ESHRE workshop in Prague 6 to 7 December 2024
ESHRE’s recent review of the number of embryos to transfer in IVF and ICSI was based on exhaustive analysis of thousands of studies (1). And the overwhelming conclusion from the guideline committee was this: there is no group of patients for whom double embryo transfer (DET) is more beneficial than single (SET).
However, what was highlighted during a two-day campus in Prague is clinics face significant challenges counselling patients who consider the transfer of two embryos in one cycle to be the best route to an IVF pregnancy – and creating a family.
Recommendations from the ESHRE guideline formed the basis of lively discussion for this well-attended workshop in Prague organised by SIGs Ethics and Law; Psychology and Counselling; and Safety and Quality in ART.
Strategies were outlined at the meeting to enable clinicians to choose the best treatment for a safe pregnancy and healthy baby while respecting their values. A recurring theme was how to balance patient autonomy with the medical evidence that SET is better for mother, baby, family and society; with safer delivery, better interactions with the child, and higher odds of full-term birth.
The first speaker, Rekha Pillai from Newcastle Upon Tyne Hospitals NHS trust, provided a comprehensive overview of the ESHRE guideline from the perspective of when to perform DET. This is a dilemma the consultant gynaecologist said she faces in her own clinic which is why the ESHRE recommendations are helpful in advising patients.
The key point from her talk was that elective single embryo transfer (eSET) should be the standard procedure whenever more than one embryo is available, a message Dr Pillai said at the outset she would repeat ‘again and again’ during her presentation.
Evidence to support this recommendation includes the fact the cumulative live birth rate (CLBR) in eSET is not inferior to that for DET; and that the multiple birth rate after DET significantly exceeds that associated with eSET. Furthermore, the guideline outlines conditions which strictly warrant the use of eSET such as in gestational carriers and for patients at risk of OHSS for whom a fresh embryo transfer is planned.
Patient factors such as how long the woman has been infertile, ovarian response and age inevitably affect outcomes. These should not, however, be reasons for performing DET to achieve an IVF pregnancy according to the ESHRE recommendations. This is not much consolation for patients: Dr Pillai said the ‘mammoth task’ of counselling must be based on a discussion that reflects both healthcare professionals’ good clinical judgement and the patients’ values and personal context, as well as other factors.
Informed patient consent and counselling was a recurring theme throughout the workshop. The conclusion from a presentation by Heidi Mertes was eSET is preferable in terms of cost and ethical considerations, and clinicians should aim to make the circumstances conducive to eSET, rather than DET. Yet she did pose the question: Are we interfering with patient autonomy when mandating eSET? The key for clinicians, said Professor Dr Mertes from Ghent University, is not to regard consent as a box-ticking exercise but to listen to people’s values so they make a good decision: the patient will probably be ’on the same page’ if all the risks are explained to them.
Higher direct and indirect costs are associated with DET although data on cost effectiveness is ‘quite messy’ she said with different types of comparisons and inclusions. Evidence shows that if insurance covers pregnancy and neonatal costs, but not ART, patients may have a financial incentive to opt for DET, rather than eSET (2). As such, health insurance policies and laws that promote eSET on health reasons are needed.
As for ethical issues, Professor Dr Mertes analysed the data on safety of the person carrying the child, the child themselves, respect for human life and similar considerations. Again, eSET comes out as preferable in terms of safety: the ESHRE guidelines warn that DET can even raise the risk of death in patients who have eSET after DET. However, Professor Dr Mertes said twins are not an adverse outcome but a happy one in the opinion of some patients. As such, exceptions to the eSET rule can be justified in very specific circumstances and with robust informed consent along with other requirements.
The goal for patients may be successful IVF, but what does this mean in terms of eSET or DET? The aim of a Europe-wide survey by ESHRE and Fertility Europe has been to find out what people really want and why, with some surprising results (3).
Based on nearly 4,000 complete responses, the findings as outlined by Dr Sara Veleva from the University of Helsinki show that while most want more than one child, the majority (68%) said they preferred singletons with an uncomplicated pregnancy among the key reasons. For those wanting twins (32%), the goal was several children as soon as possible yet only a quarter of these thought they were healthy enough to carry two babies at once.
A head-to-head debate on SET vs DET was a highlight on day two of the campus. More is not always better in IVF was the theme of a presentation by Samuel Santos-Ribeiro who said SET vs DET is still up for discussion but could soon be resolved if implanting two embryos in separate cycles (2xSET) proves superior to DET. A move away from fresh to vitrified embryo transfer has helped drive the 2xSET hypothesis with Professor Santos-Ribeiro, clinical director IVIRMA Lisbon, presenting unpublished data showing a 53% CLBR for 2xSET compared with 39% for DET, and more children born overall (with 2xSET).
An advocate of SET, Christos Venetis had the challenge of arguing the case for DET. An assistant professor at the Aristotle University of Thessaloniki in Greece, Dr Venetis said ESHRE does not advise banning DET, that the ASRM endorses the procedure under specific conditions, and that SET would not be recommended if it were an add-on given the longer time to pregnancy and other factors.
Establishing a blanket eSET policy can help significantly limit multiple births, but Dr Venetis said this ignores the ‘harsh reality’ of being an ART patient. Data shows that 40% of patients don’t return after a failed IVF cycle because of cost and the psychological burden. What is needed, he said, is advocacy to make the implementation of eSET a reality that would not disadvantage patients.
What was clear from the evidence presented at this workshop is that care standards in IVF must be of the highest quality. Optimal IVF treatment should maximise live birth rates and minimise the risk of pregnancy complications. As such, effective communication with patients is essential to make this a reality and further reduce the rate of twin and multiple pregnancies.
References:
1 Alessandra Alteri at al. ESHRE guideline: number of embryos to transfer during IVF/ICSI. Hum Reprod April 2024; Vol 39(4); 647–657. https://doi.org/10.1093/humrep/deae010
2 Stillman RJ et al. Elective single embryo transfer: A 6-year progressive implementation of 784 single blastocyst transfers and the influence of payment method on patient choice. Fert and Steril 2009; vol 92 (6); 1895-1906; https://doi.org/10.1016/j.fertnstert.2008.09.023.
3 Patient experiences and preferences regarding embryo transfer. file:///C:/Users/Sophie%20G/Downloads/ET%20Guideline%20-%20Annex%207%20-%20Patient%20survey%20results.pdf
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