Europe

In general, Northern Europe has widely adopted single embryo transfer (SET), whereas Southern Europe has yet to implement this policy.

Belgium

Policy
Patients can have up to 6 funded cycles of in vitro fertilisation (IVF) but for the first cycle, if they are under 36 years old they must have SET. Whether single embryo transfer is offered in follow-on treatment depends on the patient’s age and the quality of the embryos.
Result
Triplet births have been almost completely avoided; twin births have dropped to around 7%. There has not been a significant decrease in pregnancy rates.

Finland

Policy
There is no state regulation, but elective single embryo transfer (eSET) has been widely used for the last 10 years, together with follow-on treatment with frozen embryos. At present, single embryo transfer is used in almost 60% of cases, with triple embryo transfer reduced to under 1%.
Result
Triplet births have been almost completely avoided. The IVF twin rate has dropped significantly and continues to drop each year. Overall pregnancy rates remain unchanged.

For Finland’s IVF statistics (in English), see:
http://www.stakes.fi/EN/tilastot/statisticsbytopic/reproduction/IVFtreatments.htm

France, Greece, Portugal and Spain

Policy
There is no legislation or regulations on reducing numbers of multiple pregnancies, although the policy regarding the number of embryos transferred is now being examined in a number of countries. For example:
- In Greece, the law currently permits up to 3 embryos to be transferred for women up to the age of 40, and up to 4 for women over that age. However, the National Authority of Medically Assisted Reproduction is now deciding the exact number of embryos that should be transferred, depending on the woman’s age and general prognosis.
- In Portugal, the law contains a general edict that multiple pregnancies should be avoided if possible. However, the official body responsible for regulating some aspects of Assisted Reproductive Technology (ART) is currently formulating regulations on the number of embryos to transfer. There is also a voluntary movement amongst clinicians to limit the number of embryos transferred to a maximum of two.

Germany, Austria and Switzerland

Policy
In Germany, state regulation says that no more than 3 immature eggs can be cultured beyond an early stage, embryo selection practices are not permitted, and no cleavage stage (2–3 day) embryos can be frozen, so all embryos have to be transferred. The policy in Austria and Switzerland is similar, although there is some variation, for example in Austria restrictions are voluntary, with a general trend towards transferring no more than 2 embryos for most patients.

Result
In Germany, effective embryo selection is prevented and there is a very high triplet and twin rate. The situation in Switzerland and Austria is similar.

For information on Switzerland, see: http://www.sgrm.org/

Hungary

Policy
State regulation limits the number of embryos that can be transferred to 3, except in special circumstances (for example, older women or a history of failed IVF), when the maximum is 4.
Result
In the years 2002–4, around 10% of transfers were SET, around 25% were 2 embryo transfers, approximately 50% were 3 embryo transfers and about 15% involved 4 embryos.

This resulted in a twin rate of around 30%.

Italy

Policy
State legislation changed to say that only a maximum of three eggs can be fertilised, but all the resulting embryos must be implanted.
Result
This policy makes it difficult to offer elective single embryo transfer (eSET). The incidence of triplets is now rising in centres that had previously low rates.

Netherlands

Policy
There is no state regulation, but elective single embryo transfer (eSET) is now widely used, and a maximum of two embryos are transferred. As of January 2007, the first 3 IVF cycles are fully funded (SET or double embryo transfer (DET)).
Result
At present, a significant proportion of cycles are now eSET.

Norway and Denmark

Policy
There is no state regulation, but elective single embryo transfer (eSET) is now more widely used.
Result
Swedish, Norwegian and Danish groups have collaborated in a number of multi-centre trials and have shown good success rates for eSET cycles.

Sweden

Policy
State regulation says that in principle only one embryo should be replaced, apart from in exceptional circumstances.
Result
70% of all IVF cycles are now elective single embryo transfer (eSET) cycles. The twin rate has reduced to around 5% and pregnancy rates have been maintained.

United Kingdom

Policy
In May 2008, the Human Fertilisation and Embryology Authority (HFEA) agreed to introduce a new policy which aims to lower the average national multiple birth rate following IVF. By 1st January 2009, all licensed treatment centres will need to have developed a multiple births minimisation strategy which sets out how they intend to reduce their annual multiple birth rates and to ensure that they do not exceed HFEA-set maximum targets.

        For the calendar year 2009, the HFEA-set multiple birth rate maximum target will be 24% (the
        current national average), followed by progressively lower targets over the next 3 to 4 years.
        The HFEA will carefully monitor the impact of its policy, including any impact on fresh cycle
        pregnancy rates, to ensure that the targets are appropriate.

        This new policy builds on guidance introduced by the HFEA in 2002 suggesting limiting the number
        of embryos for transfer to 2 in women under 40, and to 3 for older women. This was introduced
        as a formal limit in 2004.

Result
Following the introduction of the formal embryo transfer limits in 2004, the incidence of triplets decreased, but the number of twins continued to rise.

The impact of the new strategy will be monitored by the HFEA.