This just came out on Medscape. Fertility specialists are getting their peers under control by making some limits on the number of embryos that can be placed in a womb. It would be far better if specialists could anticipate problems like the case in California before so many lives are affected badly by “science”. Gloria
October 28, 2009 — The American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) have released new guidelines for the number of embryos to be transferred in in vitro fertilization cycles in an effort to reduce high-risk multiple pregnancies. The guidelines, based on ASRM and SART data from 2007, were published online October 19 in Fertility and Sterility.
“High-order multiple pregnancy (three or more implanted embryos) is an undesirable consequence (outcome) of assisted reproductive technologies (ART),” the guidelines state. “Multiple gestations lead to an increased risk of complications in both the fetuses and the mothers.”
The guidelines are meant to assist ART programs and patients to determine the appropriate number of cleavage-stage (usually 2 or 3 days after fertilization) embryos or blastocysts (usually 5 or 6 days after fertilization) to transfer, and they can be modified according to the patient’s age, embryo quality, and the opportunity for cryopreservation. They may also be changed as clinical experience with newer techniques accumulates.
The guidelines include the following recommendations:
In women younger than 35 years who have a more favorable prognosis, no more than 2 embryos (cleavage stage or blastocyst) should be transferred, and consideration should be given to transferring only a single embryo.
In women between the ages of 35 and 37 years who have a more favorable prognosis, no more than 2 cleavage-stage embryos should be transferred; all others in this age group should have no more than 3 cleavage-stage embryos transferred, and no more than 2 blastocysts should be transferred if extended culture is performed.
In women between the ages of 38 and 40 years who have a more favorable prognosis, no more than 3 cleavage-stage embryos or 2 blastocysts should be transferred; all others in this age group should have no more than 4 cleavage-stage embryos or 3 blastocysts transferred.
In women between the ages of 41 to 42 years, no more than 5 cleavage-stage embryos or 3 blastocysts should be transferred.
The guidelines also state that women with 2 or more failed fresh in vitro fertilization cycles or a less favorable prognosis may have 1 embryo transferred according to individual circumstances. These women must also be counseled about the risks for multiple pregnancies, and both the counseling and the reason for exceeding the recommended limits must be documented in the patient’s permanent medical record.
The guidelines also state that data are insufficient to recommend a limit on the number of embryos to transfer in women 43 years and older.
The guidelines warn that in vitro fertilization programs that have a high-order multiple pregnancy rate that is more than 2 SDs above the mean rate for all SART reporting clinics for 2 consecutive years may be audited by SART.
This report was developed under the direction of the Practice Committee of the SART and the Practice Committee of the ASRM. Members of the ASRM Practice Committee have disclosed various financial relationships with IntegraMed, Xanodyne Pharmaceuticals, Inc; Third Wave Technologies, Inc; Wyeth; EMD Serono, Inc; Ferring Pharmaceuticals; Tokai Pharmaceuticals, Inc; Pfizer Inc; Boehringer Ingelheim GmbH; Teva Pharmaceuticals USA; Solvay Pharmaceuticals, Inc; Schering-Plough; Theralogix, LLC; Femasys Inc; Watson Pharmaceuticals, Inc; Bayer HealthCare; and Ausio Pharmaceuticals, LLC. Members of the SART Practice Committee have disclosed various financial relationships with EMD Serono, Inc; Schering-Plough; Ferring Pharmaceuticals; Theralogix, LLC; Femasys Inc; Irvine Scientific, Inc; Incept BioSystems, Inc; and Molecular Biometrics, Inc.
Fertil Steril. Published online October 19, 2009.
Clinical Context
According to SART and ASRM, an undesirable outcome of assisted reproductive technologies is 3 or more implanted embryos. In the November 17, 1999, issue of the Journal of the American Medical Association, Schieve and colleagues reported multiple-birth risks in the fetuses and the mothers.
These in vitro fertilization guidelines on the recommended number of cleavage-stage embryos (usually 2 or 3 days after fertilization) and blastocysts (usually 5 or 6 days after fertilization) to be transferred were developed by the Practice Committee of SART and the Practice Committee of ASRM. The guidelines were approved by the Executive Council of SART and by the Board of Directors of ASRM.
Study Highlights
The guidelines can be modified based on patient age, embryo quality, opportunity for cryopreservation, and experience of newer techniques.
Individual programs should continually monitor their results to adjust the number of embryos transferred.
SART might audit programs with a high-order multiple pregnancy rate of more than 2 SDs above the mean rate for all SART-reporting clinics.
A more favorable prognosis is linked with the first in vitro fertilization cycle, good-quality embryo morphologic status, excess embryos available for cryopreservation, and a previous successful in vitro fertilization cycle.
The physician and patient should agree on the number of embryos transferred.
Documentation should include informed consent and information in the clinical record.
The guidelines are based on data from assisted reproductive technologies services to be used if individual program data are lacking.
For patients younger than 35 years:
With a favorable prognosis, a single embryo is recommended.
For all others, no more than 2 embryos are recommended.
For patients aged 35 to 37 years:
With a favorable prognosis, no more than 2 embryos are recommended.
For all others, no more than 3 cleavage-stage embryos and no more than 2 blastocysts are recommended.
For patients aged 38 to 40 years:
With a favorable prognosis, no more than 3 cleavage-stage embryos and no more than 2 blastocysts are recommended.
For all others, no more than 4 cleavage-stage embryos and no more than 3 blastocysts are recommended.
For patients aged 41 to 42 years, no more than 5 cleavage-stage embryos or 3 blastocysts are recommended.
For patients with 2 or more failed in vitro fertilization cycles or a less favorable prognosis, 1 additional embryo transfer is recommended.
For patients aged at least 43 years, the limit of the number of embryos has not been determined because of lack of data.
In donor egg cycles, the number of embryos transferred should be based on donor age.
In frozen embryo transfer cycles, the number of good-quality thawed embryos transferred should not exceed the recommended number of fresh embryos transferred according to age.
In gamete intrafallopian transfer, 1 more oocyte than embryo transfer is recommended.
Clinical Implications
In women undergoing assisted reproductive technologies with a favorable prognosis, the recommended limits on numbers of embryo transfers are 1 and no more than 2 for age younger than 35 years, 2 for ages 35 to 37 years, 3 cleavage-stage embryos vs 2 blastocysts for ages 38 to 40 years, and 5 cleavage-stage embryos vs 3 blastocysts for ages 41 to 42 years.
In women undergoing assisted reproductive technologies without a favorable prognosis, the recommended limits on numbers of embryo transfers are 2 for age younger than 35 years, 3 cleavage-stage embryos vs 2 blastocysts for ages 35 to 37 years, 4 cleavage-stage embryos vs 3 blastocysts for ages 38 to 40 years, and 5 cleavage-stage embryos vs 3 blastocysts for ages 41 to 42 years.