Defining a cycle
What is included in a full cycle of IVF or ICSI treatment?
The aim of treatment must be to give the best outcome for the patient and potential children – one healthy child. At present, a major obstacle to this outcome is the practice of multiple embryo transfer, particularly in cases where the woman is at risk of multiple pregnancy and birth.
To encourage patients to accept elective single embryo transfer (eSET), it is important that the correct definition of a full cycle of treatment is followed by all those involved in the provision of fertility treatment, that is, the replacement of a fresh embryo and subsequent replacement of frozen embryos.
It is also vital that change in guidance is supported by implementing the NICE fertility guideline in full, with three full (fresh and frozen) cycles of in vitro fertilisation (IVF) or Intra-cytoplasmic sperm injection (ICSI) to all those fulfilling the NICE criteria.
What is the NICE guidance?
The relevant NICE guidelines (Clinical Guideline 11, February 2004) state that:
- Couples should be informed that the chance of multiple pregnancy following in vitro fertilisation treatment depends on the number of embryos transferred per cycle of treatment. To balance the chance of a live birth and the risk of multiple pregnancy and its consequences, no more than two embryos should be transferred during any one cycle of in vitro fertilisation treatment.This recommendation is a key priority for implementation.(para 1.10.3.1)
- Couples in which the woman is aged 23–39 years at the time of treatment and who have an identified cause for their fertility problems (such as azoospermia or bilateral tubal occlusion) or who have infertility of at least 3 years´ duration should be offered up to three stimulated cycles of in vitro fertilisation treatment. This recommendation is a key priority for implementation. (para 1.10.8.1)
- Embryos not transferred during a stimulated in vitro fertilisation treatment cycle may be suitable for freezing. If two or more embryos are frozen then they should be transferred before the next stimulated treatment cycle because this will minimize ovulation induction and egg collection, both of which carry risks for the woman and use more resources. This recommendation is a key priority for implementation. (para 1.10. 8.2)
See the NICE website for more information.
What is the view of the Department of Health?
At the time the NICE Guideline was published in February 2004, the then Secretary of State for Health, Mr John Reid MP, issued a statement on the same subject. He said that all PCTs in England were expected to provide 1 full cycle of treatment to all those fulfilling the criteria by April 2005. He also said that he expected PCTs to implement the full guideline (that is, 3 full cycles) in the longer term. In a letter from Dawn Primarolo MP (Minister of State for Public Health) in July 2007 to PCTs, the Department of Health restated the NICE recommendation on what constitutes a full cycle. The letter also said "The department is looking to PCTs to move towards the provision of three full cycles of IVF, for those who need it, as recommended in the NICE guideline."
What is the latest guidance from professional and patient organisations?
A consensus paper was produced following a meeting which took place on 23 January 2007 in London, convened by the Human Fertilisation and Embryology Authority (HFEA). Points 18 and 19 state:18. The definition of a single full treatment cycle is the
replacement of a fresh embryo and subsequent
replacement of all the frozen embryos derived
from that cycle. Adherence in this way to the NICE
Guideline would encourage and not disadvantage
patients agreeing to SET.
19. Inadequate implementation of the NICE Guideline on
Fertility (2004) has had a fundamental part to play in the
failure of UK IVF centres to adopt single embryo transfer
policies. Patients have, as a consequence, frequently
found it difficult to accept SET in their own treatment,
conscious that electing to have a single embryo
transferred, in what could be their only state funded
IVF cycle, might reduce their chance of a child.
Training workshops
Following the success of the regional workshops that were held over the summer in the UK, an additional workshop is now being held on 11 December in London on the importance of accelerating the reduction in multiple births.
The expert says...
"At present, we have huge differences between Primary Care Trusts in access to NHS infertility treatment. It is therefore understandable that some NHS patients are resistant to the move to SET. It is vital that ALL parts of the UK address this inequality as quickly as possible to offer patients – whether receiving NHS-funded or self-funded treatment – a fair chance of conceiving."
Clare Brown, Infertility Network UK
Best practice for SET
To implement best practice for single embryo transfer (SET), centres and clinics should follow the latest guidelines and have an appropriate protocol in place.