| Prognosis | Age of patient (yr) | |||
|---|---|---|---|---|
| <35 | 35–37 | 38–40 | 41 and 42 | |
| CLEAVAGE-STAGE EMBRYOS* | ||||
| Favorable† | 1 or 2 | 2 | 3 | 5 |
| All others | 2 | 3 | 4 | 5 |
| BLASTOCYSTS* | ||||
| Favorable† | 1 | 2 | 2 | 3 |
| All others | 2 | 2 | 3 | 3 |
| * See text and guidelines for more complete explanations. Justification for transferring one additional embryo (above the recommended limit) should be clearly documented in the patient’s medical record. | ||||
| †Variables indicating favorable prognosis include first cycle of IVF, good embryo quality, availability of excess embryos for cryopreservation, and previous successful IVF cycle. | ||||
WHAT THIS EVIDENCE MEANS FOR PRACTICE
All IVF clinics must adhere to the new SART and ASRM guidelines limiting the number of embryos to transfer at in vitro fertilization. In addition, it is vital for you to counsel the patient about the risk of high-order multiple gestation, and to document that such counseling took place.
Judicious management can reduce the rate of multiple gestation in ovulation stimulation
Dickey RP. Strategies to reduce multiple pregnancies due to ovulation stimulation. Fertil Steril. 2009;91:1–17.
Efforts to reduce the rate of multiple gestation should focus not only on patients undergoing IVF but on those undergoing controlled ovarian stimulation (COS) or ovulation induction. In COS, pharmacologic treatment is used to stimulate the production of more than one oocyte. In ovulation induction, pharmacologic therapy is used to induce normal cycles in anovulatory or oligo-ovulatory women.1 A substantial majority of multiple gestations are conceived using ovarian stimulation and ovulation induction. These methods may be less difficult to manage than IVF because they are less dependent on technology. Like IVF, however, they carry a high risk of multiple gestation, especially high-order multiple gestation.2
Strategies to reduce multiple gestation
As Dickey points out in a comprehensive retrospective analysis, there are strategies that can help reduce multiple gestation during COS and ovulation induction. They include the following recommendations:
Be prepared to cancel a cycle. Initiate ovulation induction only if both patient and physician are prepared to cancel any cycle that involves an excessive number of preovulatory follicles. Singleton and twin births can be confidently expected only if the cycle is cancelled when there are more than two preovulatory follicles approximately 12 mm in diameter or larger. This may be psychologically difficult for some patients and doctors.
Preemptively identify risk factors for multiple gestation, including:
- seven or more preovulatory follicles
- an estradiol concentration of 1,000 pg/mL or higher
- early cycles of treatment (cycles 1–3)
- age younger than 32 years
- body mass index below 19 kg/m2
- use of donor sperm.
When any of these risk factors is present, consider starting the patient on a lower initial dosage of gonadotropin; perform more frequent monitoring; maintain a low threshold for cancellation; and consider performing IVF with single-embryo transfer rather than COS.
Use specific drugs. Increase the likelihood of monofollicular development and double-follicular recruitment and reduce the risk of high-order multiple gestation by using clomiphene citrate, a low dosage of gonadotropin, or pulsatile gonadotropin-releasing hormone (GnRH) in the initial three or four cycles.
Continue treatment for five or more cycles to achieve an overall pregnancy rate approaching 65% without high-order multiple gestation in patients younger than 38 years who develop one or two follicles in a cycle.
Don’t rely on multifetal pregnancy reduction
This strategy has been viewed by some as a way to control the outcome of multiple gestation. For example, this is a common approach in New York, New Jersey, and Connecticut. However, the procedure has pitfalls and should not be the primary means of reducing the rate of multiple gestation because:
- It is not an acceptable option for many patients
- All fetuses may be lost in some cases
- The risks associated with multiple gestation are not completely eliminated
- It may have adverse psychological consequences.3,4
A registry is needed
Although a registry exists for IVF cycles and their outcomes and complications, none exists for cycles involving COS or ovulation induction. Despite many challenges to its development, we support the creation of such a registry.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
It is vital that you develop the expertise and adopt strategies to reduce the rate of multiple gestation associated with controlled ovarian stimulation and ovulation induction. If you chose not to do so, refer the patient to someone who has such expertise.
Consider the patient’s emotional status when determining treatment for infertility
Domar AD, Smith K, Conboy L, Iannone M, Alper M. A prospective investigation into the reasons why insured United States patients drop out of in vitro fertilization treatment. Fertil Steril. 2009 Jul 8 [Epub ahead of print].
Most physicians have been trained to concentrate on the physiologic diagnosis and management of disease. Many fertility specialists also pay attention to economic barriers to treatment, such as lack of insurance and high cost, and attempt to help their patients gain access to quality care. One aspect of infertility that might be overlooked, however, is the patient’s emotional health—but it may be as important to the success of treatment as physiologic and economic variables.