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Elective single embryo transfer (eSET) policy implementation to all UK IVF centres from 2009: Reality or Myth?

26 January 2009
By Shantal Rajah
Lead Scientist and Laboratory Manager, Brentwood Fertility, Essex
Appeared in BioNews 492
Elective single embryo transfer (eSET) policy implementation has raised many issues among patients, IVF experts and fund holders. The main concern in relation to this policy is that we do not know how much, and by what percentage, it will reduce the pregnancy rate in our patients. The policy says that the purpose of eSET is to safeguard any future outcome failures. But is it fair on patients?

One in about eight women nationwide seeks help for infertility. Among these infertile women 10 to 15 per cent of patients get pregnant having being treated with Clomid, IUI or ovulation induction, or even naturally. Women who go through IVF or ICSI treatments have been targeted for this eSET policy.

In 2006, HFEA (Human Fertilisation and Embryology Authority) figures showed that approximately 45,000 IVF/ICSI cycles were performed in the UK. 94 per cent of treatment cycles were completed with two embryo transfers. The overall pregnancy rate for women under 37 yrs was 28 per cent. The singleton live birth rate for under 35 year olds was 22 per cent and for 35 to 37 year olds was 20 per cent. The twin pregnancy live birth rate was 8 per cent and 5.7 per cent respectively. These figures for twin live birth rates are acceptable. We should not forget the non-pregnancy figure with two embryo transfer is 70-75 per cent.

The eSET policy consultation document has produced the twin pregnancy rates by calculating the number of overall pregnancies versus the number of twin pregnancies to give a figure of 25 per cent. I strongly believe the twin pregnancy rate should be calculated using the number of total cycles (pregnant and non pregnant cycles) performed with two embryo transfers versus the number of twin pregnancies achieved.

For example:

If a centre has performed 200 cycles (IVF/ICSI) of two embryo transfers and achieved 60 pregnancies in which 40 were singletons and 20 were twins, then the overall pregnancy rate would be 30 per cent. But using the HFEA's method, the multiple pregnancy rate would be calculated as 20/60x100 = 33 per cent and the centre would therefore be penalised for having a higher twinning rate.

But assuming two embryo transfers per singleton pregnancy, as is the current practice in most centres, the calculation would be 20/200x100 = 10 per cent. Employing eSET will therefore reduce the overall pregnancy rates, regardless of whether the procedure is 'elected' or not.

As a qualified scientist with 20 years experience in the field, we have always selected the best two embryos for transfer, and yet approximately 70 per cent of our patients do not get pregnant. When this happens we modify the technique to increase the chances of getting pregnant by growing the embryos to blastocyst stage or using assisted hatching or PGS (preimplantation genetic screening) for the following cycles, long before the SET workshops organised by the Association for Clinical Embryologists. I welcome these schemes and agree that they will expand our scientific knowledge for improving success rates in our centres, but disagree that this should lead us to impose eSET on patients.

eSET for patients under 37 years who are undergoing their first cycle of IVF is recommended in the new policy. However, we have always limited the use of SET to patients who have medical complications and are therefore not suitable for two embryo transfer. This has been practiced in centres long before this SET policy.

While NHS centres will be forced to apply this recommendation to their patients it is unlikely to be accepted by patients undergoing IVF in private centres, who pay large sums of money both for their treatment and for the storage of any excess embryos which they may need for future cycles. Patients with only a small number of embryos may prefer to have two embryos transferred rather than incurring extra cost through storing excess embryos, as well as risking damage to embryos during the unfreezing process.

Recipients in egg sharing schemes are also in a difficult position under the new policy. The majority are over 37 years old at the time of the treatment, making them more prone to implantation problems. They may already have waited months and years to have donor eggs and find it hard to accept SET even though they are counselled about it before starting their cycle.

NHS/PCT funding per patient can be stretched (3 cycles) by doing eSET followed by frozen embryo replacement cycles. However, the chances of getting pregnant by fresh cycles will be reduced.

What sort of number of twin pregnancies are we talking about with IVF patients?

HFEA figures for 2006 show 737,679 births for the year (natural and all fertility treatments) and about 11,100 multiple births (less than two per cent). For IVF/ICSI the figure is 10,242 (1.39 per cent of all live births).

Patients who have IVF/ICSI treatments are infertile patients. It is not fair to restrict their chances of having a baby or expect them to have a baby in natural way like the normal population when they know they have infertility problems. We are making an issue out of a mere 1.39 per cent of all UK births (singleton and multiple). Among the 1.39 per cent of all UK live births resulting from IVF/ICSI, the multiple pregnancy rate is about 20 per cent. This number may look high but it is a minor fraction of total UK live birth numbers.

I feel it is unnecessary to waste money, energy and time on meetings and consultations with regard to SET policy to NHS and private patients. Funding for IVF/ICSI patients for three fresh cycles is very costly to PCT/NHS trusts. This SET policy will stretch the funds and time, providing financial benefit to the trust, but at the expense of its patients and the centre's performance.

SOURCES & REFERENCES
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