Elective Single Embryo Transfer (eSET);

How Much Reasonable ?

Rifat H. Gürsoy ,M.D.Gazi University School of Medicine

Dept. Of Ob/GynReproductive Endocrinology & Infertility

DivisionAnkara-TURKEY

Background

• Multiple embryo tranfer during IVF has increased multiple pregnancy rates (MPR) causing maternal and perinatal morbidity

• Elective single embryo transfer (eSET) is now being considered as an effective means of reducing this iatrogenic complications

Background

Women undergoing treatment with IVF face to an approximately 20-fold increased risk of twins and 400-fold risk of higher order pregnancies

Background

When compared with single births, twins have a 4-fold increased risk of mortality and for triplets the risk is 6-fold higher.

The Perinatal Mortality Rate in England(1995)

• General : 8.7 / per 1000

• IVF singletons: 8.8 / per 1000

• IVF twins :46.8 / per 1000

• IVF triplets : 82.6 / per 1000

• All IVF births: 22.6 / per 1000

Multiple Gestations

• Increased incidence of preterm births

• Handicapped infants

–Twins : 1/13

–Triplets : 1/5

• Higher malformation rates with IVF/ICSI

Obstetric Complications ofMultiple Gestations

• Miscarriage

• Pregnancy Induced Hypertention

• Gestational Diabetes

• Premature Labour

• Abnormal Delivery

• Higher C/S indications

Economic Impact ofMultiple Gestations

• The increased cost associated with prenatal care twin and higher order pregnancies

• The cost of the subsequent neonatal intensive care

Parenthood of Multiple Gestations

• Practical dificulties

• Residuel stress

• Demand of more resources

• Emotional stress

Strategies to Minimise the Multiple Pregnancies

• Multi-fetal pregnancy reduction (MFPR)

• Individualised embryo transfer policy

• Blastocyst transfer

• Elective single embryo transfer

Elective Single Embryo Transfer(eSET)

Untill recently, eSET was not an optional in clinical practice, for fear tahat the overall success rates would decline , too far

Reason of This Presumption

• Published data of single embryo transfer where only one embryo was available

• No opportunity for selection of more suitable embryos exists

• Poor potential of the only available embryo (around 10%)

Single Embryo Transfer(Vilska ,1999-Finland)

PR (%)

Only 1 embryo available 20.2

After selection 29.7

eSET + 1frozen/ thawed 47.3 (CPR)

DET vs SET , LBR

DET vs SET , CPR

DET vs SET ,MPR

DET vs SET ,Abortion

DET vs SET+FZET , LBR

DET vs SET+FZET ,CPR

DET vs SET+FZET ,MPR

DET vs 2 f-SET, LBR

DET vs 2 f-SET, CPR

DET vs 2 f-SET, MPR

DET vs 2 f-SET, Abortion

DET vs TET , MPR

CONCLUSIONS-I

• In a single fresh IVF cycle, eSET is associated with a lower LBR than DET

• There is no significant difference in CLBR following SET+1 FZET and the LBR following a single cycle of DET

• MPR are lowered following SET compared with other transfer policies

Registry• European Society of Human Reproduction &

Embryology (ESHRE)

• Australian & New Zealand Assisted Reproduction Database (ANZARD)

• The International Committee for Monitoring Assisted Reproductive Technology (ICMART)

• Canadian ART register

• Society of Assisted Reproductive Technology, USA (SART)

• Human Fertilization & Embryology authority (HFEA, UK)

# 47 348 (20.0%) SET - Avrupa 2005 ; Sweden (69.4%), Finland (49.7%), Belgium (48.0%), Denmark (32.6%), Slovenia (30.0%), Bulgaria (8.5%), US 2007 (2.8%), Avustralya (56.9%), Kanada (11%), Latin Amerika (6.5%), Japonya (54.8%)

69.4

%

2.8

%

CONCLUSIONS-II

• e-SET may be an effective policy regarding to lower the incidence of high order pregnancies

• But should not to be considered as the only and the sole choice