Increased Success and Safety in Assisted Reproductive Technology By Using Elective Single Embryo Transfer
Washington, DC—Over the past decades, the use of assisted reproductive technology (ART) has increased globally, making pregnancy possible for many couples. With improved technology and increased access to data, obstetrician-gynecologists and patients have safer and more effective options available to them than ever before. The updated Committee Opinion, “Perinatal Risks Associated With Assisted Reproductive Technology,” from the American College of Obstetricians and Gynecologists (ACOG), evaluates the most up-to-date data on outcomes using ART, specifically focusing on IVF.
Today, more than 1.5 percent of all infants born annually in the United States are the result of pregnancies achieved through ART. As this number continues to grow, it is critical health care providers are prepared to discuss the benefits and risks of ART with patients who are considering the procedure. Even as technology and knowledge around ART increase, some risks remain, including multifetal gestations, prematurity, low birth weight, small for gestational age, perinatal mortality, caesarean delivery, preeclampsia, and birth defects. However, it remains unclear to what extent these associations might be related to the underlying causes of infertility. For this reason, patient counseling should also include information about these risks, with counseling ideally occurring in advance of infertility treatment.
With ART, higher-order multifetal pregnancy (twins, triplets, quadruplets, etc) may occur—the greatest risk associated with ART. Multifetal pregnancies have numerous associated complications for the health of both mother and fetuses, including increased fetal morbidity. In response to these potential outcomes, the updated Committee Opinion urges providers to do everything possible to reduce the likelihood of a multifetal pregnancy.
There are several known methods to limit multifetal pregnancies when using ART, including the use of low-dose stimulation protocols, close monitoring of hormone levels and follicle numbers during superovulation cycles, as well as giving patients the option of elective single embryo transfers (eSET). In particular, several studies demonstrate eSET achieves high rates of pregnancy, while simultaneously contributing to a drastic reduction in multifetal pregnancy. Already, we have begun to see the positive effects of these strategies. In 2009 approximately 50 percent of ART infants were from multifetal pregnancies but by 2014 78 percent of ART infants were single fetuses. Although patients may perceive financial disincentives to reducing the number of embryos transferred per cycle, current efforts such as increasing insurance coverage for ART and shared risk arrangements between patients and infertility providers may reduce these perceived financial risks.
“Over the past decades our understanding and capability around ART have come a long way,” said Dr. Joseph Wax, chair, Obstetrics Practice, ACOG. “While multifetal pregnancy is a commonly associated risk with ART, it is increasingly preventable. Reducing this possibility not only protects mother and fetus, but ultimately increases the likelihood that patients achieve their goal of a healthy and successful pregnancy.”
As with all medical procedures, each woman has the right to make a medically informed decision about her fertility treatments. In the case of ART, this begins with a discussion of the strategies outlined above, why they are recommended, and their respective risks.
On the topic of informed and shared decision making about ART, Dr. Wax added, “Pursuing ART is a deeply personal and significant decision for patients. It is our responsibility as providers to ensure patients and their partners are properly informed throughout the process. While we may refer many of our patients seeking ART to an infertility specialist, this process may still require ob-gyns to be capable of talking about the process comprehensively, acknowledging the risks balanced against the external factors that might influence patients’ choices.”
In some cases, multifetal pregnancies, and other risks associated with ART will arise in spite of preventive actions. In these cases, doctors and patients should discuss the options for management or treatment of the complication and determine a course of action that is best for mother and fetus(es).
Committee Opinion Number 671, ‘Perinatal Risks Associated With Assisted Reproductive Technology,’is available in the September 2016 issue of Obstetrics and Gynecology.
For more information and resources visit acog.org.
Other recommendations issued in the August Obstetrics & Gynecology:
Insect Repellants During Pregnancy in the Era of the Zika Virus
Based on available data for N,N-diethyl-meta-toluamide (DEET) and permethrin, health care providers and patients should have little reservation about recommended use during pregnancy for Zika virus prevention.
Blair J. Wylie, Marissa Hauptman, Alan D. Woolf, Rose H. Goldman
Committee Opinion #672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods
Long-acting reversible contraceptive methods are the most effective reversible contraceptives and have an excellent safety record. Although uncommon, possible long-acting reversible contraceptive complications should be included in the informed consent process. Obstetrician–gynecologists and other gynecologic care providers should understand the diagnosis and management of common clinical challenges. The American College of Obstetricians and Gynecologists recommends the algorithms included in this document for management of the most common clinical challenges.
Committee Opinion #673, Persistent Vulvar Pain
Persistent vulvar pain is a complex disorder that frequently is frustrating to the patient and the clinician. It can be difficult to treat and rapid resolution is unusual, even with appropriate therapy. Vulvar pain can be caused by a specific disorder or it can be idiopathic. Idiopathic vulvar pain is classified as vulvodynia. Although optimal treatment remains unclear, consider an individualized, multidisciplinary approach to address all physical and emotional aspects possibly attributable to vulvodynia. Specialists who may need to be involved include sexual counselors, clinical psychologists, physical therapists, and pain specialists. Patients may perceive this approach to mean the practitioner does not believe their pain is “real”; thus, it is important to begin any treatment approach with a detailed discussion, including an explanation of the diagnosis and determination of realistic treatment goals. Future research should aim at evaluating a multimodal approach in the treatment of vulvodynia, along with more research on the etiologies of vulvodynia.
Committee Opinion #674, Guiding Principles for Privileging of Innovative Procedures in Gynecologic Surgery
New or emerging surgical procedures and technologies continue to be developed at a rapid rate and must be implemented safely into clinical practice. Additional privileging may be required if substantively new technical or cognitive skills are required to implement an innovative procedure or technology. Guiding principles for privileging should include cognitive and technical assessment to ensure appropriate patient selection and performance of the new procedure. Implementation also should include pertinent institutional and staff support as needed. A dynamic process for assessment and maintenance of current competency will enhance the safety of implementation and continued application of emerging procedures and technologies. The number of cases needed to demonstrate cognitive and technical proficiency will vary depending on many factors, including the health care provider’s baseline expertise and technical acumen.
Obstetric Care Consensus, Severe Maternal Morbidity: Screening and Review
This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.
Practice Bulletin #166, Thrombocytopenia in Pregnancy
Thrombocytopenia in pregnant women is diagnosed frequently by obstetricians because platelet counts are included with automated complete blood cell counts (CBCs) obtained during routine prenatal screening (1). Although most U.S. health care providers are trained using U.S. Conventional Units, most scientists, journals, and countries use Système International (SI) units. The laboratory results reported in U.S. Conventional Units can be converted to SI Units or vice versa by using a conversion factor. The conversion factor for platelet count results is 1.0 (ie, to convert from x 103/μL, multiply by 1.0, to get x 109/L). Thrombocytopenia, defined as a platelet count of less than 150 x 109/L, is common and occurs in 7–12% of pregnancies (2, 3). Thrombocytopenia can result from a variety of physiologic or pathologic conditions, several of which are unique to pregnancy. Some causes of thrombocytopenia are serious medical disorders that have the potential for maternal and fetal morbidity. In contrast, other conditions, such as gestational thrombocytopenia, are benign and pose no maternal or fetal risks. Because of the increased recognition of maternal and fetal thrombocytopenia, there are numerous controversies about obstetric management of this condition. Clinicians must weigh the risks of maternal and fetal bleeding complications against the costs and morbidity of diagnostic tests and invasive interventions.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org