One at a Time

Earlier this week, I spoke at a workshop in Bristol organised by One at a Time about patient views about single embryo transfer. I know many people are worried that having just one embryo put back during IVF treatment will reduce the chances of success, but all the research shows that when clinics are selecting the right patients for single embryo transfer, it is quite possible to cut risk of multiple pregnancies without reducing the pregnancy rate.

The speaker who made the most impact on me was paediatrician Alun Elias-Jones, who talked about the problems of prematurity that he had frequently seen with multiple births. We all know so many twins who are perfectly fine that it's easy to assume that problems are relatively rate, but it was made very clear that this was far from the case with half of all twins being born early and often having low birth weights too, which can lead to all kinds of problems including brain injury, lung disease and cardiovascular problems. He explained that twins were three times more likely to be stillborn, five times more likely to die during their first year and four to six times more likely to have cerebral palsy. It was his description of the longer term problems that they can face with disabilities, learning difficulties and behavioural issues which was particularly striking. It's all too easy for staff in fertility clinics not to think about these potential consequences, and to pass on an ambiguous message to patients.

Going through fertility treatment isn't easy and all anyone wants is for it to work as quickly as possible. If you've got a team treating you who are all clear that the best outcome would be one healthy baby, it's something you're going to believe yourself. If you are faced with divided opinions or with some staff seeming to suggest that multiple birth might not be a bad outcome, it is hardly surprising that we sometimes end up confused.

Of course, there's one thing which really would make a difference to patient opinion and that would be the full implementation of the NICE guideline, which says that all those who are eligible should receive up to three full cycles of IVF. With adequate funding, it would be far easier to convince patients that all those most at risk of multiple pregnancy should consider having just one embryo put back at a time.

New research on how many embryos to transfer

There has been some interesting coverage today of the study published in The Lancet about how many embryos should be transferred during IVF treatment. Sadly, some of it does illustrate a lack of understanding about current practice and the move towards single embryo transfer.

The research in the Lancet found that the difference in chances of success between single embryo transfer and transferring two embryos was much greater for women of 40 or more and so recommended that there should be some flexibility in the decision about how many embryos to transfer for older women. Interestingly, the researchers found that transferring three embryos did not increase the chances of a live birth in women of any age.

This new research has been used to suggest that the move towards single embryo transfer is somehow flawed, but in fact the research backs up very well the current policy in the UK which is that single embryo transfer is recommended for those who are most at risk of twins - in other words, younger women with a good prognosis. Single embryo transfer would usually only be suggested for women of 40 and above when using donor eggs. IVF success rates for women in their forties are not high, but the age of the donor is the deciding factor when women are using donated eggs.

You can read more about the research on the Lancet website.

Canadian study shows costs of IVF multiples

Anyone who has qualms about the aim to reduce the number of multiple births after assisted conception in the UK should look at a new study from Canada published in The Journal of Pediatrics which analyses the admissions to neonatal intensive care of IVF babies.

The research shows that a hefty 17% of the newborn babies in intensive care were the result of multiple pregnancies after assisted conception, and that a policy of single embryo transfer could save 30-40 deaths across Canada each year, not to mention many serious complications.

The researchers studied a database from one hospital over a period of some years to check for significant complications, and extrapolated those findings to the whole country. They found that twins were more likely to be premature, were more likely to be admitted to intensive care and were also more likely to have other complications. They say that although fertility specialists are aware of the risks of multiple pregnancy, they are still willing to continue with procedures that carry risks for mothers and their babies and that this is partly due to the fact that people are usually paying for their treatment. The couples are therefore willing to attempt anything that might mean paying for fewer cycles, while clinics are pressured for higher "success" rates. The researchers make it clear that they feel the medical system "sometimes has the responsibility to refuse to offer interventions that increase morbidity when there are equally effective alternatives available, which lead to lower morbidity; especially when the large part of the morbidity is suffered by another individual, in this case, the baby." They call for a system where treatment costs are reimbursed and where IVF is regulated in order to save lives and long-term additional expenses.

You can read the report in full at www.jpeds.com

Reduced fees for single embryo transfer patients

Did you know that the Human Fertilisation and Embryology Authority (HFEA) will no longer charge clinics for patients who have frozen embryo transfers after putting back just one embryo in a fresh cycle?

At the moment, fertility clinics pay the HFEA a fee for each cycle they carry out, and the clinics pass this charge directly on to their patients. From October onwards, the fee will be dropped if a patient who had an unsuccessful single embryo transfer goes on to have additional frozen embryo transfers. The idea is that this will help reduce any additional financial burden from the decision to have just one embryo put back at a time.

Single embryo transfer does make sense for younger women who have good quality embryos as it means you are more likely to have a single, healthy baby. However, in the current economic climate many people do worry that it may end up costing them more to get pregnant this way. The HFEA hopes the decision will show the authority's commitment to helping patients who choose the safe and sensible option.

You can see more here

Single embryo success

Doctors at a London hospital have proved that putting back just one embryo during IVF doesn't have to reduce your chances of getting pregnant.

The team at Guys and St Thomas' managed to increase their pregnancy rate from 27% to 32%, whilst cutting their multiple birth rate in half. They did this by using more developed embryos, or blastocysts, and their newly published research shows that putting just one back at a time really does work.

For too long, the risks involved in multiple pregnancies have been played down by many fertility doctors, who don't have to see the pain and anguish of miscarriage, of premature, sick babies or of children who will have health problems for the rest of their lives. Of course, not every multiple pregnancy is problematic, but the Human Fertilisation and Embryology Authority has estimated that more than a hundred IVF babies die every year as a result of multiple embryo transfers, and this is not a risk patients should have to take.

The new research shows that fertility clinics can move to single embryo transfer without cutting the chances of success, and others should be encouraged to follow this lead so that fertility patients no longer have to take unnecessary risks with their own health, and that of their future children.

You can read a report on the study, published in the British Journal of Obstetrics and Gynaecology, in The Independent

HFEA acts to reduce multiple births

The Human Fertilisation and Embryology Authority has finally come up with a long-awaited policy to reduce multiple births after IVF, and is calling for a professionally-led national strategy to cut the twin rate to 10% over a period of three years.

Patients are often unaware of the real risks they are taking with their children's health when it comes to multiple births, and fertility clinics have not always acted in their best interests on this front. The biggest danger to the health of children conceived by IVF in the UK is multiple birth, and the HFEA estimates that around 126 IVF babies die every year purely as a result of being multiples. For many others, being a twin or triplet may mean being born prematurely and suffering life-long health problems as a result of this.

To have one healthy child at a time should be the ideal outcome of fertility treatment, but the patchy and inadequate funding for IVF and fierce commercial competition between clinics has not encouraged joined-up thinking on this matter. For too long, patients have been penalised by a system which encourages some of them to take unnecessary risks.

We must now hope that the HFEA's strategy really does make a difference, and warmly welcome the fact that the Interim Chair of the Authority, Walter Merricks, has written to the Health Minister to explain the link between patient concerns about single embryo transfer and the lack of funding for IVF treatment. Maybe now, finally, we will see a move towards the government's broken promises on this issue.

You can see the HFEA press release here