Guidance on the limits to the number of embryos to transfer: a committee opinion.

On the basis of American Society for Reproductive Medicine and Society for Assisted Reproductive Technology data, the American Society for Reproductive Medicine's guidelines for the limits on the number of embryos to be transferred during in vitro fertilization cycles have been further refined in continuing efforts to promote singleton gestation and reduce the number of multiple pregnancies. This version replaces the document titled "Criteria for number of embryos to transfer: a committee opinion" that was published most recently in August of 2017 (Fertil Steril 2017;107:901-3).

Committee Opinion No. 719 Summary: Multifetal Pregnancy Reduction.

Although not all multifetal pregnancies occur after the use of assisted reproductive technology, fertility treatments have contributed significantly to the increase in multifetal pregnancies. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy. When multifetal pregnancies do occur, incorporating the ethical framework presented in this Committee Opinion will help obstetrician-gynecologists counsel and guide patients as they make decisions regarding continuing or reducing their multifetal pregnancies.

Committee Opinion No. 719: Multifetal Pregnancy Reduction.

Although not all multifetal pregnancies occur after the use of assisted reproductive technology, fertility treatments have contributed significantly to the increase in multifetal pregnancies. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy. When multifetal pregnancies do occur, incorporating the ethical framework presented in this Committee Opinion will help obstetrician-gynecologists counsel and guide patients as they make decisions regarding continuing or reducing their multifetal pregnancies.

ACOG Committee opinion no. 553: multifetal pregnancy reduction.

Fertility treatments have contributed significantly to the increase in multifetal pregnancies. The first approach to the problem of multifetal pregnancies should be prevention, and strategies to limit multifetal pregnancies, especially high-order multifetal pregnancies, should be practiced by all physicians who treat women for infertility. Incorporating the ethical frameworks presented in this Committee Opinion will help physicians counsel and guide patients when making decisions regarding multifetal pregnancy reduction. In cases of high-order multifetal pregnancies, counseling should include the availability of multifetal pregnancy reduction. Fellows should be knowledgeable about the medical risks of multifetal pregnancy, the possible medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent in decisions regarding the use of multifetal pregnancy reduction. Physicians should not be required to act in ways that conflict with their value systems but should be prepared to react in a professional and ethical manner to patient requests for both information and intervention.

Selective termination procedures in monochorionic pregnancies.

Monochorionic twins have placental anastomoses that to varying degrees create a common circulation. This presents unique challenges for the performance of selective fetal termination in cases of twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, or discordant twin abnormalities. Multiple methods of interrupting the affected twin's circulation have been attempted with variable success. One of the most frequent complications of any approach is iatrogenic preterm premature rupture of membranes. Laser coagulation in the midtrimester appears to be safe and effective; however, it is only available at limited centers. Currently, bipolar coagulation is the method of choice in the second half of pregnancy. The recently reported technique of radiofrequency ablation appears to be successful with minimal complications. Exploration of further percutaneous and noninvasive techniques, as well as interventions to decrease the morbidity arising from preterm membrane rupture, may lead to increased survival of the remaining twin and reduced risk of maternal complications.

Multifetal pregnancies: evolution of methods of initiation and impact of REI certification for patients seeking reduction.

OBJECTIVE: Multifetal pregnancy as a result of ovulation induction (OI) and assisted reproductive technologies (ART) correlate with Board certification in reproductive endocrinology and infertility (REI). DESIGN: Retrospective chart analysis of 304 patients referred to Wayne State University (WSU) and Thomas Jefferson University (TJU) for multifetal pregnancy reduction (MFPR) from March 1986 to January 1995 compared to 275 patients referred from January 1 to December 31, 2000 at MCP Hahnemann University. MATERIAL AND METHODS: Chart review for fetal number, pregnancy generation (OI or ART) and physician REI Board certification from the American Board of Specialties Obstetrics and Gynecology. Information was available on 296 of 304 patients studied in the 1986-1995 WSU cohort and 275 patients studied from the MCP Hahnemann 2000 cohort. RESULTS: Analysis of 296 multifetal pregnancies at WSU and TJU for REI Board status showed non-REI Board-certified (NREI) physicians generated 174 pregnancies with quadruplets or more compared to 122 quadruplets or more by REI Board-certified physicians. Board certification did not impact quadruplet or more rates for OI or ART (p < 0.368). Of 275 patients with triplets or more at MCP Hahnemann, 156 (56.7%) were from ARTs versus 41.2% from 1986-1995 (chi(2) = 13.1, p < 0.001). Quintuplets or more decreased from 18.5 to 9.7% (chi(2) = 8.3, p = 0.004), and for REIs from 22.1 to 9.6% (chi(2) = 4.7, p < 0.01), while 14.4% of cases coming from non-REIs had quintuplets versus 9.6% from REIs (p = NS). CONCLUSIONS: Cases of MFPR from ARTs have risen, while percentage of cases with quintuplets have fallen in half. We found no difference in quintuplets between REIs and non-REIs overall, but REI quintuplets fell significantly, and NREI has not.

Controversial issues in the management of multiple pregnancies.

The management of multiple pregnancies represents a true challenge for all sub-specialties concerned with perinatal medicine. Many issues were neglected over the years merely because they were rare and therefore considered not sufficiently important to merit clinical trials. This paper discusses a personal selection of controversial issues, such as multifetal pregnancy reduction of triplets and twins, special cases in multifetal pregnancy reduction, need for invasive genetic studies, management of twin-twin transfusion, discordant fetal conditions, the definition of "term" in multiples, and the controversy about the mode of delivery.

Transvaginal reduction of an interstitial heterotopic pregnancy with preservation of the intrauterine gestation.

With use of transvaginal ultrasonographic guidance, cardiac activity in an interstitial heterotopic pregnancy at 7 weeks' gestation was terminated. The interstitial pregnancy resolved, and a healthy term infant was delivered. If an early diagnosis of an interstitial heterotopic pregnancy is made, selective reduction may allow preservation of the intrauterine gestation without surgery.

[Multiple pregnancies prevention in in vitro fertilization: limiting the number of transferred embryos to two maximum?]. / Prevention des grossesses multiples en FIV: vers une limitation a deux embryons replaces au maximum?

The success of an IVF-programme is mainly linked to the number and quality of embryos transferred as well as women's age, but the incidence of obstetrics complications rises significantly with the number of fetuses. Reducing the number of embryos transferred is therefore recommended in order to avoid the medical, social and financial problems associated with multiple births. Present data suggest that, when at least three embryos of good quality are available, the pregnancy rate already reaches its maximum value when two embryos are transferred. A third one merely increases the number of triple pregnancies. Further studies are needed to conclude, especially in the cases of poor quality embryos.