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A Human Fertilisation and Embryology Authority (HFEA) expert group has reported today that single-embryo transfer is the best prognosis for UK IVF patients.
Mr Peter Bowen-Simpkins, Royal College of Obstetricians and Gynaecologists, said:
“A decision to recommend single embryo transfer to women under the age of 35 is a pragmatic step forwards, in an attempt to reduce the incidence of multiple pregnancy, with its associated morbidity to both the babies and the mother.
“Evidence from Scandinavia strongly suggests that success rates do not drop, provided that frozen embryo transfer is offered in the event of the first treatment cycle failing. The Government will need to reassess the funding of IVF within the NHS.”
Dr Mohamed Taranissi, Medical Director of the Assisted Reproduction And Gynaecology Centre (ARGC), said:
“Actually the percentage of twin births as a result of IVF is quite small – less than 20% of the total number of twins born. Also many of the figures quoted seem to be from before the new policy of transferring two embryos – I think experts should allow some more time to make a proper assessment of the impact of the change – we may well find that the number of multiples births is already reduced.
“The vast majority of clinics are transferring embryos on the second or third day where most embryos may look fine but it’s really too early to be sure of the quality of the embryo making it a complete lottery as to whether you have actually transferred the best quality embryo. Perhaps the working group should look at this issue and recommend that more clinics move towards extended culture – leaving the embryos for a few more days to improve the chances of transferring a good quality single embryo.
“I am not against single embryo transfer but any restrictive policy on this would be counter to the principles of good medicine – that the clinician makes decisions about treatment based on the individual. Not only is every woman different but every cycle is different. The people who understand this best are the patients and their doctors. If the HFEA moved towards adopting single embryo transfer indiscriminately – it would probably result in a small decrease in twins but a larger number of people who do not become pregnant.”
Professor Alison Murdoch, Professor of Reproductive Medicine and Head of Surgical and Reproductive Sciences Department at Newcastle University, said:
“I am pleased that the Report recognises the importance of funding. As long as most patients are required to fund their IVF treatment themselves, it is likely that financial arguments about the cost of twin pregnancies to the NHS will fall on deaf ears.
“This is a complex issue which balances the suffering of those who wish to be parents against the risk that they might have a disabled child. Since the risk for an individual couple of having a baby with disabilities is relatively low, it is not surprising that they may request the most cost-effective option for their purse and want two embryos transferred. This gives a chance of twins and completion of the family with one treatment.”
Professor Chris Barratt, Professor of Andrology at University of Birmingham Medical School, said:
“One quarter of live births are currently twins. Even though this is perceived as a success – the truth is that it’s much better for all concerned to have one child at a time. We should be aiming for a twin birth rate that is much lower than that – more like less than 5% of births as twins.”
Dr Mark Hamilton, Chair of the British Fertility Society (BFS), said:
“The BFS welcomes this report. Nearly 40000 IVF treatment cycles are carried out each year in the UK. The outcome of a safe live birth of a healthy child is the goal for all our patients. Clinics in the UK are aware that as clinical and laboratory skills have increased the likelihood of embryo implantation has also risen. If more than one embryo is replaced in the uterus the chance of multiple implantation will inevitably be higher than if a single embryo transfer takes place.
“The BFS strongly supports the proposition that clinics should take account of the known hazards of multiple pregnancy in determining the number of embryos to replace in any treatment cycle. If the pregnancy potential for a given treatment cycle is high then a single embryo only should be transferred and any additional embryos stored for future use.
“Commissioners of IVF treatment should take account of these recommendations in determining purchasing policies in this area of clinical practice. A cycle of IVF should include not only the transfer of the fresh embryo but also the subsequent opportunity to replace any additional stored embryos. The BFS has previously recommended to commissioners that a standardised approach to funding IVF should apply throughout the country. Current evidence, more than 2 years after the Secretary of State for Health committed the government to the principle of equity of access to treatment, SHOWS THAT the post-code based variation in access to effective treatment continues. This situation is not acceptable.”
A spokesperson from the Royal College of Nursing (RCN) Fertility Nurses Group, said:
“The RCN welcomes this excellent report and wholeheartedly supports the conclusions reached by the expert group. We appreciate the considerable health risks for the babies and increased complications for mothers. We also believe that equity of access throughout the UK to NHS-funded IVF and full implementation of the NICE guidelines is crucial for patients to feel confident about moving to single embryo transfer as the norm.
“The RCN Fertility Nurses Group is also very concerned about the increasing numbers of couple going overseas for fertility treatment and how this may effect our multiple birth rates in the UK. We must all work together to raise awareness of the considerable risks of multiple pregnancy.”
Ms Jane Denton, Director of the Multiple Births Foundation, said:
“The aim of all infertility treatment should be to have one live, healthy baby. The anguish of watching one or more of your children die or living with a severe disability is a situation no parent would wish to face, yet it is a frequent consequence of multiple births that is so often underestimated. Even with healthy children, the practical, emotional and financial demands and difficulties of caring for twins can be overwhelming.
“The Multiple Births Foundation welcomes this excellent, comprehensive report and hopes the recommendations will be speedily addressed.”
Dr Simon Fishel, Director of the CARE Fertility Group, said:
“It is literally vitally important that all IVF practitioners practice in a responsible way to maximise their patients chance of becoming pregnant, whilst considering the welfare of the baby. However, it is well established that across all age ranges up to 50% of embryos, on average, carry a chromosome abnormality preventing its development or increasing the likelihood of an early miscarriage. Hence, it is uncontroversial that with current IVF practice, in which we cannot select the most viable embryos, by limiting the choice to only one per transfer the success rates across all age ranges will inevitably decline per treatment cycle or per embryo transfer. As the HFEA promulgates its audited data on a per cycle basis we shall see a significant reduction in pregnancy rates reported by this measure.
“However, with improved freezing technology it is likely we will not see a decline in overall pregnancy rates if the data is presented on a per egg collection basis (i.e. there might be 5 embryo transfers per egg collection – one fresh and 4 frozen, say, but one pregnancy per event – if the event is measured as one egg collection; or per 5 events if measured as each embryo transfer). CARE Fertility advocates eliminating any risk of multiple pregnancy. However, for all UK practitioners to favour single embryo transfers the HFEA will need to review its published data, patients must understand they will need more visits to the clinic (hence, costs likely to rise) and having babies from frozen embryos will be more common until there is newer technology that allows practitioners to select the most viable embryo. Recently CARE Fertility announced a clinical trial to evaluate such technology which, we hope, in the latter half of 2007 might bring us nearer to IVF’s ‘holy grail’ – ‘one embryo, one baby’.”
Helen Forbes, Director of Tamba (Twins & Multiple Births Association), said:
“Tamba acknowledges the risks that multiple pregnancies bring to mother and babies, and the ongoing financial and practical pressures of bringing up two or more children of the same age. However, the decision on how many embryos should be replaced in an IVF cycle is a matter for individuals to discuss with their clinicians. Where IVF treatment does result in a multiple pregnancy Tamba is able to support these families, and the thousands of others who conceive twins naturally each year, no matter what the outcome may be. Our unique support services include a helpline and specialist support groups for families with special needs multiples and those who have lost one or more babies from a multiple pregnancy.”
Professor Arne Sunde, University of Trondheim (Norway) and former chairman of the European Society of Human Reproduction and Embryology (ESHRE), said:
“The ultimate goal of all medically assisted procreation must be a singleton pregnancy. Even with the many advances in techniques over recent years, there are far too many multiple pregnancies, which carry risks for the children and their mothers.
“Experience in Nordic countries, in many of which single embryo transfer (SET) is the rule, has shown that although the birth-rate per transfer with fresh SET as opposed to double or multiple egg transfer is lower, when frozen embryo transfer is included the cumulative birth-rate per egg recovery does not go down, and the multiple pregnancy rate can be reduced to below 5% without reducing this cumulative birth rate. A successful SET programme therefore demands a good quality embryo freezing programme, and fertility experts across Europe should be putting their weight behind this.”
Clare Brown, Chief Executive of I N UK (Infertility Network UK), said:
“We share medical concerns regarding the risks of multiple births, both to the mother and children born. In conjunction with the National Infertility Awareness Campaign (NIAC) we would support a move towards single embryo transfer, but would stress the need to ensure that:
the NICE fertility guideline is implemented in full, so that couples would be able to receive up to 3 full cycles of IVF on the NHS, and
a full cycle includes frozen embryo transfer
“Despite the NICE guidelines there are still Primary Care Trusts who are not funding any treatment whatsoever, some who previously funded are now pulling funding and many are only funding one single cycle with restrictive and unfair social eligibility criteria. Without full implementation of the NICE guideline patients will not support any move towards single embryo transfer.
“Infertility Network UK and the National Infertility Awareness Campaign call on the Department of Health and the Welsh Assembly to issue clear instructions to PCTs in England and Health Boards in Wales they must fully implement the NICE guideline, including frozen embryo transfer as quickly as possible. We also call on the governments in Scotland and N. Ireland to ensure equality of provision.
“Improving embryo selection is also vital and further research is needed to ensure that single embryo transfer does not compromise success rates for patients.
“Savings which would be made on the cost of neonatal care should be put towards implementing the three cycles recommended by NICE giving patients a much greater chance of success. In countries such as Belgium and Denmark where SET is the norm, couples are able to have six and five attempts respectively.”
Yacoub Khalaf MSc, MD, MRCOG, Consultant in Reproductive Medicine & Surgery Lead Clinician, The Assisted Conception Unit, Guy’s Hospital London, said:
“Further to our conversation, I am pleased to report that we have just completed 100 cycles of blastocyst transfer. Three quarters of patients accepted our advise to have only one blastocyst transferred.
“We are very pleased that those patient who had single balstocyst transferred had a 56% pregnancy rate with 0% twin pregnancy rate.
“This is the first and largest British experience of single blastocyst transfer. The results confirm our belief that for a selected group of patient replacing a single embryo is effective, safe and achieves an excellent pregnancy rate with excellent prospects of having a health child as a result of this pregnancy by reducing multiple pregnancy this particular group.”
Patricia Hamilton, President, Royal College of Paediatrics and Child Health, said:
“Paediatricians strongly support the report’s recommendations which aim to provide the best outcomes for the child, family and the NHS. A significant proportion of twins are born extremely early and are at a high risk of death or disability. Importantly, many spend weeks or months in neonatal intensive care cots. There is not the capacity in local neonatal intensive care units to cope with this and many are transferred out to other hospitals. Twins may be separated from each other or their mother during this time.”
Dr Alan Thornhill, Scientific Director of The London Bridge Fertility, Gynaecology and Genetics Centre, said:
“We welcome any initiative that will make IVF safer for mother and baby. We hope that any single embryo transfer policy retains a degree of flexibility to acknowledge biological variance and ensure that the needs of patients are put first. In combination with improved embryo selection, screening and freezing techniques, a flexible policy will allow doctors and patients to choose the safest and most effective option together.”