Clinical |
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:
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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