Elective single embryo transfer (eSET) policy in the first three IVF/ICSI treatment cycles

Aafke P.A.van Montfoort 1 2 John C.M.Dumoulin 1 2 Jolande A.Land 0 1 Edith Coonen 1 2 Josien G.Derhaag 1 2 Johannes L.H.Evers 0 1 0 Department of Obstetrics & Gynaecology, Academic Hospital Maastricht , Maastricht , The Netherlands 1 Maastricht , The Netherlands 2 Research Institute of Growth & Development (GROW), University of Maastricht and IVF-Laboratory BACKGROUND: Elective single embryo transfer (eSET), applied in the first or second IVF cycle in young patients with good quality embryos, has been demonstrated to lower the twin pregnancy rate, while the overall pregnancy rate is not compromised. It is as yet unclear whether eSET could be the preferred transfer policy in all treatment cycles, or that it should be restricted to the first or first two cycles. METHODS: eSET policy (when two or more embryos were available, at least one of them being of good quality) was offered to patients younger than 38 years in the first three treatment cycles. Retrospectively, treatment cycle outcome was studied. RESULTS: In 326 patients, 586 treatment cycles were performed (326 first, 168 second and 92 third treatment cycles). In 65 cycles (11%), eSET could not be applied because there was either no fertilization, or only one embryo available. In the remaining 521 cycles, eSET was performed in 111 cycles (19%), while in 410 cycles, no good quality embryo was available resulting in the transfer of two embryos (double embryo transfer, DET). No significant differences in ongoing pregnancy rates after transfer of fresh embryos were observed between eSET and DET in the first (both 33%), second (36 and 23%, respectively) and third treatment cycles (20 and 24%, respectively). In significantly more eSET cycles compared to DET cycles, could embryos be frozen. This resulted in a significantly higher cumulative pregnancy rate after eSET compared to DET. CONCLUSIONS: In patients younger than 38 years with at least one top quality embryo, eSET can be the transfer policy of choice in at least the first three treatment cycles, since the pregnancy rates obtained in each treatment cycle are comparable to those after DET. Introduction Multiple pregnancy rates are high in assisted reproductive technology (ART) cycles. Recently, the European IVF-monitoring programme of the European Society of Human Reproduction and Embryology (ESHRE) reported a 26.3% multiple delivery rate in 258 460 IVF/ICSI treatment cycles initiated during 1999 in 22 countries (ESHRE, 2002). The majority of multiple deliveries after IVF and ICSI concern twins, representing 24.0% of all deliveries (ESHRE, 2002). Twin pregnancies must be regarded as a serious complication of ART cycles, with relatively high risks of health problems in the children (both during the pre- and perinatal period and later in life) and their mothers, social problems, and high economic costs (ESHRE Capri Workshop, 2000; Gerris et al., 2004). The high twin pregnancy rate after IVF is the result of the current standard practice of transferring more than one embryo. The elective transfer of only a single embryo (eSET) has been shown to be an effective method to reduce the incidence of twin pregnancies in twin-prone IVF/ICSI patients without compromising the overall ongoing pregnancy rate (Vilska et al., 1999; ESHRE Campus Course Report, 2001; Gerris et al., 2001, 2002; Martikainen et al., 2001; Tiitinen et al., 2001, 2003; De Neubourg and Gerris, 2003). It was recently recommended by the ESHRE consensus meeting on risks and complications in ART that eSET should be proposed in the first and second treatment cycles (Land and Evers, 2003). Since 2003 in Belgium, SET in the first, and eSET in the second treatment cycle is mandatory in patients younger than 36 years of age, to obtain maximal reimbursement of the costs of IVF treatment (Ombelet, 2004,). However, little information is available on eSET results to substantiate this proposal to limit eSET to the first two treatment cycles. In the present study we evaluate the results per treatment cycle number in a cohort of patients in whom eSET was offered as the standard transfer policy during the first three treatment cycles. Materials and methods Patients All IVF/ICSI patients who started their first treatment cycle in the period from July 2000 until December 2001 in the academic hospital Maastricht were included in this study. A treatment cycle was defined as an ovarian s timulation cycle which resulted in an ovum pick-up. In the study period eSET was offered as our standard transfer policy (see below) to patients younger than 38 years at the time of transfer, irrespective of the rank of the cycle and of previous IVF results. Only patients who were 38 years or older, patients with a strong wish for the transfer of either one or two embryos, patients who had a medical or socio/psychological reason to prevent a twin pregnancy, and patients requesting preimplantation genetic diagnosis (PGD) were excluded from the standard eSET policy. In the stud (...truncated)