestly and comprehensively counseled regarding the potential risks of twins (as it is, most of our patients are already taking an increased risk of genetically abnormal babies due to age in attempting pregnancy). They the patients should be allowed to choose without interference from the Physician or the Government. After all, they are paying for it. In states or countries where their insurance or government is the payor, then it can be mandated by regulation, and the insurance or government has the right to decide instead of the patient.

When the technology reaches the point where we can accurately distinguish between good and bad embryos with certainty, and SET offers the best PR for the patient, meeting our obligation to the patient, then it will be time to only transfer one embryo per cycle. Until then, we can keep this as our goal and do the best that we can with the information that we have to work with currently, and strive to reduce the higher order multiple PR (triplet or more). We should strive for singletons but allow twins. We cannot forget that success is what serves our patients best.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

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