One at a Time, medical professionals united for eSET

May 31, 2011Carole No Comments »

In my last post, I mentioned how one fertility physician was trying to reduce the financial barriers for patients who wanted to only transfer one embryo. He took the financial issue off the table by offering a free follow-up frozen embryo transfer cycle if the elective single embryo transfer (eSET) fresh transfer didn’t result in a viable pregnancy. Of course, to be eligible for eSET, the patient had to have a good prognosis for pregnancy with a single embryo.  This post elicited comments from several patients, each with their own perspective on why they chose or didn’t choose eSET.  One commenter had such a bad experience with IVF, that even with endless free cycles, she thought she would still transfer more than one to optimize their chances of pregnancy on one attempt. It brought home to me how varied the perspectives on this issue really are. Financial hurdles are only one barrier to singleton pregnancies from IVF.

It also reaffirmed my feeling that patients need as much information about the risks, benefits and alternatives to transferring one or more embryos as possible so that they can make an informed decision for themselves and their families. Toward that end, I wanted to share a website I recently found which is a great resource for patients and professionals alike who want to know more about eSET. A group of medical professionals have united to contribute information to the website “One at a Time”, whose purpose is to reduce the risks of multiple pregnancies from fertility treatment.

In the Patients section, there are patient stories about deciding to do eSET and raising twins, information about the risks of prematurity associated with multiple births, questions to ask your doctor and a section on the benefits of eSET. Some of the information, particularly regarding insurance, won’t apply to the US patient because this site is a United Kingdom site where national health care funding is offered for infertility treatments. It may interest you to read about what is covered (with some restrictions) in Britain, Wales, Scotland and Northern Ireland.

If you want to read the primary research papers that are behind the recommendations for eSET, you can read them in a section called Research and Evidence. There’s also data from the world experience with eSET collected in Europe, North America and Australia. This world experience has demonstrated that when administered appropriately, eSET can be used to reduce the multiple rate without reducing the pregnancy rate, particularly when follow-up frozen embryo transfer cycles are part of the eSET plan. Obviously, there are many reasons why patients are resistant to eSET and not all of them can be addressed to make eSET palatable to all eligible patients.

I keep writing about eSET because I think that too many patients really aren’t getting the facts about the risks of transferring multiples from their infertility clinic and then are blind-sided when it goes bad. That’s a shame. eSET is a complicated issue for patients and for their physicians because the primary goal from treatment has been to get the patient pregnant as soon as possible. The possibility of waiting for a second fresh cycle to achieve pregnancy is a hard sell for someone who fears they will NEVER be pregnant, much less ever have to worry about obstetrical risks from multiple fetal pregnancy. Because it’s hard for both patients and their physicians to accept a failed pregnancy test, acceptance of eSET is an uphill battle. Change is difficult.

Patient education may not be enough according to Dr. Alan Thornhill who argues that a cultural shift may be necessary. He points out eSET isn’t without its own risks because to get good pregnancy rates, eSET must be coupled with extended in vitro culture and transfer at the blastocyst stage. Because day 5 culture allows us to identify those embryos that can go the distance to “implantation ready”, we can transfer one and expect implantation and pregnancy to happen more than 50% of the time. But for some reason which we don’t understand, blastocysts have a slightly higher risk of splitting (compared to day 3 embryos) and causing monozygotic twins which can have pretty bad obstetrical outcomes, perhaps even worse than fraternal twins (from two distinct eggs). So to achieve the greatest good- a healthy singleton birth- you may inadvertently have increased the risk of a more rare kind of twin which also causes obstetrical issues.

The other issue Dr. Thornhill brings up is that when a society or government creates health care goals for a patient population and health care providers,  targets must be flexible enough to allow room for patient autonomy. Particularly in highly personal  and culturally sensitive areas of reproductive choice and family building, patients must retain autonomy when it comes to making decisions about their health care. Of course, physicians also have to have the right to choose not to offer services she feels are medically dangerous or unethical. And incentives such as free cycles and perhaps expanded health care coverage have their place in influencing those decisions.

Does that mean we should just accept twins and more as the best we can do from IVF? No, because that approach is clearly and unequivocably associated with poor obstetrical outcomes. So what can be done to increase the number of healthy singleton pregnancies achieved from IVF? In my opinion, patients should be encouraged to educate themselves and fully participate in their care. That’s why I keep writing about eSET as an option to consider and discuss with your doctor.

© 2011, Carole. All rights reserved.

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