Financial incentives for elective single embryo transfer (eSET)

May 25, 2011Carole 15 Comments »

I saw this headline the other day, “Doctor bucking trend by using one IVF embryo”, which talks about how at least one  physician is trying to make elective single embryo transfer (eSET) more appealing to patients. Dr. George Grunert with Fertility Specialists of Houston offers a “second transfer free” if first single embryo transfer doesn’t result in a pregnancy. He says, “If it doesn’t work, if you’re one of the 50 percent of people who doesn’t get pregnant, we’ll transfer that second embryo for free, and we’ll give you that second chance for pregnancy.”

You can see his SART pregnancy data from 2009 here.  Forty-three percent of transfers to women under 35 years of age resulted in live births. In 2009, he reported only 1.9% of the transfers in his program were eSET so perhaps this data was collected before initiating an incentive program.  His reported implantation rate (pregnancy rate per embryo transferred) was 30.6%. With an average of 1.9 embryos transferred, the program’s twin rate in the under 35 years of age group was 35.4% and his triplet rate was 1.8%.  What is remarkable about this program is that it represents the respectable middle of good programs, not an exceptional top 3 in the country program, crushing the premise that you need to have 60-70% pregnancy rates before  offering eSET.

So, in spite of having average pregnancy rates and no embarrassing “multiples issue to solve”,  this physician has taken the admirable stand of offering eligible patients a financial incentive for eSET, and for this I applaud him. I appreciate his efforts to reduce the financial risk for patients so that they can more easily make the decision to try eSET. There is no obvious financial incentive for the program to offer this– it actually costs them money to provide transfers for free but it is the right thing to do.  There is tons of evidence showing that singleton pregnancies have better medical outcomes for both mother and child than pregnancies with twins or more.

I don’t know if Dr. Grunert is “bucking a trend”, so much as being a pioneer in what lies ahead for every decent program. I realize that eSET is most appropriate for the under 35 years of age group- at least with our current understanding of which embryos are most capable of implantation- but as our ability to identify good embryos increases, perhaps everyone will be eligible for eSET one day.

I looked for other programs that offer a financial incentives for eSET and found this link to Reproductive Partners Medical Group’s blog in which they apparently considered the idea in 2009 and were soliciting patient ideas. One patient suggested a 100% refund and free second fresh cycle which obviously did not gain much traction with the program’s physicians. There is surprisingly little information about programs currently offering eSET that I could find on-line.

Does your program offer incentives for eSET? Would you do eSET if your doctor offered a free frozen transfer if the first fresh transfer failed? Have you ever asked your doctor for a financial incentive to do eSET if eSET was offered to you because you met eligibility requirements? If so, I’d love to hear about your experiences and I would like to acknowledge programs offering incentives to patients to promote singleton pregnancies. I think these brave programs need to be supported. Please comment below or privately via “Contact Me” if you wish to remain anonymous.

 

 

 

© 2011, Carole. All rights reserved.

15 Responses to this entry

  • Effing Infertility Says:

    I’m under 35 with tubal infertility and in Germany – I wanted eSET the first time because I don’t want the added worry and risk of a twin pregnancy. The doctors here discourage eSET because the success rates are lower than in the US (d/t embryo protection laws) and they really wanted me to do 2 to up my chances. I didn’t get pregnant and I’m gearing up for a second fresh cycle now – and this time they didn’t even ask me before marking on the form that I wanted 2 transferred. It turns out I do want to try it this time, mostly just so they’ll be allowed to culture more embryos in the fresh cycle (stupid laws again) but talk about pressure!

  • Carole Says:

    Dear EI,
    Thanks for sharing your experience with eSET. I would suspect that part of the reason pregnancy rates may be lower in Germany specifically, is the limitation- as you mention- of fresh embryos (3) that can be produced and must be transferred in every fresh cycle. In my own experience, when patients limit the lab to only fertilizing three eggs, we have poorer outcomes compared to when we add sperm to all eggs and let nature figure out which eggs are best and will produce good embryos. When we try to select the 3 best eggs, we often get it wrong. Another unexpected consequence of requiring all embryos be transferred (at least in Germany) is apparently increased use of selective reduction to achieve singleton pregnancies on the tail end of the process. The insistence that all 3 embryos, if viable, must be transferred results in more use of fetal reduction –Here’s a link to more info on German laws and the impact on IVF practice, http://www.ivf.net/ivf/germany%92s-embryo-protection-law-is-%93killing-embryos-rather-than-protecting-them%94-o2806.html The best technical option, IMO, is fertilize all, freeze embryos and transfer them one at a time in the fresh and then if needed, subsequent frozen cycles. I wish you all the best for a BFP this cycle!! Good Luck!!

  • Kate Says:

    Wow. I did not know that about German IVF laws. (My husband is German… thank goodness we pursued IVF here in the states!)

    For us, the decision to transfer two embryos had nothing to do with finances (not that we’ve got thousands to blow on medical procedures– we just happen to have extremely generous infertility coverage), and far more to do with the fact that IVF is horrible. Horrible, horrible, horrible. I keep trying to find an appropriate analogy, but I can’t seem to find one. Basically, I don’t know of any other medical “cure” where they would encourage you to take a lesser chance of success, because, you know, you could just come back and do this lengthy, invasive, painful, emotionally-draining medical procedure all over again in a month or two if this one doesn’t work. I think doctors sometimes get a little desensitized to the process and perhaps don’t consider that patients aren’t always transferring more than one solely because they can’t afford to financially.

    In our case, we were lucky to have two textbook perfect embryos to transfer on day 5, and yes, after consulting with the embryologist on the increased chances of twinning, we did consider only transferring one. However, I simply couldn’t handle the thought, if the cycle didn’t work, that I could have done something to increase the odds of success.

    Instead, we took the risk and are now happily parenting twins. I think often about talking to couples about choosing eSET, because parenting twins is HARD. HARD, HARD, HARD.

    BUT, I find it difficult to do sometimes, knowing that if we had to go back, I’d probably make the same decision again. So, all of this is just a lengthy way of saying that people have many, many reasons for choosing to transfer more than one, and frankly, my doctor could have offered us our current cycle for free, and endless additional cycles for free, and I still would have transferred two. IVF is just too terrible to want to do it a second time!

  • Carole Says:

    Dear Kate,
    Thanks very much for sharing your perspective on the embryo transfer decision. I am sorry your IVF experience was so horrible, but glad things worked out well for you and your twins in the end. 🙂 Best Wishes, Carole.

  • LisainSK Says:

    Carole,

    I am currently 32w4d pg via DE IVF. We were patients of the Colorado Center for Reproductive Medicine. I am 32 and my DH is 34. Our donor was 33 at time of retrieval. We elected for eSET for this pregnancy and was VERY lucky to have got pregnant upon our first transfer. There was not a financial incentive to undergo eSET. It was an excruciatingly hard decision. Definitely the hardest decision to date. But both of us were terrified of any birth complications as a result of multiples…terrified of premature birth, etc. We focused on the end result rather than just to get pg. We decided that we would transfer the risks over two transfers if need be even though it will cost us approx. another $7000 for the chance (we live in Canada so that includes travel costs to CCRM). And we are by no means rich. We had no family financial assistance either. We just felt that we would never ever forgive ourselves should a complication happen that likely was the result of multiples. We would reduce if needed but having gone through two prior m/c it would have been a terrible predicament to be in. Plus raising one baby will be hard enough…never mind multiples. This pregnancy has been relatively complication free but challenging…can’t imagine gestation of multiples!!But even today, if faced with another transfer, we would still be extremely tempted to transfer two. Such financial incentive would have been a dream scenario for us and I applaud this doctor for doing the right thing. In fact we believed that if we tested our DE embryos for neuploidy/aneuploidy it would be a useful tool in determining which embryo was best for eSET. Yeah…so we forked out another $5500 US for the testing. So you can say that we are definitely extreme pro-eSET. But now nearing 33 weeks pg, I can in no way sit on my laurels and shake a finger at couples who decide to transfer two or more…in fact just the opposite. These couples need more support and the clinic mentioned in Houston is doing just that. We were lucky…plain and simple.

  • Carole Says:

    Dear LisainSK,
    Congrats on your pregnancy and thanks for your comment! I agree with you that a decision about eSET is very personal. I would love to see financial hurdles removed for couples who might otherwise prefer eSET. Unfortunately, I have seen the pregnancy losses and poor health outcomes from twin and greater pregnancies in our IVF program. Granted, they were the minority but still tough to see when you know what the couples went through to get pregnant. Those sad outcomes push me to keep talking about eSET so that patients can be fully informed and make the best decision for their family. Carole

  • Effing Infertility Says:

    Hi Carole,
    Thanks for your response. What you suggest is what we did the first time. They do fertilize all the eggs at retrieval, but they freeze all but three at the 2pn stage. Then we had those individually transferred after the fresh cycle didn’t work. The problem is that they don’t survive well after 2pn stage freezing – at least not here, and the chances of pregnancy for FET are something like 17% (that’s pooled, there’s no data available according to how many are transferred). If only they could culture all the embryos from the start and freeze them when they are hardier. In this case the whole experience was dragged out for months transferring these embryos that had almost no chance, possibly because of how they’ve been treated. I think the laws are well-intentioned but are a disaster.

    I have seen some US sites say that survival of frozen 2pn cells is up to over 90% now! Is this true? If so it’s a lot better than what I had here – 50% of mine made it, but none implanted.

  • Carole Says:

    Dear EI,
    I am very surprised that your program has such poor freezing rates for 2PNs. 2PN or fertilized egg stage has always been the easiest stage to freeze with the older slow freeze technology. Yes, 90% is quite possible for 2PNs. That’s why we have so many programs with embryo decision trees that require freezing at least some 2PNs because that was a slam dunk compared to waiting for cleavage state or later to freeze. Of course, some of these 2PNs would turn out to be non-viable with no growth potential and that’s why waiting for blast and freezing helps ensure you are getting viable embryos stored. Vitrification- done correctly, unlike slow freezing, works very well at every stage-making it the technology all reasonable labs are moving toward. You might benefit from blast culture because that would distinguish between embryonic failure due to poor freezing and that due to failure to thrive in culture past the 2PN stage. Can you interview some other programs to find some with better success rates or are you locked into this program because of the insurance coverage? Carole

  • Effing Infertility Says:

    This clinic actually has better overall success rates than the German average, so unless I leave the country I don’t think I’ll find anything better. If it doesn’t work this time, then I think we would only continue with IVF if we did it in another country – one where they can culture everything to blast so we can figure out what we are dealing with. (Of course then we lose insurance cover, but you get better chances for the extra money.) I’m in for tubal infertility after 3 ectopic pregnancies so I should be able to make good embryos, but maybe not in the lab? Regardless, you’re right, I feel like we’re really lacking information on whether things aren’t working because of the freezing or because of the embryos themselves.

  • Kevin H - IVF Costs Says:

    Couples can take some of the financial sting out of single embryo transfers using the tax code. The IRS allows un-reimbursed medical expense deductions for amounts over 7.5% of adjusted gross income.

    A couple’s first IVF cycle may not generate much in tax savings due to the IRS expense hurdle. If a single embryo transfer leads to a subsequent IVF cycle in the same tax year, then those costs may generate bigger tax savings.

  • Effing Infertility Says:

    Carole,
    Back to the 2PN cells, could I ask a couple more questions? When you say there can be 90% survival when freezing them, is that an average for all patients? Are there some patients for whom what appeared to be healthy cells just don’t survive freezing as well?
    Also, from any places you know of that freeze 2PN cells – when they thaw them, do they culture them to blast? My clinic does 2-day transfers with the frozen ones and told me they don’t grow as well in culture after freezing so they didn’t want to culture them further, although they do culture to blast in fresh cycles. I’d like to just grow them because I’d rather find out they were bad right away rather than endure my sixth failed ART two-week-wait thinking there’s some chance, but if this is actually a really bad idea I won’t argue.

  • Carole Says:

    Hi EI,
    Most embryologists have little difficulty freezing and thawing 2PN stage embryos, using either slow freeze or vitrification technology and 2PNs tolerate either freezing procedure very well and usually thaw very well. Other stages of development–such as cleavage stage or blastocyst stage usually represent more of a technical challenge. Whether a previously frozen fertilized egg (a 2PN) grows well in culture depends on not just the technical skill of the lab, but also genetic and metabolic factors in the fertilized egg/embryo. So it is always possible that some patients may not do as well as expected even if technically, 2PNs are expected to freeze and thaw well. If your program tells you that they expect poor results with an approach, it’s probably better to go with what works for that lab. What concerns me is that in most labs, culturing after 2PN freeze and thaw–even to blast– usually works well, so you also might get a second opinion from another IVF programs, if you can. Best Wishes, Carole

  • Katie Says:

    Hi Carole,
    I’m starting my first IVF cycle, just before I turn 41. At age 37/38, I had done two cycles to freeze eggs, and so have about 30 eggs on ice.
    I’m about to do a fresh cycle, though, to try it since it will be covered by insurance and using my frozen eggs is not (which is crazy if you think about it logically).
    Anyway, the clinic–a very well regarded one–is pushing me hard to state my intention for a single embryo transfer, even before I know if I get any eggs, let alone embryos.
    I’m really struggling with making that decision. I know my age makes it very dangerous to have twins, but on the other hand I know my age makes it very unlikely any given embryo will implant.
    Do you have any information that would be helpful to be in making this decision? (and no, the clinic doesn’t offer free cycles if an eSET doesn’t take–if they did I’d do that in a second).
    Thanks!

  • Carole Says:

    Hi Katie,
    This is really more of a medical, than lab question. However, the American Society for Reproductive Medicine (ASRM) put out some practice guidelines in 2013 to help physicians with deciding on how many embryos to transfer based om two factors: the patient’s age and whether their prognosis for pregnancy was favorable or unfavorable. You can read and print out the guidelines here:http://asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/Guidelines_and_Minimum_Standards/Guidelines_on_number_of_embryos%281%29.pdf For age 38-40 with a favorable prognosis, they recommend transferring 2 blastocysts or 3 cleavage stage embryos. With an unfavorable prognosis (meaning you have multiple issues to overcome) they recommend transferring 3 blastocysts or 4 cleavage stage embryos. Once you get to be 41, the recommended embryos to transfer goes up to 3 blastocysts and 5 cleavage with no distinction between favorable and unfavorable prognosis. I think if you bring a copy of these guidelines in to your doctor and ask him to explain why in your case, he does not recommend following the professional guidelines, he may adjust his recommendation to more than one. Good Luck!! Carole

  • Katie Says:

    Thanks so much, Carole!

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