1
|
Jayakumar NP, Solanki M, Karuppusami R, Joseph T, Kunjummen AT, Kamath MS. Acceptance of Elective Single-embryo Transfer in a Resource-limited Setting: A Cross-sectional Questionnaire-based Study. J Hum Reprod Sci 2023; 16:233-241. [PMID: 38045498 PMCID: PMC10688277 DOI: 10.4103/jhrs.jhrs_79_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 12/05/2023] Open
Abstract
Background While elective single-embryo transfer (eSET) has been advocated in select countries, the global acceptance of the eSET policy has been undermined due to various issues. It is imperative to understand the couples' perspectives regarding the number of embryos transferred. Aims We planned a study to evaluate the knowledge and attitude of infertile couples undergoing assisted reproductive technology towards eSET in self-funded treatment cycles in a low-resource setting. Settings and Design We conducted a cross-sectional study at a tertiary-level referral facility between February 2020 and September 2022. Materials and Methods This was an interviewer-administered questionnaire-based survey in two stages. The first stage involved the assessment of the knowledge of the participants. Following this, participants were given an information pamphlet and the second stage of the interview was conducted to assess the attitude and change in preference for embryo transfer number. Statistical Analysis Used The Chi-square and Fisher's exact test were applied to find an association between categorical variables. Logistic regression was used to assess the association between factors and outcomes. Results eSET was the preferred choice for only 5.8% of the participants. Following our educational intervention using an information leaflet, there was a statistically significant increase in the preference for eSET (P = 0.01). Univariate logistic regression analysis revealed that participants with a monthly income of ≤50,000 INR had a significantly higher preference for eSET. Conclusion Continued emphasis on the risks of double-embryo transfer coupled with individualised selection criteria for eSET may help to achieve reasonable congruency between the clinician and couples' decision.
Collapse
Affiliation(s)
- Nithya Panapakkam Jayakumar
- Department of Reproductive Medicine and Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Megha Solanki
- Department of Reproductive Medicine and Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Treasa Joseph
- Department of Reproductive Medicine and Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | - Mohan Shashikant Kamath
- Department of Reproductive Medicine and Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| |
Collapse
|
2
|
De Neubourg D, Dancet EAF, Pinborg A. Single-embryo transfer implies quality of care in reproductive medicine. Reprod Biomed Online 2022; 45:899-905. [PMID: 35927209 DOI: 10.1016/j.rbmo.2022.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 12/24/2022]
Abstract
This review appraises evidence on the difference between single- and double-embryo transfer (SET, DET) in assisted reproductive technology (ART) regarding the four healthcare quality dimensions most important to fertility patients and doctors. Regarding safety, not only does DET create the uncontested perinatal risks of twin pregnancies, but compelling evidence has added that singleton pregnancies after a vanishing twin also have poorer perinatal outcomes. SET is as effective as DET, as shown by meta-analyses of randomized controlled trials, comparing two cycles of SET versus DET and shown by cumulative live birth rates of entire ART trajectories of up to six cycles. Proposing SET, which is safer than DET and as effective, as the gold standard is not irreconcilable with patient-centred care if patients are thoroughly informed on the reasoning behind the proposition and welcomed to challenge whether it fits their personal values. The cost-efficiency of SET is clearly higher, which has even induced certain countries to start reimbursing ART on the condition that SET is used. In conclusion, SET should be the gold standard offered to all patients. The question is not whether to apply SET but how to apply it in terms of patient selection, patient-centred counselling and coverage of treatment.
Collapse
Affiliation(s)
- Diane De Neubourg
- Center for Reproductive Medicine, Antwerp University Hospital, Faculty of Medicine and Health Sciences, University of Antwerp, Edegem, Belgium.
| | - Eline A F Dancet
- Leuven University Fertility Clinic - Leuven University Hospitals, Leuven, Belgium
| | - Anja Pinborg
- Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
3
|
The parent trap: desire for multifetal gestation among patients treated for infertility. J Assist Reprod Genet 2022; 39:1399-1407. [PMID: 35508690 PMCID: PMC9067551 DOI: 10.1007/s10815-022-02508-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/25/2022] [Indexed: 11/05/2022] Open
Abstract
Objective To evaluate predictors for patient preference regarding multifetal or singleton gestation among women presenting for infertility care. Design Cross-sectional study. Setting Academic university hospital-based infertility clinic. Patient(s) Five hundred thirty-nine female patients with infertility who presented for their initial visit. Main outcome measure(s) Demographic characteristics, infertility history, insurance coverage, desired treatment outcome, acceptability of multifetal reduction, and knowledge of the risks of multifetal pregnancies were assessed using a previously published 41-question survey. Univariate analysis was performed to assess patient factors associated with the desire for multiple births. Independent factors associated with this desire were subsequently assessed by multivariate logistic regression analysis. Result(s) Nearly a third of women preferred multiples over a singleton gestation. Nulliparity, lower annual household income, older maternal age, marital status, larger ideal family size, openness to multifetal reduction, and lack of knowledge of the maternal/fetal risks of twin pregnancies were associated with pregnancy desire. Older age (OR (95% CI) 1.66 (1.20–2.29)), nulliparity (OR (95% CI) 0.34 (0.20–0.58)), larger ideal family size (OR (95% CI) 2.34 (1.73–3.14)), and lesser knowledge of multifetal pregnancy risk (OR (95% CI) 0.67 (0.55–0.83)) were independently associated with desire. Conclusion(s) A large number of patients undergoing fertility treatment desire multifetal gestation. Although a lack of understanding of the risks associated with higher order pregnancies contributes to this desire, additional individual specific variables also contribute to this trend. Efforts to reduce the incidence of multiples should focus not only on patient education on comparative risks of multiples vs singleton pregnancies but also account for individual specific reservations.
Collapse
|
4
|
Jull J, Köpke S, Smith M, Carley M, Finderup J, Rahn AC, Boland L, Dunn S, Dwyer AA, Kasper J, Kienlin SM, Légaré F, Lewis KB, Lyddiatt A, Rutherford C, Zhao J, Rader T, Graham ID, Stacey D. Decision coaching for people making healthcare decisions. Cochrane Database Syst Rev 2021; 11:CD013385. [PMID: 34749427 PMCID: PMC8575556 DOI: 10.1002/14651858.cd013385.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms. For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.
Collapse
Affiliation(s)
- Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Anne C Rahn
- Institute of Social Medicine and Epidemiology, Nursing Research Unit, University of Lubeck, Lubeck, Germany
| | - Laura Boland
- Integrated Knowledge Translation Research Network, The Ottawa Hospital Research Institute, Ottawa, Canada
- Western University, London, Canada
| | - Sandra Dunn
- BORN Ontario, CHEO Research Institute, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Andrew A Dwyer
- William F. Connell School of Nursing, Boston University, Chestnut Hill, Massachusetts, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jürgen Kasper
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Simone Maria Kienlin
- Faculty of Health Sciences, Department of Health and Caring Sciences, University of Tromsø, Tromsø, Norway
- The South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
| | - Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | | | - Claudia Rutherford
- School of Psychology, Quality of Life Office, University of Sydney, Camperdown, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Junqiang Zhao
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
| |
Collapse
|
5
|
Is guided, targeted information about the risks of twin pregnancy able to increase the acceptance of single embryo transfer among IVF couples? A prospective study. J Assist Reprod Genet 2020; 37:1669-1674. [PMID: 32440931 DOI: 10.1007/s10815-020-01820-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To assess whether receiving information about twin pregnancy in the form of oral presentation given by a physician could affect the acceptance of single embryo transfer (SET) by couples undergoing IVF. STUDY DESIGN Prospective interventional study. SETTING University hospital IVF unit. PATIENTS One hundred and forty patients (70 couples) undergoing IVF. INTERVENTIONS A questionnaire to measure patients' emotions about twin pregnancy was administered to IVF patients just before and immediately after attending a slide presentation in which the risks of twin pregnancy were explained. Patients scored (1 to 6) ten adjectives linked either to positive or negative emotions; scores before and after presentation were compared. The patients' preference between double embryo transfer (DET) and SET was also registered before and after the presentation. RESULTS The presentation about twin pregnancy caused a significant (p < 0.001) shift of the score distribution toward lower values for positive adjectives referred to twin pregnancy and higher values for negative adjectives. Information impacted similarly on women and men. Despite the relevant change in the emotional attitude, after presentation, 45.7% of women and 48.6% of men were still favorable to DET, whereas 24.3% of women and 37.1% of men preferred SET. CONCLUSIONS Oral information on the risks of twin pregnancy can affect the emotional attitude of patients toward twin pregnancy, but the wish of getting pregnant after fresh embryo transfer overcomes all rational consideration, and the majority of patients still prefer DET.
Collapse
|
6
|
Clua E, Roca-Feliu M, Tresánchez M, Latre L, Rodriguez I, Martínez F, Barri PN, Veiga A. Single or double embryo transfer? Decision-making process in patients participating in an oocyte donation program. Gynecol Endocrinol 2020; 36:365-369. [PMID: 31464145 DOI: 10.1080/09513590.2019.1653845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
In IVF/ICSI programs, after receiving the information about the success results of single embryo transfer (SET) vs double embryo transfer (DET) and the risks of multiple pregnancy, a significant number of patients opt for SET. Up to date, no comparable studies have been published in oocyte recipients. The aim of this study was to evaluate if the counseling provided to oocyte recipients influence their decision on the number of embryos to be transferred. Fifty-five recipients expressed their preference and the relevance for the decision-making process that they attribute to certain factors through an anonymous questionnaire completed pre and post-counseling. Before counseling, 32 out of 55 recipients preferred DET, 13 preferred SET and 10 were undecided. From the 32 recipients who preferred DET, 16 (50%) maintained their preference after counseling, 13 (40.6%) changed their decision to SET and 3 (9.4%) changed to undecided (McNemar's test: p < .05). After counseling, the patients attached less importance to the probability of pregnancy and more importance to maternal and perinatal risks (p < .05). We conclude that after counseling, a significant number of recipients changed their preferences from DET to SET.
Collapse
Affiliation(s)
- Elisabet Clua
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | - Marta Roca-Feliu
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | - Marta Tresánchez
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | - Laura Latre
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | | | - Francisca Martínez
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | - Pedro Nolasco Barri
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| | - Anna Veiga
- Department of Gynecology, Obstetrics and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain
| |
Collapse
|
7
|
Sunderam S, Kissin DM, Zhang Y, Folger SG, Boulet SL, Warner L, Callaghan WM, Barfield WD. Assisted Reproductive Technology Surveillance - United States, 2016. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2019; 68:1-23. [PMID: 31022165 PMCID: PMC6493873 DOI: 10.15585/mmwr.ss6804a1] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PROBLEM/CONDITION Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016. PERIOD COVERED 2016. DESCRIPTION OF SYSTEM In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants. INTERPRETATION Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. PUBLIC HEALTH ACTION Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.
Collapse
Affiliation(s)
- Saswati Sunderam
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Dmitry M. Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Yujia Zhang
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Suzanne G. Folger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | | | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - William M. Callaghan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Wanda D. Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| |
Collapse
|
8
|
Hendriks S, van Wely M, D'Hooghe TM, Meissner A, Mol F, Peeraer K, Repping S, Dancet EAF. The relative importance of genetic parenthood. Reprod Biomed Online 2019; 39:103-110. [PMID: 31006544 DOI: 10.1016/j.rbmo.2019.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 11/24/2022]
Abstract
RESEARCH QUESTION How much do patients with severe infertility and their gynaecologists value genetic parenthood relative to other key treatment characteristics? DESIGN A discrete choice experiment included the following treatment characteristics: genetic parenthood, pregnancy rate, curing infertility, maternal health, child health and costs. The questionnaire was disseminated between 2015 and 2016 among Dutch and Belgian patients with severe infertility and their gynaecologists. RESULTS The questionnaire was completed by 173 patients and 111 gynaecologists. When choosing between treatments that varied in safety, effectiveness and costs, the treatment's ability to lead to genetic parenthood did not affect the treatment preference of patients with severe infertility (n = 173). Genetic parenthood affected the treatment preference of gynaecologists (n = 111) less than all other treatment characteristics. Patients indicated that they would switch to a treatment that did not enable genetic parenthood in return for a child health risk reduction of 3.6%, a cost reduction of €3500, an ovarian hyperstimulation risk reduction of 4.6%, a maternal cancer risk reduction of 2.7% or a pregnancy rate increase of 18%. Gynaecologists made similar trade-offs. CONCLUSIONS While awaiting replication of this study in larger populations, these findings challenge the presumed dominant importance of genetic parenthood. This raises questions about whether donor gametes could be presented as a worthy alternative earlier in treatment trajectories and whether investments in novel treatments enabling genetic parenthood, like in-vitro gametogenesis, are proportional to their future clinical effect.
Collapse
Affiliation(s)
- Saskia Hendriks
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands; Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda MD, USA
| | - Madelon van Wely
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands
| | - Thomas M D'Hooghe
- Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| | - Andreas Meissner
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands
| | - Femke Mol
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands
| | - Karen Peeraer
- Leuven University Fertility Clinic, Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| | - Sjoerd Repping
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands.
| | - Eline A F Dancet
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam Amsterdam, The Netherlands; Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| |
Collapse
|
9
|
Meldrum DR, Adashi EY, Garzo VG, Gleicher N, Parinaud J, Pinborg A, Van Voorhis B. Prevention of in vitro fertilization twins should focus on maximizing single embryo transfer versus twins are an acceptable complication of in vitro fertilization. Fertil Steril 2018; 109:223-229. [PMID: 29447664 DOI: 10.1016/j.fertnstert.2017.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 11/30/2022]
Affiliation(s)
- David R Meldrum
- Reproductive Partners San Diego, San Diego, California; Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California.
| | - Eli Y Adashi
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - V Gabriel Garzo
- Reproductive Partners San Diego, San Diego, California; Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California
| | | | - Jean Parinaud
- Department of Reproductive Medicine, Paule de Viguier Hospital, Toulouse Teaching Hospital Group, Toulouse, France
| | - Anja Pinborg
- Fertility Clinic, Department of Obstetrics and Gynecology, Hvidovre University Hospital, Hvidovre, Copenhagen, Denmark
| | - Brad Van Voorhis
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
10
|
Sunderam S, Boulet SL, Jamieson DJ, Kissin DM. Effects of patient education on desire for twins and use of elective single embryo transfer procedures during ART treatment: A systematic review. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2018; 6:102-119. [PMID: 30761357 PMCID: PMC6287049 DOI: 10.1016/j.rbms.2018.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 08/22/2018] [Accepted: 10/16/2018] [Indexed: 06/02/2023]
Abstract
Twin births among users of assisted reproductive technology (ART) pose serious risks to both mothers and infants. However, patients may prefer twins and may be unaware of the risks of twin pregnancies. Increasing use of elective single embryo transfers (eSET) through improved patient education could help to reduce twin births and related adverse health consequences. A systematic review of PUBMED and EMBASE databases was conducted to evaluate the effectiveness of patient education among ART users on knowledge of twin pregnancy risks, desire for twins, preference for or use of eSET, and twin pregnancy rates. Of 187 references retrieved, six met the selection criteria. Most focused on patients undergoing their first ART cycle aged < 35 years. Patient education was delivered via written materials, DVDs or discussion. Four studies reporting on knowledge of risks or desire for twins showed significant effects of oral and written descriptions of multiple pregnancy complications, risks of twins versus singletons, and DVDs with factual information. Five studies showed increased eSET use or preference after patients were educated on the risks of multiple pregnancy and success rates associated with different types of ART procedures, when combined with clinic policies that supported single blastocyst transfers or provided options for insurance. In younger ART users, patient education on twin pregnancy risks and success rates of eSET may improve knowledge of twin pregnancy risks and increase use of eSET, and may be important for wider implementation of eSET in countries such as the USA where the use of eSET remains low. Clinic policies of single blastocyst transfers or financial incentives may strengthen these effects.
Collapse
Affiliation(s)
- Saswati Sunderam
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sheree L. Boulet
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Dmitry M. Kissin
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
11
|
Monteleone PAA, Peregrino PFM, Baracat EC, Serafini PC. Transfer of 2 Embryos Using a Double-Embryo Transfer Protocol Versus 2 Sequential Single-Embryo Transfers: The Impact on Multiple Pregnancy. Reprod Sci 2018; 25:1501-1508. [DOI: 10.1177/1933719118756750] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Pedro A. A. Monteleone
- Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Centro de Reprodução Humana Governador Mario Covas, Universidade de Sao Paulo (HCFMUSP), Sao Paulo, Brazil
| | - Pedro F. M. Peregrino
- Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Centro de Reprodução Humana Governador Mario Covas, Universidade de Sao Paulo (HCFMUSP), Sao Paulo, Brazil
| | - Edmund C. Baracat
- Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Centro de Reprodução Humana Governador Mario Covas, Universidade de Sao Paulo (HCFMUSP), Sao Paulo, Brazil
| | - Paulo C. Serafini
- Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Centro de Reprodução Humana Governador Mario Covas, Universidade de Sao Paulo (HCFMUSP), Sao Paulo, Brazil
| |
Collapse
|
12
|
Sunderam S, Kissin DM, Crawford SB, Folger SG, Boulet SL, Warner L, Barfield WD. Assisted Reproductive Technology Surveillance - United States, 2015. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2018; 67:1-28. [PMID: 29447147 PMCID: PMC5829941 DOI: 10.15585/mmwr.ss6703a1] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PROBLEM/CONDITION Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g) infants. This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2015 and compares birth outcomes that occurred in 2015 (resulting from ART procedures performed in 2014 and 2015) with outcomes for all infants born in the United States in 2015. PERIOD COVERED 2015. DESCRIPTION OF SYSTEM In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System, a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS In 2015, a total of 182,111 ART procedures (range: 135 in Alaska to 23,198 in California) with the intent to transfer at least one embryo were performed in 464 U.S. fertility clinics and reported to CDC. These procedures resulted in 59,334 live-birth deliveries (range: 55 in Wyoming to 7,802 in California) and 71,152 infants born (range: 68 in Wyoming to 9,176 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART utilization rate, was 2,832. ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Virginia). Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.6 among women aged <35 years, 1.8 among women aged 35-37 years, and 2.3 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 34.7% (range: 11.3% in Puerto Rico to 88.1% in Delaware). In 2015, ART contributed to 1.7% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.5% in Massachusetts). ART also contributed to 17.0% of all multiple-birth infants, 16.8% of all twin infants, and 22.2% of all triplets and higher-order infants. The percentage of multiple-birth infants was higher among infants conceived with ART (35.3%) than among all infants born in the total birth population (3.4%). Approximately 34.0% of ART-conceived infants were twins and 1.0% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.1% of all low birthweight infants. Among ART-conceived infants, 25.5% had low birthweight, compared with 8.1% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (31.2%) than among all infants born in the total birth population (9.7%). Among singletons, the percentage of ART-conceived infants who had low birthweight was 8.7% compared with 6.4% among all infants born. The percentage of ART-conceived infants who were born preterm was 13.4% among singletons compared with 7.9% among all infants. INTERPRETATION Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who are typically considered good candidates for eSET, the national average of 1.6 embryos was transferred per ART procedure. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), three (Illinois, Massachusetts, and New Jersey) had rates of ART use exceeding 1.5 times the national rate. This type of mandated insurance coverage has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTION Twins account for the majority of ART-conceived multiple births. Reducing the number of embryos transferred and increasing use of eSET when clinically appropriate could help reduce multiple births and related adverse health consequences for both mothers and infants. State-based surveillance of ART might be useful for monitoring and evaluating maternal and infant health outcomes of ART in states with high ART use.
Collapse
Affiliation(s)
- Saswati Sunderam
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Dmitry M. Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Sara B. Crawford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Suzanne G. Folger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Sheree L. Boulet
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Wanda D. Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| |
Collapse
|
13
|
Prados N, Quiroga R, Caligara C, Ruiz M, Blasco V, Pellicer A, Fernández-Sánchez M. Elective single versus double embryo transfer: live birth outcome and patient acceptance in a prospective randomised trial. Reprod Fertil Dev 2017; 27:794-800. [PMID: 25128910 DOI: 10.1071/rd13412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/24/2014] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to determine which strategy of embryo transfer has a better trade-off in live birth delivery rate versus multiple pregnancy considering patient acceptance: elective single embryo transfer (eSET) or elective double embryo transfer (eDET). In all, 199 women <38 years of age undergoing their first IVF treatment in a private centre were included in a prospective open-label randomised controlled trial. Patients were randomised into four groups: (1) eSET on Day 3; (2) eSET on Day 5; (3) eDET on Day 3; and (4) eDET on Day 5. Per patient, main analysis included acceptance of assigned group, as well as multiple and live birth delivery rates of the fresh cycle. Secondary analysis included the rates of subsequent cryotransfers and the theoretical cumulative success rate. Of 98 patients selected for eSET, 40% refused and preferred eDET. The live birth delivery rate after eDET was significantly higher after eDET versus eSET (65% vs 42%, respectively; odds ratio=1.6, 95% confidence interval 1.1-2.1). No multiple births were observed after eSET, compared with 35% after eDET. Although live birth delivery is higher with eDET, the increased risk of multiple births is avoided with eSET. Nearly half the patients refused eSET even after having been well informed about its benefits.
Collapse
Affiliation(s)
- Nicolás Prados
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| | - Rocío Quiroga
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| | - Cinzia Caligara
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| | - Myriam Ruiz
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| | - Víctor Blasco
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| | - Antonio Pellicer
- Instituto Valenciano de Infertilidad (IVI), Parc Científic Universitat de València, Calle Catedrático Agustín Escardino 9, PC 46980, Paterna, Valencia, Spain
| | - Manuel Fernández-Sánchez
- Instituto Valenciano de Infertilidad (IVI) Sevilla, Avenida de la República Argentina 58, PC 41011, Sevilla, Spain
| |
Collapse
|
14
|
Sunderam S, Kissin DM, Crawford SB, Folger SG, Jamieson DJ, Warner L, Barfield WD. Assisted Reproductive Technology Surveillance - United States, 2014. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2017; 66:1-24. [PMID: 28182605 PMCID: PMC5829717 DOI: 10.15585/mmwr.ss6606a1] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PROBLEM/CONDITION Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2014 and compares birth outcomes that occurred in 2014 (resulting from ART procedures performed in 2013 and 2014) with outcomes for all infants born in the United States in 2014. PERIOD COVERED 2014. DESCRIPTION OF SYSTEM In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS In 2014, a total of 169,568 ART procedures (range: 124 in Wyoming to 21,018 in California) with the intent to transfer at least one embryo were performed in 458 U.S. fertility clinics and reported to CDC. These procedures resulted in 56,028 live-birth deliveries (range: 52 in Wyoming to 7,230 in California) and 68,782 infants born (range: 64 in Wyoming to 8,793 in California). Nationally, the total number of ART procedures performed per million women of reproductive age (15-44 years), a proxy measure of the ART usage rate, was 2,647 (range: 364 in Puerto Rico to 6,726 in Massachusetts). ART use exceeded the national average in 13 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Virginia). Eight reporting areas (Connecticut, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, and New York) had rates of ART use exceeding 1.5 times the national average. Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.7 among women aged <35 years, 1.9 among women aged 35-37 years, and 2.3 among women aged >37 years). Among women aged <35 years, who typically are considered to be good candidates for elective single embryo transfer (eSET) procedures, the national eSET rate was 28.5% (range: 4.3% in Puerto Rico to 67.9% in Delaware). In 2014, ART contributed to 1.6% of all infants born in the United States (range: 0.4% in Puerto Rico to 4.7% in Massachusetts) and 18.3% of all multiple-birth infants (range: 5.5% in Alaska and West Virginia to 37.3% in Hawaii), including 18.0% of all twin infants (range: 5.2% in some states to 36.2% in Hawaii) and 26.4% of all triplets and higher-order infants (range: 0% in some states to 65.2% in Hawaii). Percentages of live births that were multiple-birth deliveries were higher among infants conceived with ART (39.4%; range: 11.5% in Delaware to 55.6% in Puerto Rico) than among all infants born in the total birth population (3.5%; range: 2.2% in Puerto Rico to 4.4% in New Jersey). Approximately 38.0% of ART-conceived infants were twin infants, and 2.0% were triplets and higher-order infants. ART-conceived twins accounted for approximately 95.3% of all ART-conceived infants born in multiple deliveries. Nationally, infants conceived with ART contributed to 5.5% of all low birthweight (<2,500 g) infants (range: 1.2% in West Virginia to 14.2% in Massachusetts). Among ART-conceived infants, 27.8% were low birthweight (range: 10.6% in Delaware to 44.4% in Puerto Rico), compared with 8.0% among all infants (range: 5.9% in Alaska to 11.3% in Mississippi). ART-conceived infants contributed to 4.7% of all preterm (<37 weeks) infants (range: 1.2% in Puerto Rico to 13.4% in Massachusetts). Percentages of preterm births were higher among infants conceived with ART (33.2%; range: 18.9% in the District of Columbia to 45.9% in Puerto Rico) than among all infants born in the total birth population (11.3%; range: 8.5% in California to 16.0% in Mississippi). The percentage of ART-conceived infants who were low birthweight was 8.9% (range: 3.2% in some states to 16.1% in Vermont) among singletons and 55.2% (range: 38.5% in Delaware to 77.8% in Alaska) among twins; the corresponding percentages of low birthweight infants among all infants born were 6.3% for singletons (range: 4.6% in Alaska, North Dakota, and Oregon to 9.5% in Puerto Rico) and 55.2% for twins (range: 46.1% in Alaska to 65.6% in Mississippi). The percentage of ART-conceived infants who were preterm was 13.2% (range: 7.5% in Rhode Island to 23.4% in West Virginia) among singletons and 62.2% (range: 33.3% in some states to 81.4% in Mississippi) among twins; the corresponding percentages of preterm infants among all infants were 9.7% for singletons (range: 1.7% in the District of Columbia to 14.2% in Mississippi) and 56.6% for twins (range: 47.2% in Vermont to 66.9% in Wyoming). INTERPRETATION The percentage of infants conceived with ART varied considerably by reporting area. Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born. Low birthweight and preterm infant birth rates were disproportionately higher among ART-conceived infants than among the overall birth population. Although women aged <35 years are typically considered good candidates for eSET, on average two embryos were transferred per ART procedure with women in this group. Compared with ART-conceived singletons, ART-conceived twins were approximately five times more likely to be born preterm and approximately six times more likely to be born with low birthweight. Singleton infants conceived with ART had higher percentages of preterm birth and low birthweight than all singleton infants born in the United States. ART use per population unit was geographically variable, with 13 reporting areas showing ART use higher than the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), three (Illinois, Massachusetts, and New Jersey) had rates of ART use exceeding 1.5 times the national rate. This type of mandated insurance has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTION Reducing the number of embryos transferred and increasing use of eSET when clinically appropriate could help reduce multiple births and related adverse health consequences. Because twins account for the majority of ART-conceived multiple births, improved provider practices and patient education and counseling on the maternal and infant health risks of having twins are needed. Although ART contributes to high percentages of multiple births, other factors not investigated in this report (e.g., delayed childbearing and use of non-ART fertility treatments) also contribute to multiple births and warrant further study.
Collapse
Affiliation(s)
- Saswati Sunderam
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Dmitry M. Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Sara B. Crawford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Suzanne G. Folger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Denise J. Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Wanda D. Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| |
Collapse
|
15
|
Klitzman R. Deciding how many embryos to transfer: ongoing challenges and dilemmas. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2016; 3. [PMID: 29541689 PMCID: PMC5846681 DOI: 10.1016/j.rbms.2016.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Despite the risks associated with twin and higher-order multiple births, and calls in many countries for single-embryo transfer as the standard of care for good-prognosis patients, providers frequently transfer additional embryos, raising critical questions as to why this is the case and what can be done about it. In-depth interviews of approximately 1 h each were conducted with 27 IVF providers (17 physicians and 10 other healthcare providers) and 10 patients. Professional guidelines often contain flexibility and ambiguities or are unenforced. Thus, both providers and patients frequently wrestle with several dilemmas. Decisions about the number of embryos to transfer emerge as dyadic, dynamic and affected by several factors (e.g. providers' type of institution, and personal and professional experiences and perceptions of the data), leading to differences in whether, how and with what effectiveness clinicians address these issues with patients. Many clinicians feel that the evidence concerning the apparent increased risk associated with a twin birth is not 'compelling', and patients frequently minimize the hazards. These data, the first to explore several critical aspects of how providers and patients view and make decisions about the number of embryos to transfer, thus highlight tensions, uncertainties and challenges that providers and patients confront, and have key implications for future practice, research, policy and education.
Collapse
|
16
|
Sunderam S, Kissin DM, Crawford SB, Folger SG, Jamieson DJ, Warner L, Barfield WD. Assisted Reproductive Technology Surveillance -
United States, 2013. MMWR. SURVEILLANCE SUMMARIES : MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES 2015; 64:1-25. [PMID: 26633040 DOI: 10.15585/mmwr.ss6411a1] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PROBLEM/CONDITION Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including Puerto Rico) on ART procedures performed in 2013 and compares infant outcomes that occurred in 2013 (resulting from ART procedures performed in 2012 and 2013) with outcomes for all infants born in the United States in 2013. REPORTING PERIOD COVERED 2013. DESCRIPTION OF SYSTEM In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia [DC], and Puerto Rico). RESULTS In 2013, a total of 160,521 ART procedures (range: 109 in Wyoming to 20,299 in California) with the intent to transfer at least one embryo were performed in 467 U.S. fertility clinics and were reported to CDC. These procedures resulted in 53,252 live-birth deliveries (range: 47 in Alaska to 6,979 in California) and 66,691 infants (range: 61 in Alaska to 8,649 in California). Nationally, the total number of ART procedures performed per million women of reproductive age (15-44 years), a proxy measure of the ART usage rate, was 2,521 (range: 352 in Puerto Rico to 7,688 in DC). ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Virginia, and DC). Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.8 among women aged <35 years, 2.0 among women aged 35-37 years, and 2.5 among women aged >37 years). Among women aged <35 years, who typically are considered to be good candidates for elective single embryo transfer (eSET) procedures, the national eSET rate was 21.4% (range: 4.0% in Idaho to 77.5% in Delaware). In 2013, ART contributed to 1.6% of all infants born in the United States (range: 0.2% in Puerto Rico to 4.8% in Massachusetts) and 18.7% of all multiple-birth infants (range: 4.5% in Puerto Rico to 35.7% in Massachusetts), including 18.5% of all twin infants (range: 4.5% in Mississippi to 35.3% in Massachusetts) and 25.2% of all triplet and higher-order infants (range: 0% in several reporting areas to 51.5% in New Jersey). Multiple-birth deliveries were higher among infants conceived with ART (41.1%; range: 20.4% in Delaware to 61.6% in Wyoming) than among all infants born in the total birth population (only 3.5%; range: 1.8% in Puerto Rico to 4.5% in Massachusetts and New Jersey). Approximately 39% of ART-conceived infants were twin infants, and 2% were triplet and higher-order infants. ART-conceived twins accounted for approximately 95.4% of all ART-conceived infants born in multiple deliveries. Nationally, infants conceived with ART contributed to 5.8% of all low birthweight (<2,500 grams) infants (range: 0.9% in Puerto Rico to 15.1% in Massachusetts). Among ART-conceived infants, 29.1% were low birthweight (range: 18.3% in Delaware to 42.6% in Louisiana), compared with 8.0% among all infants (range: 5.8% in Alaska to 11.5% in Mississippi). ART-conceived infants contributed to 4.6% of all preterm (<37 weeks) infants (range: 0.6% in Puerto Rico to 13.3% in Massachusetts). Preterm birth rates were higher among infants conceived with ART (33.6%; range: 22.3% in DC to 50.7% in Louisiana) than among all infants born in the total birth population (11.4%; range: 8.8% in California to 16.6% in Mississippi). The percentage of ART-conceived infants who were low birthweight was 9.0% (range: 5.1% in Mississippi to 19.7% in Puerto Rico) among singletons and 56.3% (range: 48.3% in Maine to 72.4% in Puerto Rico) among twins; the corresponding percentages among all infants born were 6.3% for singletons (range: 4.6% in Alaska to 9.6% in Mississippi and Puerto Rico) and 55.3% for twins (range: 43.6% in Alaska to 65.6% in Mississippi). The percentage of ART-conceived infants who were preterm varied from 13.3% (range: 8.7% in Rhode Island to 26.9% in West Virginia) among singletons to 61.0% (range: 47.8% in DC to 78.8% in Oklahoma) among twins; the corresponding percentages among all infants were 10.1% for singletons (range: 6.8% in Vermont to 14.8% in Mississippi) and 56.6% for twins (range: 44.7% in New Hampshire to 68.9% in Louisiana). INTERPRETATION The percentage of infants conceived with ART varied considerably by reporting area. In most reporting areas, multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born, and the low birthweight and preterm infant birth rates were disproportionately higher among ART-conceived infants than among the overall birth population. Although women aged <35 years are typically considered good candidates for eSET, on average two embryos were transferred per ART procedure with women in this group, increasing the overall multiple-birth rates in the United States. Compared with ART-conceived singletons, ART-conceived twins were approximately four-and-a-half times more likely to be born preterm, and approximately six times more likely to be born with low birthweight. Singleton infants conceived with ART had slightly higher rates of preterm delivery and low birthweight than all singleton infants born in the United States. ART use per population unit was geographically variable, with 13 reporting areas showing ART use above the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), two states (Massachusetts and New Jersey) had rates of ART use exceeding twice the national level. This type of mandated insurance has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTIONS Reducing the number of embryos transferred per ART procedure and increasing use of eSET, when clinically appropriate (typically for women aged <35 years), could help reduce multiple births, particularly ART-conceived twin infants, and related adverse consequences of ART. Because twins account for the majority of ART-conceived multiple births, improved patient education and counseling on the maternal and infant health risks of having twins is needed. Although ART contributes to high rates of multiple births, other factors not investigated in this report (e.g., delayed childbearing and non-ART fertility treatments) also contribute to multiple births and warrant further study.
Collapse
|
17
|
Ezugwu EC, Van der Burg S. Debating Elective Single Embryo Transfer after in vitro Fertilization: A Plea for a Context-Sensitive Approach. Ann Med Health Sci Res 2015; 5:1-7. [PMID: 25745568 PMCID: PMC4350055 DOI: 10.4103/2141-9248.149761] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The number of embryos transferred after in vitro fertilization (IVF) have been a topic of debate for over a decade now. Due to the risk associated with multiple pregnancy, there has been a global effort at reducing the multiple pregnancy rates to a minimum while maintaining an acceptable level of successful IVF pregnancy rate. Elective single embryo transfer (eSET) is advocated in most European countries. In Belgium and Sweden, eSET is mandatory for couples with a good prognosis. However, despite clinical recommendations and policy statements, patients in clinical practice frequently do request for the transfer of multiple embryos in order to have twins. Such requests conflict with policy guidelines and create an ethical dilemma for physicians: Should the physician do as the couple requests, and there with respect the autonomy of patients, or adhere to medical policy that takes the health of the mother and children at heart? This article provides an exploration of the arguments found in the literature that plays a role in the discussion on this topic and eventually argues that what a physician should do depends on the specificities of the context in which patients and physicians are implicated. These contextual issues can be taken into account in a shared decision-making procedure, which allows reflections and the responsibilities of both patients and physicians to be attended in decision about assisted reproduction.
Collapse
Affiliation(s)
- EC Ezugwu
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Itukku-Ozalla, PMB 01129, Enugu State, Nigeria
| | - S Van der Burg
- IQ Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ Healthcare, 6500 HB Nijmegen, Netherlands
| |
Collapse
|
18
|
Md Latar IL, Razali N. The Desire for Multiple Pregnancy among Patients with Infertility and Their Partners. Int J Reprod Med 2014; 2014:301452. [PMID: 25763396 PMCID: PMC4334053 DOI: 10.1155/2014/301452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/08/2014] [Accepted: 07/09/2014] [Indexed: 11/29/2022] Open
Abstract
Objective. To study the predictors for desire for multiple pregnancies and the influence of providing information regarding the maternal and fetal complications associated with multiple pregnancies on their preference for multiple pregnancies. Methods. Couples attending an infertility clinic were offered to fill up a questionnaire separately. Following this, they were handed a pamphlet with information regarding the risks associated with multiple pregnancies. The patients will then be required to answer the question on the number of pregnancies desired again. Results. Two hundred fifty three out of 300 respondents completed the questionnaires adequately. A higher proportion of respondents, 60.3% of females and 57.9% of males, prefer singleton pregnancy. Patients who are younger than 35 years, with preexisting knowledge of risks associated with multiple pregnancies and previous treatment for infertility, have decreased desire for multiple pregnancies. However, for patients who are older than 35, with longer duration of infertility, and those patients who have preexisting knowledge of the increased risk, providing further information regarding the risks did not change their initial preferences. Conclusion. Providing and reinforcing knowledge on the risks to mother and fetus associated with multiple pregnancies did not decrease the preference for multiple pregnancies in patients.
Collapse
Affiliation(s)
- Ida Lilywaty Md Latar
- Department of Obstetrics & Gynaecology, Universiti Malaya, 59100 Kuala Lumpur, Malaysia
| | - Nuguelis Razali
- Department of Obstetrics & Gynaecology, Universiti Malaya, 59100 Kuala Lumpur, Malaysia
| |
Collapse
|
19
|
Bhattacharya S, Kamath MS. Reducing multiple births in assisted reproduction technology. Best Pract Res Clin Obstet Gynaecol 2014; 28:191-9. [DOI: 10.1016/j.bpobgyn.2013.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
|
20
|
Forman EJ, Hong KH, Franasiak JM, Scott RT. Obstetrical and neonatal outcomes from the BEST Trial: single embryo transfer with aneuploidy screening improves outcomes after in vitro fertilization without compromising delivery rates. Am J Obstet Gynecol 2014; 210:157.e1-6. [PMID: 24145186 DOI: 10.1016/j.ajog.2013.10.016] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/01/2013] [Accepted: 10/16/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We sought to determine whether performing elective single embryo transfer (eSET) after trophectoderm biopsy and rapid aneuploidy screening results in improved obstetrical and neonatal outcomes compared with transferring 2 untested embryos. STUDY DESIGN The Blastocyst Euploid Selective Transfer (BEST) Trial enrolled infertile couples with a female partner up to age 42 years who were undergoing in vitro fertilization. They were randomized to receive transfer of a single euploid embryo (eSET) or to the standard of care with transfer of 2 embryos that were not biopsied for aneuploidy screening (untested 2-embryo transfer). Gestational age at delivery, birthweight, and neonatal intensive care unit (NICU) lengths of stay were compared with Mann-Whitney U. The risk of preterm delivery, low birthweight, and NICU admission were compared with χ(2). RESULTS Among the 175 randomized patients, the delivery rates were similar (69% after euploid eSET vs 72% after untested 2-embryo transfer; P = .6) through the fresh cycle and up to 1 frozen transfer, with a dramatic difference in multiple births (1.6% vs 47%; P < .0001). The risk of preterm delivery (P = .03), low birthweight (P = .002), and NICU admission (P = .04) were significantly higher after untested 2-embryo transfer. Babies born after untested 2-embryo transfer spent >5 times as many days in the NICU (479 vs 93 days; P = .03). CONCLUSION By enhancing embryo selection with a validated method of aneuploidy screening, a single euploid embryo with high reproductive potential can be selected for transfer. Using this approach, eSET can be performed without compromising delivery rates and improving the chance of having a healthy, term singleton delivery after in vitro fertilization.
Collapse
|
21
|
Newton C, Feyles V, Asgary-Eden V. Effect of mood states and infertility stress on patients' attitudes toward embryo transfer and multiple pregnancy. Fertil Steril 2013; 100:530-7. [DOI: 10.1016/j.fertnstert.2013.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
|
22
|
Stillman RJ, Richter KS, Jones HW. Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction. Hum Reprod 2013; 28:2599-607. [PMID: 23904468 DOI: 10.1093/humrep/det317] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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.
Collapse
Affiliation(s)
- Robert J Stillman
- Shady Grove Fertility Reproductive Science Center, 15001 Shady Grove Road, Rockville, MD 20850, USA
| | | | | |
Collapse
|
23
|
In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril 2013; 100:100-7.e1. [DOI: 10.1016/j.fertnstert.2013.02.056] [Citation(s) in RCA: 365] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 01/30/2013] [Accepted: 02/25/2013] [Indexed: 11/18/2022]
|
24
|
van Loendersloot L, van Wely M, Goddijn M, Repping S, Bossuyt P, van der Veen F. Pregnancy and twinning rates using a tailored embryo transfer policy. Reprod Biomed Online 2013; 26:462-9. [DOI: 10.1016/j.rbmo.2013.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
|
25
|
van den Akker OBA. For your eyes only: Bio-behavioural and psycho-social research priorities. HUM FERTIL 2013; 16:89-93. [DOI: 10.3109/14647273.2013.779391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Olga B A van den Akker
- Middlesex University, Department of Psychology, School of Health & Education, Hendon, London, UK.
| |
Collapse
|
26
|
Griffin D, Brown L, Feinn R, Jacob MC, Scranton V, Egan J, Nulsen J. Impact of an educational intervention and insurance coverage on patients’ preferences to transfer multiple embryos. Reprod Biomed Online 2012; 25:204-8. [DOI: 10.1016/j.rbmo.2012.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 04/06/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
|
27
|
Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion. Fertil Steril 2012; 97:825-34. [DOI: 10.1016/j.fertnstert.2011.11.048] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 11/29/2011] [Indexed: 11/23/2022]
|
28
|
Elective single embryo transfer and perinatal outcomes: a systematic review and meta-analysis. Fertil Steril 2012; 97:324-31. [DOI: 10.1016/j.fertnstert.2011.11.033] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 11/18/2011] [Accepted: 11/28/2011] [Indexed: 11/24/2022]
|
29
|
van den Akker O, Purewal S. Elective single-embryo transfer: persuasive communication strategies can affect choice in a young British population. Reprod Biomed Online 2011; 23:838-50. [DOI: 10.1016/j.rbmo.2011.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 07/15/2011] [Accepted: 07/18/2011] [Indexed: 11/29/2022]
|
30
|
Chambers GM, Illingworth PJ, Sullivan EA. Assisted reproductive technology: public funding and the voluntary shift to single embryo transfer in Australia. Med J Aust 2011; 195:594-8. [DOI: 10.5694/mja10.11448] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Georgina M Chambers
- Perinatal and Reproductive Epidemiology Research Unit, School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| | - Peter J Illingworth
- Westmead Clinical School, University of Sydney, Sydney, NSW
- IVFAustralia, Sydney, NSW
| | - Elizabeth A Sullivan
- Perinatal and Reproductive Epidemiology Research Unit, School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| |
Collapse
|
31
|
Fiddelers AAA, Nieman FHM, Dumoulin JCM, van Montfoort APA, Land JA, Evers JLH, Severens JL, Dirksen CD. During IVF treatment patient preference shifts from singletons towards twins but only a few patients show an actual reversal of preference. Hum Reprod 2011; 26:2092-100. [PMID: 21546387 DOI: 10.1093/humrep/der127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Knowledge of patients' preferences for elective single embryo transfer (eSET) or double embryo transfer (DET) and for singletons or twins is of great importance in counselling for embryo transfer (ET) strategies. In this study, the stability of IVF patients' preferences over time for either a healthy single child or healthy twins was measured and we investigated which factors could explain preference shifts. METHODS Infertile women (n = 177) who participated in an RCT comparing one cycle eSET with one cycle DET were included. A satisfaction questionnaire was developed to measure patient preferences and attitudes at two moments in time, i.e. at 2 weeks before ET and at 2 weeks following ET, after the results of the pregnancy test. Regression analysis examined the effect of several variables on preference shifts. RESULTS Before ET, most patients expressed a preference for a singleton, whereas most patients were indifferent 2 weeks after ET, resulting in an overall preference shift towards twins (P = 0.002; n = 145). Overall, 62% of patients showed a preference shift. Preference shifts were explained by patients' global satisfaction of the information given by the fertility clinic staff received by the fertility clinic staff, and an interaction between the occurrence of pregnancy and transfer policy (eSET or DET). CONCLUSIONS In general, patients' preferences for a singleton or twins are not stable during IVF treatment. Possible explanations of a shift in preference are that pregnant patients attuned their preferences to what they expect their pregnancy to result in, whereas non-pregnant patients shifted towards a preference for twins in order to be able to fulfil their ultimate child wish.
Collapse
Affiliation(s)
- Audrey A A Fiddelers
- Department of Clinical Epidemiology and Medical Technology Assessment, Research Institute Grow and Development, and Care and Public Health Research Institute, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
McLernon DJ, Harrild K, Bergh C, Davies MJ, de Neubourg D, Dumoulin JCM, Gerris J, Kremer JAM, Martikainen H, Mol BW, Norman RJ, Thurin-Kjellberg A, Tiitinen A, van Montfoort APA, van Peperstraten AM, Van Royen E, Bhattacharya S. Clinical effectiveness of elective single versus double embryo transfer: meta-analysis of individual patient data from randomised trials. BMJ 2010; 341:c6945. [PMID: 21177530 PMCID: PMC3006495 DOI: 10.1136/bmj.c6945] [Citation(s) in RCA: 228] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2010] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effectiveness of elective single embryo transfer versus double embryo transfer on the outcomes of live birth, multiple live birth, miscarriage, preterm birth, term singleton birth, and low birth weight after fresh embryo transfer, and on the outcomes of cumulative live birth and multiple live birth after fresh and frozen embryo transfers. DESIGN One stage meta-analysis of individual patient data. DATA SOURCES A systematic review of English and non-English articles from Medline, Embase, and the Cochrane Central Register of Controlled Trials (up to 2008). Additional studies were identified by contact with clinical experts and searches of bibliographies of all relevant primary articles. Search terms included embryo transfer, randomised controlled trial, controlled clinical trial, single embryo transfer, and double embryo transfer. Review methods Comparisons of the clinical effectiveness of cleavage stage (day 2 or 3) elective single versus double embryo transfer after fresh or frozen in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatments were included. Trials were included if the intervention differed only in terms of the intended number of embryos to be transferred. Trials that involved only blastocyst (day five) transfers were excluded. RESULTS Individual patient data were received for every patient recruited to all eight eligible trials (n=1367). A total of 683 and 684 women randomised to the single and double embryo transfer arms, respectively, were included in the analysis. Baseline characteristics in the two groups were comparable. The overall live birth rate in a fresh IVF cycle was lower after single (181/683, 27%) than double embryo transfer (285/683, 42%) (adjusted odds ratio 0.50, 95% confidence interval 0.39 to 0.63), as was the multiple birth rate (3/181 (2%) v 84/285 (29%)) (0.04, 0.01 to 0.12). An additional frozen single embryo transfer, however, resulted in a cumulative live birth rate not significantly lower than the rate after one fresh double embryo transfer (132/350 (38%) v 149/353 (42%) (0.85, 0.62 to 1.15), with a minimal cumulative risk of multiple birth (1/132 (1%) v 47/149 (32%)). The odds of a term singleton birth (that is, over 37 weeks) after elective single embryo transfer was almost five times higher than the odds after double embryo transfer (4.93, 2.98 to 8.18). CONCLUSIONS Elective single embryo transfer results in a higher chance of delivering a term singleton live birth compared with double embryo transfer. Although this strategy yields a lower pregnancy rate than a double embryo transfer in a fresh IVF cycle, this difference is almost completely overcome by an additional frozen single embryo transfer cycle. The multiple pregnancy rate after elective single embryo transfer is comparable with that observed in spontaneous pregnancies.
Collapse
Affiliation(s)
- D J McLernon
- Medical Statistics Team, Section of Population Health, University of Aberdeen, Aberdeen AB25 2ZD, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
van Heesch MMJ, Bonsel GJ, Dumoulin JCM, Evers JLH, van der Hoeven MA, Severens JL, Dykgraaf RHM, van der Veen F, Tonch N, Nelen WLDM, van Zonneveld P, van Goudoever JB, Tamminga P, Steiner K, Koopman-Esseboom C, van Beijsterveldt CEM, Boomsma DI, Snellen D, Dirksen CD. Long term costs and effects of reducing the number of twin pregnancies in IVF by single embryo transfer: the TwinSing study. BMC Pediatr 2010; 10:75. [PMID: 20961411 PMCID: PMC2978208 DOI: 10.1186/1471-2431-10-75] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 10/20/2010] [Indexed: 11/24/2022] Open
Abstract
Background Pregnancies induced by in vitro fertilisation (IVF) often result in twin gestations, which are associated with both maternal and perinatal complications. An effective way to reduce the number of IVF twin pregnancies is to decrease the number of embryos transferred from two to one. The interpretation of current studies is limited because they used live birth as outcome measure and because they applied limited time horizons. So far, research on long-term outcomes of IVF twins and singletons is scarce and inconclusive. The objective of this study is to investigate the short (1-year) and long-term (5 and 18-year) costs and health outcomes of IVF singleton and twin children and to consider these in estimating the cost-effectiveness of single embryo transfer compared with double embryo transfer, from a societal and a healthcare perspective. Methods/Design A multi-centre cohort study will be performed, in which IVF singletons and IVF twin children born between 2003 and 2005 of whom parents received IVF treatment in one of the five participating Dutch IVF centres, will be compared. Data collection will focus on children at risk of health problems and children in whom health problems actually occurred. First year of life data will be collected in approximately 1,278 children (619 singletons and 659 twin children). Data up to the fifth year of life will be collected in approximately 488 children (200 singletons and 288 twin children). Outcome measures are health status, health-related quality of life and costs. Data will be obtained from hospital information systems, a parent questionnaire and existing registries. Furthermore, a prognostic model will be developed that reflects the short and long-term costs and health outcomes of IVF singleton and twin children. This model will be linked to a Markov model of the short-term cost-effectiveness of single embryo transfer strategies versus double embryo transfer strategies to enable the calculation of the long-term cost-effectiveness. Discussion This is, to our knowledge, the first study that investigates the long-term costs and health outcomes of IVF singleton and twin children and the long-term cost-effectiveness of single embryo transfer strategies versus double embryo transfer strategies.
Collapse
Affiliation(s)
- Mirjam M J van Heesch
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Rai V, Betsworth A, Beer C, Ndukwe G, Glazebrook C. Comparing patients' and clinicians' perceptions of elective single embryo transfer using the attitudes to a twin IVF pregnancy scale (ATIPS). J Assist Reprod Genet 2010; 28:65-72. [PMID: 20862535 DOI: 10.1007/s10815-010-9484-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 09/13/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study evaluated a questionnaire originally developed for use with health professionals to explore and compare patients' and clinicians' perceptions of elective single embryo transfer and twin births. METHODS IVF clinicians and patients attending an independent Fertility clinic were surveyed using the Attitudes to a twin birth scale (ATIPS) comprising two subscales: attitudes to twins (A-Twin) and attitudes to elective single embryo transfer (A-SET). After refinement total sample scores showed both subscales were reliable with Cronbach's alpha >0.8 and item-total correlations >0.35. RESULTS Questionnaires were completed by 100 female IVF patients and 17 IVF clinicians. A-Twin subscale scores indicated neither the IVF clinicians nor female IVF patients demonstrated very positive attitudes to a twin birth although the IVF female patients were more in favour (t = 5.29, n = 117, p = <0.001). Responses suggest both groups would benefit from increased information about the risks of a twin birth for the baby. First cycle IVF female patients were significantly more positive about eSET (z = 3.94, n = 100, p = <0.001). Clinicians perceive both their colleagues' and female patients' negativity towards eSET; suggesting a role for education. CONCLUSIONS This study found the ATIPS to be a reliable measure which could be useful in evaluating interventions to promote single embryo transfer.
Collapse
Affiliation(s)
- Vibha Rai
- Division of Psychiatry, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | | | | | | | | |
Collapse
|
36
|
|
37
|
Hope N, Rombauts L. Can an educational DVD improve the acceptability of elective single embryo transfer? A randomized controlled study. Fertil Steril 2010; 94:489-95. [DOI: 10.1016/j.fertnstert.2009.03.080] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 03/07/2009] [Accepted: 03/24/2009] [Indexed: 11/24/2022]
|
38
|
Connolly MP, Ledger W, Postma MJ. Economics of assisted reproduction: access to fertility treatments and valuing live births in economic terms. HUM FERTIL 2010; 13:13-8. [PMID: 19903117 DOI: 10.3109/14647270903401747] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The intricate relationship between economic conditions and natural fertility is known to influence both the timing and number of children conceived. For infertile couples, the relationship between economics and fertility is more explicit because of the necessity for many couples to pay for treatment to achieve childbirth. Consequently, affordability often dictates whether or not someone is able to undergo treatment, as well as the types of treatments available. Economics can also be used to describe treatment outcomes achieved through the use of fertility treatments. While gynaecologists and couples speak of outcomes in terms of live births, economists are often inclined to view live births and their influence on society in economic terms. In this review we consider two distinct elements of economics and assisted reproduction. Firstly, how economics (i.e. affordability) can influence demand for, and access to, fertility treatments, and secondly, how methods for valuing live births achieved using assisted reproductive technologies in economic terms can highlight the importance of these children in the context of ageing populations. This review will attempt to illustrate that the economic benefits attributed to children conceived through fertility treatments are much greater than health costs required for conception and should be considered in future reimbursement decisions in this therapy area.
Collapse
Affiliation(s)
- Mark P Connolly
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics, University of Groningen, Groningen, The Netherlands.
| | | | | |
Collapse
|
39
|
Leese B, Denton J. Attitudes towards single embryo transfer, twin and higher order pregnancies in patients undergoing infertility treatment: a review. HUM FERTIL 2010; 13:28-34. [PMID: 20141337 DOI: 10.3109/14647270903586364] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The problems associated with twin and higher order pregnancies have assumed major importance, with international debate about multiple pregnancy; the single biggest risk with in vitro fertilisation (IVF). We have critically reviewed published papers on female patients' and their partners' views of single embryo transfer (SET) and twin or higher level pregnancies to identify the requirements needed to improve the acceptability of SET. Twenty relevant papers were identified and included in the review. Although the majority of IVF patients and their partners, in the more recent studies, exhibited a desire for twins rather than singletons, closer examination of the evidence revealed that elective SET (eSET) could become increasingly acceptable. As success rates of IVF have improved and the risks and consequences of multiple pregnancies are well-documented, patients have accepted the transfer of two rather than three embryos as standard practice. However, more would accept eSET if success rates approached those of double embryo transfer (DET). This emphasises the importance of improving success rates of eSET so that more patients can achieve a singleton birth with one IVF cycle. If patients were offered only SET, it is likely that this would be acceptable as the normal expectation of pregnancy is one baby. Measures to improve the acceptability of SET include: using eSET, especially with younger patients; including partners when providing risk information; improving eSET success rates; improving outcomes with cryopreserved embryos; changing reimbursement/free cycles to favour eSET; using legal enforcement.
Collapse
Affiliation(s)
- Brenda Leese
- Multiple Births Foundation, Queen Charlotte's and Chelsea Hospital, DuCane Road, London W12 0HS, UK.
| | | |
Collapse
|
40
|
Min JK, Hughes E, Young D. [Single embryo transfer for in vitro fertilization]. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:477-494. [PMID: 20500958 DOI: 10.1016/s1701-2163(16)34503-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
41
|
Bonetti TCS, Melamed RMM, Braga DPAF, Madaschi C, Iaconelli A, Pasqualotto FF, Borges E. Assisted reproduction professionals' awareness and attitudes towards their own IVF cycles. HUM FERTIL 2009; 11:254-8. [DOI: 10.1080/14647270802245885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
42
|
Baruffi RLR, Mauri AL, Petersen CG, Nicoletti A, Pontes A, Oliveira JBA, Franco JG. Single-embryo transfer reduces clinical pregnancy rates and live births in fresh IVF and Intracytoplasmic Sperm Injection (ICSI) cycles: a meta-analysis. Reprod Biol Endocrinol 2009; 7:36. [PMID: 19389258 PMCID: PMC2680863 DOI: 10.1186/1477-7827-7-36] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 04/23/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It has become an accepted procedure to transfer more than one embryo to the patient to achieve acceptable ongoing pregnancy rates. However, transfers of more than a single embryo increase the probability of establishing a multiple gestation. Single-embryo transfer can minimize twin pregnancies but may also lower live birth rates. This meta-analysis aimed to compare current data on single-embryo versus double-embryo transfer in fresh IVF/ICSI cycles with respect to implantation, ongoing pregnancy and live birth rates. METHODS Search strategies included on-line surveys of databases from 1995 to 2008. Data management and analysis were conducted using the Stats Direct statistical software. The fixed-effect model was used for odds ratio (OR). Fixed-effect effectiveness was evaluated by the Mantel Haenszel method. Seven trials fulfilled the inclusion criteria. RESULTS When pooling results under the fixed-effect model, the implantation rate was not significantly different between double-embryo transfer (34.5%) and single-embryo transfer group (34.7%) (P = 0.96; OR = 0.99, 95% CI 0.78, 1.25). On the other hand, double-embryo transfer produced a statistically significantly higher ongoing clinical pregnancy rate (44.5%) than single-embryo transfer (28.3%) (P < 0.0001; OR:2.06, 95% CI = 1.64,2.60). At the same time, pooling results presented a significantly higher live birth rate when double-embryo transfer (42.5%) (P < 0.001; OR: 1.87, 95% CI = 1.44,2.42) was compared with single-embryo transfer (28.4%). CONCLUSION Meta-analysis with 95% confidence showed that, despite similar implantation rates, fresh double-embryo transfer had a 1.64 to 2.60 times greater ongoing pregnancy rate and 1.44 to 2.42 times greater live birth rate than single-embryo transfer in a population suitable for ART treatment.
Collapse
Affiliation(s)
- Ricardo LR Baruffi
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
| | - Ana L Mauri
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
| | - Claudia G Petersen
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
| | - Andréia Nicoletti
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
| | - Anagloria Pontes
- Department of Gynecology and Obstetrics, Botucatu Medical School, São Paulo State University – UNESP, Botucatu, Sao Paolo, Brazil
| | - João Batista A Oliveira
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
- Department of Gynecology and Obstetrics, Botucatu Medical School, São Paulo State University – UNESP, Botucatu, Sao Paolo, Brazil
| | - José G Franco
- Center for Human Reproduction – Prof Franco Junior, Ribeirão Preto, Sao Paolo, Brazil
- Department of Gynecology and Obstetrics, Botucatu Medical School, São Paulo State University – UNESP, Botucatu, Sao Paolo, Brazil
| |
Collapse
|
43
|
Veleva Z, Karinen P, Tomás C, Tapanainen JS, Martikainen H. Elective single embryo transfer with cryopreservation improves the outcome and diminishes the costs of IVF/ICSI. Hum Reprod 2009; 24:1632-9. [PMID: 19318704 DOI: 10.1093/humrep/dep042] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zdravka Veleva
- Department of Obstetrics and Gynecology, University of Oulu, PO Box 5000, Oulu FIN-90014, Finland
| | | | | | | | | |
Collapse
|
44
|
Garel M, Blondel B, Karpel L, Blanchet V, Breart G, Frydman R, Olivennes F. Patient attitudes towards twin pregnancies and SET: a questionnaire study. Hum Reprod 2008; 23:1232-3; author reply 1233-4. [DOI: 10.1093/humrep/den076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
45
|
Khalaf Y, El-Toukhy T, Coomarasamy A, Kamal A, Bolton V, Braude P. Selective single blastocyst transfer reduces the multiple pregnancy rate and increases pregnancy rates: a pre- and postintervention study. BJOG 2008; 115:385-90. [PMID: 18190376 PMCID: PMC2253713 DOI: 10.1111/j.1471-0528.2007.01584.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective To examine the clinical pregnancy rate (CPR) and multiple pregnancy rate (MPR) in a large in vitro fertilisation (IVF) programme before and after the introduction of single blastocyst transfer (SBT) strategy in a selected group of women. Design A 3-year pre- and postintervention study. Setting A tertiary reproductive medicine and assisted conception unit in a London teaching hospital. Population Two thousand four hundred and fifty-one fresh IVF cycles performed between July 2004 and June 2007 at the Assisted Conception Unit at Guy’s and St Thomas’ Hospital NHS Foundation Trust were included in the study. Methods In January 2006, we implemented a multidisciplinary intervention involving the introduction of a selective day 5 SBT service together with an educational programme on the risks of multiple pregnancy and potential advantages of blastocyst transfer aimed at couples at high risk of multiple pregnancy. Main outcome measures The CPR per cycle started and MPR per clinical pregnancy achieved. Results A statistically significant increase in the CPR from 27% (324/1198) to 32% (395/1253) (risk difference [RD] 5%, risk ratio [RR] 1.17, 95% CI 1.03–1.32, P = 0.015) and reduction in the MPR per clinical pregnancy from 32% (103/272) to 17% (69/395) (RD 15%, RR 0.46, 95% CI 0.35–0.60, P < 0.001) were observed after introduction of the SBT service. Conclusion Selective SBT in women with good prognosis can reduce the MPR after IVF while maintaining the overall success rate of the IVF programme. Please cite this paper as:Khalaf Y, El-Toukhy T, Coomarasamy A, Kamal A, Bolton V, Braude P. Selective single blastocyst transfer reduces the multiple pregnancy rate and increases pregnancy rates: a pre- and postintervention study. BJOG 2008;115:385–390.
Collapse
Affiliation(s)
- Y Khalaf
- Assisted Conception Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK.
| | | | | | | | | | | |
Collapse
|
46
|
de Lacey S, Davies M, Homan G, Briggs N, Norman RJ. Factors and perceptions that influence women's decisions to have a single embryo transferred. Reprod Biomed Online 2008; 15:526-31. [PMID: 18028744 DOI: 10.1016/s1472-6483(10)60384-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to identify factors that inhibit or promote the adoption of single embryo transfer (SET). A cohort of 163 women patients receiving IVF/intracytoplasmic sperm injection treatment, comprising 87 women choosing SET and 63 women choosing double embryo transfer (DET), were interviewed using a structured questionnaire. The data were compared using logistic regression analysis. Confidence in the chance of pregnancy with SET, younger age and first treatment were predictive of a decision for SET. Preference for a healthy and singleton pregnancy was predictive but perceptions of the incidence or risk of multiple gestation were not. Factors such as a sense of time urgency and past experience of treatment were significant and predictive of diminished choice of SET. The clinic doctor was an important influencing factor. The results of this study confirm that improved pregnancy rates in SET coupled with an official clinic policy to promote SET in younger, first cycle patients influenced many women to choose SET. However, repeated treatment, advancing age and urgency to become pregnant are factors that moderate a woman's choice for SET.
Collapse
Affiliation(s)
- S de Lacey
- Discipline of Obstetrics and Gynaecology, Research Centre for Reproductive Health, School of Paediatrics and Reproductive Health, University of Adelaide, South Australia.
| | | | | | | | | |
Collapse
|
47
|
Twisk M, van der Veen F, Repping S, Heineman MJ, Korevaar JC, Bossuyt PMM. Preferences of subfertile women regarding elective single embryo transfer: additional in vitro fertilization cycles are acceptable, lower pregnancy rates are not. Fertil Steril 2007; 88:1006-9. [PMID: 17416363 DOI: 10.1016/j.fertnstert.2006.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Revised: 12/04/2006] [Accepted: 12/05/2006] [Indexed: 11/16/2022]
Abstract
With identical pregnancy rates after elective single embryo transfer (ET) and double ET strategies consisting of three cycles of IVF or intracytoplasmic sperm injection (ICSI) plus transfers of thawed/frozen embryos if available, 46% of the women undergoing IVF/ICSI favor elective single ET. If elective single ET lowers pregnancy chances with 1%, 3%, or 5%, the percentage of women preferring elective single ET drops to 34%, 24%, and 15%, respectively. If four, five, or six cycles with elective single ET are needed to match the success rate of three cycles with double ET, the percentage of women with a preference for elective single ET drops from 46% to 40%, 36%, and 35% respectively.
Collapse
Affiliation(s)
- Moniek Twisk
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
48
|
Ryan GL, Sparks AET, Sipe CS, Syrop CH, Dokras A, Van Voorhis BJ. A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates. Fertil Steril 2007; 88:354-60. [PMID: 17490657 DOI: 10.1016/j.fertnstert.2007.03.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 03/02/2007] [Accepted: 03/02/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To reduce the twin rate in our IVF program. DESIGN A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING University-based infertility center. PATIENT(S) One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S) A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S) Knowledge of twin risks and desired number of embryos transferred before and after education. Pregnancy rates, number of embryos transferred, and multiple-gestation rates before and after mSBT policy. RESULT(S) After education, knowledge of twin risks improved and a significant number of subjects changed their desired outcome to a lower gestational number. There was no change in ongoing pregnancy rates with blastocyst transfer before and after mSBT (63% vs. 58%; NS). Program-wide number of embryos transferred (2.1 +/- 0.6 vs. 1.9 +/- 0.7) and multiple-gestation rates (35% vs. 19%) decreased significantly while pregnancy rates were maintained. CONCLUSION(S) Simple educational materials can improve knowledge of twin pregnancy risks and affect decision making. In high-risk patients, mSBT results in pregnancy rates similar to two-blastocyst transfer, with decreased twin rates.
Collapse
Affiliation(s)
- Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242-1080, USA
| | | | | | | | | | | |
Collapse
|
49
|
Scotland GS, McNamee P, Peddie VL, Bhattacharya S. Safety versus success in elective single embryo transfer: women's preferences for outcomes of in vitro fertilisation. BJOG 2007; 114:977-83. [PMID: 17578474 DOI: 10.1111/j.1471-0528.2007.01396.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess whether women waiting to undergo in vitro fertilisation (IVF) view adverse outcomes associated with twin pregnancy as more desirable than having no pregnancy at all. DESIGN Women's preference values for five adverse birth outcomes associated with twin pregnancy were compared with their preference value for treatment failure (TF), i.e. no pregnancy at all. SETTING Aberdeen Fertility Centre, University of Aberdeen, UK. POPULATION A total of 74 women waiting to undergo IVF. METHODS The standard gamble method was used to elicit women's preference values for giving birth to a child with physical impairments (PI), cognitive impairments (CI), or visual impairments (VI), perinatal death (PD) without a subsequent pregnancy, premature delivery (PremD), and TF (no pregnancy). MAIN OUTCOME MEASURES Preference values were elicited on a scale where 1 represents giving birth to a healthy child and 0 represents immediate death. RESULTS The median preference values for having a child with PI, CI, or VI were 0.940, 0.970, and 0.975, respectively. The median values for PremD, PD, and TF were 0.955, 0.725, and 0.815, respectively. Having no child at all was valued significantly lower than having a child with PI, CI, or VI (P < 0.01) but significantly higher than PD (P < 0.01). CONCLUSIONS Some women waiting for IVF treatment view severe child disability outcomes associated with double embryo transfer as being more desirable than having no child at all. Women embarking on IVF may be influenced more strongly by considerations of 'treatment success' rather than future risks to their offspring.
Collapse
Affiliation(s)
- G S Scotland
- Health Economics Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK.
| | | | | | | |
Collapse
|
50
|
Abstract
Mrs Z is a 47-year-old woman with long-standing infertility who is about to undergo in vitro fertilization (IVF) using donor oocytes from an anonymous donor. She has already undergone an IVF cycle with her own oocytes and an IVF cycle using donor oocytes from a known donor without a successful pregnancy. Mrs Z has been advised by her infertility physician to consider the transfer of a single embryo, but she does not wish to decrease her likelihood of conception, and, after her long and expensive infertility saga, wishes to conceive twins. The science of IVF has evolved significantly in the last several years, increasing the likelihood of successful pregnancy and reducing the need to transfer more than 1 embryo with its inherent risks of multiple pregnancy. The state of the science and why patients may continue to want multiple embryos transferred, including costs and lack of insurance coverage for infertility treatments, are discussed.
Collapse
Affiliation(s)
- Robert J Stillman
- Shady Grove Fertility Reproductive Science Center, Rockville, MD 20850, USA.
| |
Collapse
|