Gestational carrier pregnancy outcomes from frozen embryo transfer depending on the number of embryos transferred and preimplantation genetic testing: a retrospective analysis.

OBJECTIVE: To compare gestational age, birth weight (BW), and live birth rates in gestational carriers (GC) after the transfer of 1 or 2 frozen embryo(s) with or without preimplantation genetic testing for aneuploidy (PGT-A), with the understanding that several social and economic factors may motivate intended parents to request the transfer of 2 embryos and/or PGT-A when using a GC. DESIGN: Retrospective cohort study SETTING: An assisted reproductive technology practice. PATIENT(S): All frozen blastocyst transfers with GCs from 2009-2018. INTERVENTION(S): One or 2 embryo frozen embryo transfers with and without PGT-A. MAIN OUTCOME MEASURE(S): Live birth, preterm birth, and low BW. RESULTS: A total of 583 frozen embryo transfer cycles with vitrified high-grade blastocysts (grade BB or higher) to GCs were analyzed. Although the live birth rate was significantly greater in frozen embryo transfers with 2 embryos, after single embryo transfer (SET), the mean gestational age and BW of live births were statistically significantly greater than those of double embryo transfer (DET). The rate of multiple births was 1.9% for SET compared to 20.0% for DET per transfer. Only 3.8% of live births from SET experienced low BW and 0.6% had very low or extremely low BW. By comparison, 12.5% of DET live births were low BW and 5% were very low BW. After SET, 13.4% of live births were preterm, compared with 40% in DET. The analysis also included a total of 194 transfers with PGT-A compared to 389 cycles without. Overall, live births per transfer were not significantly different between these latter 2 subgroups. CONCLUSION: Frozen embryo transfer cycles in GCs with DET were associated with more preterm births and lower birth weights compared with those of SET. Intended parents and GCs should be counseled that DET is associated with greater risks of adverse pregnancy and perinatal outcomes, which mitigates higher live birth rates. The use of PGT-A did not appear to improve the live birth rate.

Successful elective and medically indicated oocyte vitrification and warming for autologous in vitro fertilization, with predicted birth probabilities for fertility preservation according to number of cryopreserved oocytes and age at retrieval.

OBJECTIVE: To evaluate a single treatment center's experience with autologous IVF using vitrified and warmed oocytes, including fertilization, embryonic development, pregnancy, and birth outcomes, and to estimate the likelihood of live birth of at least one, two, or three children according to the number of mature oocytes cryopreserved by elective fertility preservation patients. DESIGN: Retrospective cohort study. SETTING: Private practice clinic. PATIENT(S): Women undergoing autologous IVF treatment using vitrified and warmed oocytes. Indications for oocyte vitrification included elective fertility preservation, desire to limit the number of oocytes inseminated and embryos created, and lack of available sperm on the day of oocyte retrieval. INTERVENTION(S): Oocyte vitrification, warming, and subsequent IVF treatment. MAIN OUTCOME MEASURE(S): Post-warming survival, fertilization, implantation, clinical pregnancy, and live birth rates. RESULT(S): A total of 1,283 vitrified oocytes were warmed for 128 autologous IVF treatment cycles. Postthaw survival, fertilization, implantation, and birth rates were all comparable for the different oocyte cryopreservation indications; fertilization rates were also comparable to fresh autologous intracytoplasmic sperm injection cycles (70% vs. 72%). Implantation rates per embryo transferred (43% vs. 35%) and clinical pregnancy rates per transfer (57% vs. 44%) were significantly higher with vitrified-warmed compared with fresh oocytes. However, there was no statistically significant difference in live birth/ongoing pregnancy (39% vs. 35%). The overall vitrified-warmed oocyte to live born child efficiency was 6.4%. CONCLUSION(S): Treatment outcomes using autologous oocyte vitrification and warming are as good as cycles using fresh oocytes. These results are especially reassuring for infertile patients who must cryopreserve oocytes owing to unavailability of sperm or who wish to limit the number of oocytes inseminated. Age-associated estimates of oocyte to live-born child efficiencies are particularly useful in providing more explicit expectations regarding potential births for elective oocyte cryopreservation.

Single vitrified blastocyst transfer maximizes liveborn children per embryo while minimizing preterm birth.

OBJECTIVE: To compare live-birth rates, blastocyst to live-birth efficiency, gestational age, and birth weights in a large cohort of patients undergoing single versus double thawed blastocyst transfer. DESIGN: Retrospective cohort study. SETTING: Assisted reproduction technology (ART) practice. PATIENT(S): All autologous frozen blastocyst transfers (FBT) of one or two vitrified-warmed blastocysts from January 2009 through April 2012. INTERVENTION(S): Single or double FBT. MAIN OUTCOME MEASURE(S): Live birth, blastocyst to live-birth efficiency, preterm birth, low birth weight. RESULT(S): Only supernumerary blastocysts with good morphology (grade BB or better) were vitrified, and 1,696 FBTs were analyzed. No differences were observed in patient age, rate of embryo progression, or postthaw blastomere survival. Double FBT yielded a higher live birth per transfer, but 33% of births from double FBT were twins versus only 0.6% of single FBT. Double FBT was associated with statistically significant increases in preterm birth and low birth weight, the latter of which was statistically significant even when the analysis was limited to singletons. Of the blastocysts transferred via single FBT, 38% resulted in a liveborn child versus only 34% with double FBT. This suggests that two single FBTs would result in more liveborn children with significantly fewer preterm births when compared with double FBT. CONCLUSION(S): Single FBT greatly decreased multiple and preterm birth risk while providing excellent live-birth rates. Patients should be counseled that a greater overall number of live born children per couple can be expected when thawed blastocysts are transferred one at a time.

Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction.

Much recent progress has been made by assisted reproductive technology (ART) professionals toward minimizing the incidence of multiple pregnancy following ART treatment. While a healthy singleton birth is widely considered to be the ideal outcome of such treatment, a vocal minority continues a campaign to advocate the benefits of multiple embryo transfer as treatment and twin pregnancy as outcome for most ART patients. Proponents of twinning argue four points: that patients prefer twins, that multiple embryo transfer maximizes success rates, that the costs per infant are lower with twins and that one twin pregnancy and birth is associated with no higher risk than two consecutive singleton pregnancies and births. We find fault with the reasoning and data behind each of these tenets. First, we respect the principle of patient autonomy to choose the number of embryos for transfer but counter that it has been shown that better patient education reduces their desire for twins. In addition, reasonable and evidentially supported limits may be placed on autonomy in exchange for public or private insurance coverage for ART treatment, and counterbalancing ethical principles to autonomy exist, especially beneficence (doing good) and non-maleficence (doing no harm). Second, comparisons between success rates following single-embryo transfer (SET) and double-embryo transfers favor double-embryo transfers only when embryo utilization is not comparable; cumulative pregnancy and birth rates that take into account utilization of cryopreserved embryos (and the additional cryopreserved embryo available with single fresh embryo transfer) consistently demonstrate no advantage to double-embryo transfer. Third, while comparisons of costs are system dependent and not easy to assess, several independent studies all suggest that short-term costs per child (through the neonatal period alone) are lower with transfers of one rather than two embryos. And, finally, abundant evidence conclusively demonstrates that the risks to both mother and especially to children are substantially greater with one twin birth compared with two singleton births. Thus, the arguments used by some to promote multiple embryo transfer and twinning are not supported by the facts. They should not detract from efforts to further promote SET and thus reduce ART-associated multiple pregnancy and its inherent risks.

Contribution of male age to outcomes in assisted reproductive technologies.

OBJECTIVE: To evaluate the relationship between male age and pregnancy outcome in donor oocyte assisted reproductive technology cycles. DESIGN: Retrospective cohort. SETTING: Private IVF center. PATIENT(S): A total of 1,392 donor cycles from 1,083 female recipients and their male partners. INTERVENTION(S): Oocyte donor cycles. MAIN OUTCOME MEASURE(S): Live birth. RESULT(S): Increasing male age was associated with semen parameters including volume and motility; however, male age was not observed to have a statistically significant association with likelihood of live birth in donor cycles after adjustment for female recipient age. CONCLUSION(S): When treatment cycle number and female recipient age were taken into account, male age had no significant association with pregnancy outcomes in assisted reproductive technology donor cycles in this study population.

The Suleman octuplets: what can an aberration teach us?

The Suleman case shows that there are "heightened expectations" of our field on the part of our colleagues, the public, legislative and regulatory officials, and our patients. And it can teach us that we have both the history and the promise within our own field to fulfill those heightened expectations through continued clinical progress in promoting safe successful outcomes.

Elective single embryo transfer: a 6-year progressive implementation of 784 single blastocyst transfers and the influence of payment method on patient choice.

OBJECTIVE: To evaluate efforts to reduce twin pregnancies through progressive implementation of elective single embryo transfer (eSET) among select patients over a 6-year period. DESIGN: Retrospective review. SETTING: Private practice IVF center. PATIENT(S): Infertile women undergoing 15,418 consecutive IVF-ET cycles. INTERVENTION(S): IVF-ET, including blastocyst-stage eSET among select patients with good prognosis and high risk of multiple pregnancy. MAIN OUTCOME MEASURE(S): Pregnancy, multiple pregnancy, method of payment. RESULT(S): Pregnancy rates were similar for autologous eSET versus double-blastocyst transfer (65% vs. 63%), while twin rates were much lower (1% vs. 44%). For recipients of donor oocytes, pregnancy rates were slightly lower with eSET (63% vs. 74%), while twin rates were much lower (2% vs. 54%). There was no decrease in overall pregnancy rates, despite a dramatic rise in eSET use over time (1.5% to 8.6% of all autologous transfers and 2.0% to 22.5% of all transfers to donor oocyte recipients between 2002 and 2007). Overall singleton pregnancy rates increased, while twin pregnancy rates declined significantly over time. Use of eSET was significantly more common among patients with insurance coverage or who were participating in our Shared Risk money-back guarantee program. CONCLUSION(S): Selective eSET use among good-prognosis patients can significantly reduce twin pregnancies without compromising pregnancy rates. Patients are more likely to choose eSET when freed from financial pressures to transfer multiple embryos.

A 47-year-old woman with fertility problems who desires a multiple pregnancy.

Mrs Z is a 47-year-old woman with long-standing infertility who is about to undergo in vitro fertilization (IVF) using donor oocytes from an anonymous donor. She has already undergone an IVF cycle with her own oocytes and an IVF cycle using donor oocytes from a known donor without a successful pregnancy. Mrs Z has been advised by her infertility physician to consider the transfer of a single embryo, but she does not wish to decrease her likelihood of conception, and, after her long and expensive infertility saga, wishes to conceive twins. The science of IVF has evolved significantly in the last several years, increasing the likelihood of successful pregnancy and reducing the need to transfer more than 1 embryo with its inherent risks of multiple pregnancy. The state of the science and why patients may continue to want multiple embryos transferred, including costs and lack of insurance coverage for infertility treatments, are discussed.

Salpingectomy or proximal tubal occlusion of unilateral hydrosalpinx increases the potential for spontaneous pregnancy.

BACKGROUND: Studies carried out over the past 10 years have suggested that hydrosalpinges reduce the pregnancy rate in IVF. Here we report our observations of spontaneous pregnancies in patients who underwent salpingectomy (n = 18) or proximal tubal occlusion (n = 7) following diagnoses of unilateral hydrosalpinges and patent contralateral tubes. METHODS: This multi-centre, retrospective study included 25 infertility patients with known unilateral hydrosalpinges with a patent contralateral Fallopian tube. Laparoscopic treatment of unilateral hydrosalpinges by either salpingectomy or tubal occlusion was performed in each patient. Rates of subsequently observed spontaneous pregnancy, and time to pregnancy, are reported. RESULTS: The average duration of infertility in these patients was 3 years with a range of 1-10 years. Following laparoscopic surgical treatment, a total of 22 patients (88%) achieved intrauterine pregnancies, all without IVF treatment. Pregnancies occurred in an average of 5.6 months with a range of 1-21 months. There were no ectopic pregnancies in the study population. CONCLUSIONS: Selected patients with unilateral hydrosalpinges and a patent contralateral Fallopian tube may exhibit increased cycle fecundity after salpingectomy or proximal tubal occlusion of the affected tube and conceive without the need for IVF.

Healthy twin delivery after day 7 blastocyst transfer coupled with assisted hatching.

OBJECTIVE: To report a normal twin delivery after transfer of two fresh day 7 blastocysts. DESIGN: Case report. SETTING: Private infertility clinic. PATIENT(S): A 35-year-old woman with a 6-year history of primary infertility with significant pelvic adhesions. INTERVENTION(S): Review of individual IVF-ET therapy cycle. MAIN OUTCOME MEASURE(S): Full-term delivery after day 7 blastocyst transfer. RESULT(S): During the patient's first IVF-ET cycle, the decision was made to undertake blastocyst transfer after extended culture. No blastocysts had formed until late on day 6, by which time the patient had been hospitalized with a renal stone. Subsequently, on day 7, the patient was asymptomatic and presented for embryo transfer, and after assisted hatching, two expanded blastocysts were transferred to her uterus under ultrasound guidance. After confirmation of implantation of a viable twin, pregnancy was uneventful with no obstetrical complications, and a dizygotic twin was delivered vaginally at 38 weeks of gestation. CONCLUSION(S): Few reports have been made regarding viability of more slowly developing blastocysts; however, this case indicates that blastocysts that did not fully expand until day 7 of extended in vitro culture are still able to implant after superovulation and IVF-ET therapy. Assisted hatching of these embryos may have been beneficial in achieving this successful outcome by hastening the blastocyst hatching, allowing more rapid contact with the endometrium.