Investigation of staff and patients’ opinions of a proposed trial of elective single embryo transfer

Critical appraisal of the Vienna consensus: performance indicators for assisted reproductive technology laboratories

The Vienna consensus, based on the recommendations of an expert panel, has identified 19 performance indicators for assisted reproductive technology (ART) laboratories. Two levels of reference values are established for these performance indicators: competence and benchmark. For over 10 years, the Spanish embryology association (ASEBIR) has participated in the definition and design of ART performance indicators, seeking to establish specific guidelines for ART laboratories to enhance quality, safety and patient welfare. Four years ago, ASEBIR took part in an initiative by AENOR, the Spanish Association for Standardization and Certification, to develop a national standard in this field (UNE 17900:2013 System of quality management for assisted reproduction laboratories), extending the former requirements, based on ISO 9001, to include performance indicators. Considering the experience acquired, we discuss various aspects of the Vienna consensus and consider certain discrepancies in performance indicators between the consensus and UNE 179007:2013, and analyse the definitions, methodology and reference values used.

Elective single versus double embryo transfer: live birth outcome and patient acceptance in a prospective randomised trial

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.

Raising multiples: mental health of mothers and fathers in early parenthood

The rate of twin and higher-order gestation births has risen dramatically in recent decades in the United States as well as other Western countries. Although the obstetrical and neonatal risks of multiple gestation pregnancies are well-documented, much less is known regarding the mental health impact on parents of multiples during the perinatal and early parenthood period. Given that parents of multiples face greater functional demands, as well as other pressures (financial, medical) this population may be at risk for heightened distress. We conducted a systematic review of quantitative, English language studies that assessed mental health outcomes of parents of multiples during pregnancy, in the first postpartum year, and in the period of early parenthood, including depression, anxiety, stress, and related constructs. Twenty-seven articles published between 1989 and 2014 met selection criteria and were included in the review. Studies utilized a wide range of methods and outcome constructs, often making comparisons difficult. Although some studies found no differences, most investigations that compared mental health outcomes in parents of multiples versus parents of singletons found that parents of multiples experience heightened symptoms of depression, anxiety, and parenting stress. We discuss gaps in the existing body of literature on parental mental health related to multiple gestation birth and conclude by discussing the need for novel intervention strategies to meet the needs of this growing population. Parents of multiples may experience worse mental health outcomes than parents of singletons. More research is needed, and future work should explore potential treatment and support options.

What women want from women's reproductive health research: a qualitative study

BACKGROUND

Researchers are being urged to involve patients in the design and conduct of studies in health care with limited insight at present into their needs, abilities or interests. This is particularly true in the field of reproductive health care where many conditions such as pregnancy, menopause and fertility problems involve women who are otherwise healthy.

OBJECTIVE

To ascertain the feasibility of involving patients and members of the public in research on women's reproductive health care (WRH).

SETTING

University and tertiary care hospital in north-east Scotland; 37 women aged 18-57.

METHOD

Four focus groups and one individual interview were audio-recorded and verbatim transcripts analysed thematically by two researchers using a grounded theory approach.

RESULTS AND DISCUSSION

Most participants were interested in WRH, but some participated to promote a health issue of special concern to them. Priorities for research reflected women's personal concerns: endometriosis, polycystic ovary syndrome, menopause, fertility risks of delaying parenthood and early post-natal discharge from hospital. Women were initially enthusiastic about getting involved in research on WRH at the design or delivery stage, but after discussion in focus groups, some questioned their ability to do so or the time available to commit to research. None of the respondents expected payment for any involvement, believing that the experience would be rewarding enough in itself.

CONCLUSIONS

Involving patients and public in research would include different perspectives and priorities; however, recruiting for this purpose would be challenging.

The use of single embryo transfer to reduce the incidence of twins: Implications and questions for practice from the 'towardSET?' project

In vitro fertilisation treatments where multiple embryos are transferred are associated with high multiple birth rates leading to a corresponding high infant morbidity. Here we review the results from a multidisciplinary project which aimed to combine state of the art statistical modelling of routine clinical data with consideration of patient perspectives to explore options for reducing multiple birth incidence by increased use of single embryo transfer (SET). Modelling was based on a large multicentre cohort, supplemented by analysis of HFEA register data. Patient perspectives were explored in qualitative interviews and focus groups. The data confirm the reduction of around one-third in the chance of a live birth for any couple in moving from double embryo transfer (DET) to SET in a fresh cycle. This can be somewhat offset by appropriate patient and cycle selection for SET, with many suggested schemes performing similarly, although many patients perceive such selection as unfair. If we take a complete cycle perspective, and consider the transfer of all good-quality embryos with cryopreservation then it is possible for SET to match or even outperform DET. However, the additional treatment cycles are seen by patients as physically and emotionally burdensome. Such treatments will require optimisation of embryo freezing policies and a number of options are explored.

Clinical effectiveness of elective single versus double embryo transfer: meta-analysis of individual patient data from randomised trials

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.

Comparing patients' and clinicians' perceptions of elective single embryo transfer using the attitudes to a twin IVF pregnancy scale (ATIPS)

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.

Attitudes towards single embryo transfer, twin and higher order pregnancies in patients undergoing infertility treatment: a review

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.

Single-embryo transfer reduces clinical pregnancy rates and live births in fresh IVF and Intracytoplasmic Sperm Injection (ICSI) cycles: a meta-analysis

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.

Why don't we perform elective single embryo transfer? A qualitative study among IVF patients and professionals

BACKGROUND

Elective single embryo transfer (eSET) enables the prevention of multiple pregnancies after in vitro fertilization (IVF). However, in Europe, the multiple pregnancy rate after IVF remains stable at approximately 23%, with SET occurring in 15% of all IVF cycles. In most European clinics, the decision for the number of embryos transferred is established through a form of shared decision-making between patients and professionals. The aim of this study is to explore factors influencing this decision, in particular factors preventing eSET use.

METHODS

We performed explorative, semi-structured, in-depth interviews, based on two theoretical models. The interviews were performed among 19 Dutch IVF professionals and 20 patients who had just undergone IVF or were on the waiting list for IVF. The interviews were fully transcribed and two researchers independently scored the factors according to the models.

RESULTS

We identified a wide variety of factors, potentially influencing eSET use: 37 with the professionals and 26 among the patients. Examples of factors mentioned by both patients and professionals were: uncertainty about the eSET technique, couples' lack of knowledge about essential eSET aspects, absence of a reimbursement system which favours eSET, inadequate options to select couples suitable for eSET and inferior cryopreservation success rates.

CONCLUSIONS

This study demonstrates that both IVF professionals and patients identify numerous factors preventing eSET use in clinical practice. To estimate the impact of these factors identified, a quantitative confirmation and assessment of the magnitude of the effect is necessary.

Safety versus success in elective single embryo transfer: women's preferences for outcomes of in vitro fertilisation

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.

Guidelines for the number of embryos to transfer following in vitro fertilization

OBJECTIVE

To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies.

OPTIONS

Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared.

OUTCOMES

Clinical pregnancy, multiple pregnancy, and live birth rates.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles.

VALUES

Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.

A qualitative study of the experience of treatment for infertility among women who successfully became pregnant

BACKGROUND

In a study in which 18,503 women who had recently given birth were interviewed, 460 women who had received treatment for infertility (2.6%) were asked to participate in a postal study. The aim was to investigate the experience of women who had undergone treatment for infertility and given birth as a consequence, focusing on perceptions of treatment and care.

METHODS

The study relies on responses to open-ended questions about the impact of treatment, how treatment could be improved and advice to policy makers. The text responses to these questions were analysed qualitatively.

RESULTS

A total of 230 women responded (50%). Emergent themes related to the treatment process, pain and distress, lack of choice and control, timing, emotional and financial costs, fairness and contrasts in care.

CONCLUSIONS

Women wished to be treated with respect and dignity and given appropriate information and support. They wanted their distress recognized, to feel cared for and to have confidence in health professionals in situations where outcomes are uncertain. Women acknowledged receiving care from motivated and skilled health professionals and value the children they have enormously. For many, there is now a sense of being complete, though for some this has been at great emotional and financial cost.

Contribution of embryo cryopreservation to elective single embryo transfer in IVF–ICSI

Single embryo transfer is the best way to reduce the risk of multiple pregnancy in IVF-intracytoplasmic sperm injection (ICSI). Between June 2002 and December 2004, all patients (first cycle, female age <38 years) were offered the choice between having one (SET) or two (DET) embryos transferred. Among 493 couples, 428 had at least two good quality embryos, and among them, 32% opted for SET. The SET and DET populations were not comparable (patients in the SET group were younger and had more oocytes retrieved), and therefore a paired, case-control analysis was performed involving 130 SET couples and 130 DET couples, matched according to the female partners' ages and the numbers of embryos available. All of the SET patients, and 82% of the DET group, had at least one embryo cryopreserved, (3.9 versus 2.8 embryos). The option of SET was continued for the frozen-thawed embryo transfers. The pregnancy rate following embryo transfer was significantly lower after SET compared with DET for both fresh (27.6 versus 36.9%; P < 0.05) and frozen-thawed (14.4 versus 23.5%) embryos. However, the cumulative live birth rates following the transfer of fresh and frozen embryos were identical between the two groups (43 versus 45%), with a high prevalence of twins following DET (34 versus 0%).

The psychological impact of mild ovarian stimulation combined with single embryo transfer compared with conventional IVF

BACKGROUND

The objective of this study was to assess the psychological implications of mild ovarian stimulation combined with single embryo transfer (SET) during a first IVF cycle.

METHODS

We conducted a randomized controlled two-centre trial. Three hundred and ninety-one couples were randomized to undergo either mild ovarian stimulation with GnRH antagonist co-treatment and SET (n=199) or conventional GnRH agonist long protocol ovarian stimulation with double embryo transfer (DET) (n=192). Women completed the Hospital Anxiety and Depression Scale, the Hopkins Symptom Checklist and the Subjective Sleep Quality Scale at baseline, on the first day of ovarian stimulation and following embryo transfer. Affect was assessed daily with the Daily Record Keeping Chart from the first day of ovarian stimulation until the day treatment outcome became known.

RESULTS

The conventional IVF group experienced elevated levels of physical and depressive symptoms during pituitary downregulation. At oocyte retrieval, this group experienced more positive affect and less negative affect than the mild IVF group. In the conventional IVF group, cycle cancellation was associated with less positive and more negative affect.

CONCLUSIONS

During the first IVF treatment cycle, mild ovarian stimulation and SET does not lead to more psychological complaints than conventional IVF.