PREVENTION OF MULTIPLES FROM A CLINICIANS STANDPOINT Bulent
Urman M.D. American Hospital of Istanbul Slide 2 TRENDS IN EMBRYO
TRANSFER PRACTICE NO LEGAL OR ETHICAL RESTRICTIONS IN THE NUMBER OF
TRANSFERRED EMBRYOS FROM SINGLE TO MULTIPLE EMBRYO TRANSFERS
PREVENTION OF TRIPLETS AND HOMP PREVENTION OF TWINS EARLY 1980s
1985-1995 1995-2000 2000-TODAY PREGNANCY========HEALTHY
BABIES========HEALTHY SINGLE BABY Slide 3 Current Turkish
Legislation A maximum of 3 embryos are allowed to be transferred
The number can be increased if the clinician feels that it is
indicated under special circumstances Slide 4 How many embryos do
we actually transfer? Slide 5 Slide 6 Is there a need to change the
current policy? Should we decrease the number of transferred
embryos? Slide 7 If yes: Questions! Why should we reduce the number
of transferred embryos? How is the success of ART affected? SET vs
DET Are we ready to do it in Turkey? A proposed national model
Slide 8 Factors affecting embryo transfer policy Pressure to be
successful Insurance non coverage Pressure form patients-twins are
the ideal outcome Implantation rates of the individual center
Cryopreservation Availability Uptake Slide 9 Slide 10 From
Blennborn et al. Hum Reprod 2005 The couples decision-making in
IVF: one or two embryos at transfer? Slide 11 Probabilities for
singleton and multiple pregnancies after in vitro fertilization
Peter M. Martin, M.D.,* and H. Gilbert Welch M.D., M.P.H. FERTILITY
AND STERILITYt VOL. 70, NO. 3, SEPTEMBER 1998 Slide 12
Probabilities for singleton and multiple pregnancies after in vitro
fertilization Peter M. Martin, M.D.,* and H. Gilbert Welch M.D.,
M.P.H. FERTILITY AND STERILITYt VOL. 70, NO. 3, SEPTEMBER 1998
Slide 13 Probabilities for singleton and multiple pregnancies after
in vitro fertilization Peter M. Martin, M.D.,* and H. Gilbert Welch
M.D., M.P.H. FERTILITY AND STERILITYt VOL. 70, NO. 3, SEPTEMBER
1998 Slide 14 Probabilities for singleton and multiple pregnancies
after in vitro fertilization Peter M. Martin, M.D.,* and H. Gilbert
Welch M.D., M.P.H. FERTILITY AND STERILITYt VOL. 70, NO. 3,
SEPTEMBER 1998 Slide 15 Pregnancy and live birth rates after the
transfer of 2-3 embryos Number of embryos transferred No of
transfer procedures Number of pregnancies PR/ET %Live birth /
transfer % Two from only two available 81182220 Two from more than
two available 58521336 Three98282928 From Brinsden RBM Online 2003
Slide 16 Factors affecting success in IVF Age Tubal infertility
Previous IVF outcome Gonadotropin dose Initial Total Good quality
embryos Available Transferred Cryopreserved From Strandell et al.
2000 Slide 17 Is there a subset of couples who would benefit from
(no compromise in PR and no twins) from single embryo transfer?
Slide 18 Pregnancy rate according to the number of embryos
transferred From Zhang et al. 2008 Slide 19 Multiple pregnancy rate
according to the number of embryos transferred From Zhang et al.
2008 Slide 20 From Saldeen and Sundstom Hum Reprod 2005 Results of
SET and DET according to embryo morphology Slide 21 Optimal number
of embryos to be transferred based on quality From Hu et al. Fertil
Steril 1998 Slide 22 From Roberts et al. Hum Reprod 2009 Slide 23
Cohort studies of SET vs DET StudyCyclesSingle ETDouble ET PR
%Twins %PR %Twins % Gerris 2002115235.11/12436.235.6 De Sutter 2003
289828.21/16331.730.4 Tiitinen 2003 149434.52/16236.730.1 Catt
200338544.11/4958.844.1 Gerris 200436740.3040.430.8 Martikainen
2004 111134.71/10731.8NA TOTAL740733.91.035.032.6 From Gerris et
al. Hum Reprod Update 2005 Slide 24 Prospective evaluation of
elective single-embryo transfer versus double-embryo transfer
following in vitro fertilization: a two-year French hospital
experience From Leniaud et al. Gynecol Obstet Fertil. 2008
Feb;36(2):159-65 Slide 25 Randomized trials of SET vs DET
StudyCyclesSingle ETDouble ET PR %Twins %PR %Twins % Gerris 1999
5338.5107437 Martikainen 2001 14432.44.147.118.2 Gardner 2004
4860.907647.4 Thurin 2004 66127.61.143.536.1
TOTAL90630.72.147.636.1 From Gerris et al. Hum Reprod Update 2005
Slide 26 From Fiddelers et al. Hum Reprod 2006 Single versus double
embryo transfer: cost-effectiveness analysis alongside a randomized
clinical trial Slide 27 In unselected patients, elective single
embryo transfer prevents all multiples, but results in
significantly lower pregnancy rates compared with double embryo
transfer: a randomized controlled trial From van Monfoort et al.
Hum Reprod 2006 Slide 28 Slide 29 Better embryo selection?
Blastocyst transfer PGS Slide 30 Single vs double blastocyst
transfer: randomized trial Slide 31 Papanikolaou, E. et al. N Engl
J Med 2006;354:1139-1146 Slide 32 A prospective randomized
controlled trial of preimplantation genetic screening in the "good
prognosis" patient From Meyer et al. Fertil Steril 2008 Slide 33
Randomized single versus double embryo transfer: obstetric and
paediatric outcome and a cost-effectiveness analysis From Kjellberg
et al. Hum Reprod 2006 Slide 34 Transfer policy in the American
Hospital Prior to August 2000 Up to 3-4 embryos until the age of 39
5-6 embryos after 40 After August 2000 Maximum 2 good quality fresh
or frozen thawed embryos up to 37 If embryo quality is suboptimal 3
is allowed Maximum 3 good quality fresh or frozen thawed embryos
after 37 If embryo quality is suboptimal 4 is allowed after 40
Slide 35 Transfer edilen ortalama embryo says Slide 36 7300 D3
embryo transferinde klinik gebelik oranlar Slide 37 1100 D5 embryo
transferinde klinik gebelik oranlar Slide 38 Incidence of
singletons, twins, and HOMPs in the American Hospital Slide 39
Number of embryos transferred in view of Efficacy Implantation and
pregnancy rates Side effects Multiple pregnancies Cost
effectiveness Society resources Can the system handle increasing
multiples? Slide 40
