ATLANTA — The American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology have issued tighter guidelines on the number of embryos that should be transferred during in vitro fertilization.
The guidelines recommend that only one more embryo than called for in four age-based prognostic categories should be transferred in patients with a less favorable prognosis.
They also encourage individual fertility programs to generate and use their own data regarding patient characteristics and the number of embryos to be transferred.
In the absence of these data, the societies recommend that for patients under age 35 who have a favorable prognosis, “consideration should be given to transferring only a single embryo.
“No more than two embryos (cleavage stage or blastocyst) should be transferred.”
The number of embryos recommended for transfer increases with age, with no more than five cleavage-stage embryos or three blastocysts to be transferred in women aged 41-42 years.
Data were insufficient to recommend a limit on the number of embryos to transfer in women 43 years or older, Dr. Glenn L. Schattman said during a press briefing at the ASRM's annual meeting, where the newly revised guidelines were announced.
The announcement was made less than 1 year after the previous embryo transfer guidelines were published (Fertil. Steril. 2008;90[suppl.]:S163-4), and came amid news that the ASRM had expelled Dr. Michael Kamrava, the fertility doctor to the so-called “octomom” Nadya Suleman.
The guidelines were further refined as part of the societies' continuing efforts to reduce the number of high-order multiple pregnancies in which three or more embryos are implanted, Dr. Schattman, chairman of SART's Practice Committee, told reporters. Restricting the number of embryos transferred has helped reduce the risk of high-order multiple pregnancies from 6% in 2003 to less than 2% today.
“This has been a focus of our society for years,” Dr. Schattman said in an interview. “This is not just in response to a certain event that happened in the last year.”
He also noted that there has been a paucity of guidelines on frozen embryo and blastocyst transfer. The new guidelines make explicit that the number of embryos transferred is the same for fresh or frozen embryos.
Dr. Kamrava of the West Coast IVF Clinic, in Beverly Hills, Calif., reportedly transferred six frozen embryos into Ms. Suleman, the single mother of six who gave birth at age 33 to eight premature infants.
“This was obviously a particularly egregious [event],” Dr. Marc A. Fritz, chair of the ASRM's Practice Committee, said in an interview. “I think that the society has come to the conclusion that it needs and wants to take a more active role in promoting the practice standards that the Practice Committee documents espouse.”
As professional organizations, however, he noted that the ASRM and SART are limited in what they can do.
Only state medical boards have the power to revoke medical licenses. Still, many insurance companies will cover only infertility treatments provided by ASRM/SART members.
Former ASRM Executive Director Robert Visscher said in an interview that other cases have been brought to ASRM's Judiciary Committee for possible expulsion. “It's indirect you might say, but there are ramifications of losing your membership and losing your ability to report and publish your data,” Dr. Visscher said.
“Practically every patient that comes into an [in vitro fertilization] program looks up the data—the CDC- or the SART-reported data—so it is a big deal,” he said.
As noted in the previous guidelines, the societies recommend that fertility programs monitor their results continually and adjust the number of embryos transferred to minimize undesirable outcomes.
Programs that have a high-order multiple pregnancy rate that is greater than 2 standard deviations above the mean for all SART-reporting clinics for 2 consecutive years may be audited by SART.
Still, sorting through the data may be difficult, as the new guidelines allow for exceptions for patients with a less favorable prognosis.
One additional embryo may be transferred in each of the four age groups for patients with a less favorable prognosis or two or more previous failed fresh in vitro fertilization [IVF] cycles. The patient must be counseled regarding the risks of a multifetal pregnancy, and the justification for exceeding the recommended limits must be documented in the patient's medical record.
Characteristics associated with a favorable prognosis, independent of age, include first cycle of IVF, good-quality embryos as judged by morphological criteria, excess embryos of sufficient quality to warrant cytopreservation, and previous success with IVF.
The complete guidelines are expected to be published in this month's issue of Fertility and Sterility.
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