Saturday, October 27, 2012

Single Embryo Transfer

When I've seen this written out, it's always been "Elective Single Embryo Transfer," but why?  In Australia, transferring one is typically recommended (*edited - thanks for the info Aussies!).  But in the United States, transferring two embryos in the norm.  Is it to keep SART statistics up?

Before I explain why I wish I had only transferred one embryo, I want to acknowledge that there are definitely situations where transferring two or even three embryos is the right decision.  If there is a definite egg quality issue or advanced maternal age or history of failed IVF cycles, two or three might be the correct course.

But for me, I don't think it was the right choice.

When you go through IVF you get warned about all potential problems.  Increased risk of birth defecst and other problems too numerous to list right now.  Also increased risk of twins and higher order multiples.  But everything is given a percentage.  With the exception of twins with a 30% chance, everything is given miniscule odds.  Because there are so many possible things that can happen and because many of these things can happen in a typical pregnancy also, we, and I bet many other people, just glossed right over them. "Sure, sure, we accept the risks."

Now for our situation.  We definitely had a morphology issue (4%), but it was unclear whether we had issues on my side or not.  I spotted consistently for 2-3 days before my period and had a rather short luteal phase, but the RE did not seem overly concerned about this and only proscribed Progesterone for our IVF cycle, not the Clomid cycles (who knows if this was a good decision or not).  I also had borderline numbers for some egg quality markers, but my antral follicle scan showed 16 I think?  A pretty good number.  It looks as though all of the markers of egg quality (or ovarian reserve) are pretty poor, especially when your numbers are right on the edge of normal.  I had also had one chemical pregnancy (out of about 15 natural cycles) which shows that we could get pregnant.  Again, who knows what caused it not to work.

My husband and I were fully prepared to have twins.  We did a little bit of research about the risks and knew it was a very high probability and we accepted it.  We never ever considered the chance of higher order multiples for a couples of reasons.  One, the biggest chance was associated with Injectibles + IUI cycles because there is less control of how many embryos are released at ovulation (that what gave Kate + 8 her sextuplets).  Then looking at the numbers, the risk was extremely low with transferring 2 embryos.

But after finding out that one of our embryos split into identical triplets, I started doing more research and although identical triplets are still extremely rare, identical twinning with IVF seemed to be somewhat more common.  I started to wonder why more data has not been collected and why this issue wasn't discussed with us carefully beforehand.  We honestly did not really realize it was a possibility.

I really loved my RE.  And I trusted him.  And still do.  But at some point when this is less fresh, I'm definitely going to discuss this with him.  Even if it still is as rare as they say, I'm still going to encourage him to counsel couples about the possibility.

Because all that would have changed if we had transferred one egg, is time.  It might have taken longer for IVF to work.  (We did a plan that was called a "success guarantee."  If we used all of our eggs from one fresh cycle either in the fresh IVF or FET and did not have a take home baby, we would get all of our money back.)  But that guarantee stipulated transferring 2 embryos.  I think he would have negotiated on this point, but still.

After all of what we've been through, time is the least of our concerns.  It seemed that we were trying to have a child FOREVER and that Mr. GG was getting older quickly (he's 43),but  if we could have delayed this process for a few months and had a simpler pregnancy, we would have done it in a heartbeat.

I encourage you to talk to your doctor carefully about how many embryos to transfer.


  1. In Australia we can transfer two but are counseled against it. In my last two cycles i transferred two and got a BFP both times only one stuck and I had one m/c.

    Like you I was advised of the risks and had to sign a disclaimer and like you I thought it was never going to happen statistics wise.

    I am so sorry you had to make the decision I know you didn't take it lightly. I don't understand how people can support abortion but be so adamant against this. I don't know if I could have done it (bearing in mind five ivf failures had it been the first time probably a different story) but I support your choice in your body.

    I hope Dylan is thriving.

  2. I've thought a lot about SETs and such since we lost our twins. I have a post similar to this on the backburner about what I wish I had known and been advised on. This is something that I think goes on at a lot of clinics - the idea that transferring two is the best idea. I agree with your mindset and am so glad someone else is speaking out on this subject. I plan on finishing my own post and expanding on my experience as well.

  3. I don't know that it's law persay; but it's definitely policy in a lot of clinics that single is preferred, particularly if you're under 35 and have completed less than "X" amount of cycles.

    I will admit to you, I was happy transferring one - but also a little jealous at the prospect of those allowed to transfer two without a fight. (As it DID seem that their pregnancy rates were higher.) Part of me wonders if we'd transferred two in IVF #1, would we have been successful? All just speculation.

    As you know, our IVF #2 with a SET worked, and so I'm pleased about that. :)

    I definitely think people need to be aware of the risks. Stories like yours may not be common, but they're out there.

  4. Thank you for writing this post. I am a HUGE supporter of eSET's for people who fit the criteria...usually under 35 with good quality blastocysts. You are 100% correct that time is the only thing you "waste" when you transfer one embryo at a time. People are scared of FET statistics because they usually freeze the "b" team--but if you freeze part of the "a" team that embryo will make a baby someday when it is transferred (if it is a competent embryo). Of course cost is also an issue...but what costs less overall is a healthy pregnancy and subsequent healthy birth. I strongly encourage couples to talk to their RE's about this issue and advocate for the best possible decison for their personal situation. My prayers are with you and your son. May he thrive as he grows stronger each day!

  5. I'm old....and from our first IVF consult, my RE recommended we transfer 2 because it was our best shot to get pregnant. On my fresh cycle, the embryologist looked at the embryos and said she recommended a single transfer. I panicked and thought for sure we would be wasting a daughter is now almost 11 months old. I'm glad we did what we did. We have started on the road for number 2 and well, we did a single FET and it was unsuccessful. Our last 4 embryos are frozen in sets of 2. At this time, we do not feel we can discard any embryos and my RE does not recommend refreezing so if both embryos survive the thaw, we'll transfer both. However, if only one survives, we'll just do a single transfer. I know so many people who transfer multiple embryos...octo mom anyone? I think the success rate for single embryo transfers has increased dramatically and there is an increase in clinics recommending a single transfer.

    As a NICU nurse, I see what happens. I know too much on both sides. I'm so sorry you were forced into a situation with such a challenging decision. I know you did what was best for you and your babies. I have so much respect for you to be so honest and candid with your situation. I'm with Chon, I don't know if I could have done it, but I have so much respect for you for doing what was right for you and your family, but I'm old and my time is super limited....we did sign the papers saying selective reduction was an acceptable option, but I have no idea what we would do.

    Thank you for sharing your story and for putting this out there...So many IFers out there are so misinformed. I would love the link to Dylan's blog...I love following NICU babies, it's kinda my thing...

  6. Amen...we had 21 eggs retrieved, 19 mature, FIVE fertilized. Day 3 transfer, stated 3% odds of triplest (yours were probably lower than that...) and didn't even think about higher-order multiples. I was 30 turning 31 that year. Unexplained infertility. All three took. Shocker. I trusted my doctor too, and still do, and I guess I think that it's impossible to predict what embryos will take. 2 were grade A no fragmentation, one was a little less great. But way to predict what embryos will twin, or triplet. No way.

  7. I live in Israel where unlimited IVF is covered by our national insurance (incredibly!). Here, anyone under 30 undergoing their first transfer must transfer only 1 embryo. I learned this a week before my transfer, and happened to have turned 30 two days before my transfer. We put in two, and both stuck. I love my twins (they're still cooking at almost 30 weeks) and wouldn't change it for the world, but twin pregnancies are hard and a bit scary and require you to have a lot of help towards the end. I often think about how difficult this would be were I single.

  8. Thank you for sharing your story. I found your blog last night and will go back and read the entire thing when I have time. I am gearing up for my first IVF and we will be doing a eSET when the time comes. I will already be a high risk pregnancy so I cannot add multiples to that equation. I know one embryo can split so that's a risk we will take, but we will not transfer more than one. I'm so sorry you've gotten such horrible comments from people. I read through some of your posts last night about your selective reduction and I cried a couple of times when I read some of the nasty comments. How anyone can actually write those things is beyond me. Anyway, I would to have the link to Dylan's blog so I will send you an email.

  9. I was very grateful that I had a conservative doctor who would not transfer 2 at my age. She said the current pedagogy is to recommend only eSet unless the maternal age is over 35 or there are other conditions that affect egg quality. I'm so sorry for all you've been through because you were not pushed in that direction.

  10. This post is very timely for me. If you are willing, would you mind giving a little more info? I am considering transferring more than one embryo after two failed SETs. I previously conceived triplets with clomid, injectibles, and timed intercourse and I delivered them pre-term. The doctor thinks it might have been incompetent cervix but we don't know for sure. Here are my questions:

    1. Did you find out the cause of your pre-term labor? Do you think it had anything to do with the reduction?
    2. How did you handle the emotional aspect of the reduction, and if you had to would you do it again?

    It's ok if you don't want to answer these, I am just trying to get as much info as possible before we make this decision. It's been really rough. I really applaud your candid-ness on your blog, and completely agree that in a lot of cases one embryo is best. I feel like I am starting to get into that gray area. Best wishes for you and your family!

  11. I'll be honest--my RE (and the mountains of paperwork that I signed) did NOT ever mention the embryo splitting--I read about this on google.

    And with that said, there is evidence that suggests that assisted hatching increases the embryo spliting odds. Again, not something I was ever warned about.

    I think the RE is mostly concerned with business and stats, and transferring two ups their chances of getting those great stats.

    Any future FETS will be SET, especially since 4 of the 5 frozen are excellent quality.

    Had I known all this then? Hmmm...I am not really sure if things would have changed. I did only want to do SET. Hubs wanted to go with the doctor's suggestion, so we did two. Frankly, I wanted to get pregnant, so I went with two.

    1. I also read that Day 5 Blasts are more likely to split than Day 3. I'm pretty sure they did assisted hatching on one of the embryos and we transferred on Day 5.

  12. I would recommend talking to your doctor about this before transfer day too. Mine assumed we wanted two transferred as that is their standard protocol. There was never a discussion about, "Okay, how many do we want to transfer?" We questioned the decision right before transfer time and it was kind of an awkward and stressful talk to have right before that moment when you want to be relaxed. Our RE was very pro-double transfer, so we ended up going with his recommendation. Didn't get pregnant that time, but on our FET we also transferred two again and wound up pregnant with twins. I am now losing one of the twins at 7 weeks and it is an unpleasant and scary process. Next time, I think I'd go SET.

  13. Wow, do you really think there is a higher incidence of identicals among IVF babies than the general population? it's making me wonder, why has nobody studied that? And why is it the case? The implications there are huge, as you suggest.

    Thanks for writing this.

  14. (Tried to comment once before but it seems to have gotten eaten by the blog monsters). Hindsight is 20/20, and you don't know what the outcome would have been different had you transferred only one. You had one egg that split in to three. So even if only one had been transferred, you could have found yourself in the same situation - trying to decide whether to carry on with a triplet pregnancy or to terminate.

    1. True, but we had 4 take. The triplets ended up becoming twins. So we would have either had 1 or 2.

  15. We transferred two. It is the doc's protocol. Honestly I'd love to have twins - but I do not want triplets or quads...however - I know that it IS a possibility. Not a probability but definitely a possibility. We are in our 2ww right now though and I'm just hoping and praying that at least ONE took! But, like you, we are MFI and as far as we know I'm "perfectly fine" with just a day or two of spotting then a 3 day period and a 28 day cycle...
    Again, just hoping and praying at least 1 took. :)

    BTW, I nominated you for the Leibster award! Check it out on my page:

  16. I'm so sorry you went through such a heart wrenching decision. Thank you for sharing your story.

    ICLW #74 Dragondreamer's Lair

  17. In Australia three embryos can also transferred, depending on the clinic/your age/failed IVF attempts. I was actually surprised when they told me that I could transfer two if I wished as I'm only 22 (but I have low AMH so need to get pregnant soon if I want children). But overall most clinics/FS push single transfer.

  18. our clinic is very conservative - i think they are just as worried about their multiples stats as their overall success rates. i hear you about the age thing though... that is a factor for my dh as well as he is in his 50's!

    for iui's our clinic would cancel the cycle if there were more than 2-3 maturing follicles of the same size. AND they would instruct you not to have sex.

    for ivf it is all about power of selection. if the eggs make it to blast, and the patient is under 35, only 1 will be tferred. it is up for discussion above 35 because the chances of the DNA in both blasts being robust is far less. if there are only 2 8-cell pre-blasts and nothing else, that is a point where the statistics break and tferring 2 is recommended because it is unlikely that with such limited success (only 2 8-cells out of all eggs collected are growing and progressing), that both 8-cells will progress to blast, implant, and progress to twins.

    it is amazing to hear my doc talk stats. that is what drives everything at the practice and all of her decisions. she's cancelled my cycles before because "the stats don't add up". of course i was disappointed at the time, but trusted her judgment. its a huge practice too (lucky enough to live in a major metro area) so they have lots of patient's stats to go on and they clearly keep up with the literature. also, the monitoring is intense. it gets to the point nearing trigger time where i am in every single day... my veins are a mess from all the blood draws and i'm late for work... but, i think the intense daily monitoring is key to success.

    anyway, i guess my only advice to others would be to do your homework and chose what is right for you, and make sure your doc doesnt just Rx you meds and leave you to be until ER day (risking ohss, or very few eggs at ER). definitely, mrs. gg, your journey helped me to be ok with my decisions, as with everyone else who shares here and on other blogs, and THANK YOU FOR HAVING THE GUTS TO SHARE!! you have helped more people than i think you know. and you can tell dylan that when he's old enough to understand;)