Clinic B tells their story

Clinic profile

  • 400 IVF cycles per annum
  • • NHS (60%) and self funding cycles (40%)

 

Pre-January 2009

  • Approximately a quarter of pregnancies resulting from IVF treatment cycles performed at the Unit have resulted in multiple births (22 – 30% over the past 4 years).  
  • Nationally the multiple birth rate varies from one clinic to the next and differences may be attributed to differences in the underlying patient population treated at each clinic. 
  • Over 50% of patients attending our Unit for treatment are aged less than 35 years. This age group are significantly more likely to conceive and as such are more likely to achieve a multiple pregnancy if more than one embryo is transferred. 
  • The Unit’s responsible embryo transfer replacement policy has reduced the number of triplet births to zero (>90% of patients had 2 cleavage stage embryos replaced).
  • The Unit was however keen to implement good practice guidelines and as such a targeted single embryo transfer policy was introduced in January to reduce the incidence of twin implantations.

 

Policy change (January 2009)

The policy was based on female age and embryo quality. Patients were advised on the number of embryos suitable to be replaced on the basis of their individual circumstances, as depicted in figure 1.

The policy was discussed with patients at their consultation, at information evenings and presented to them in the form of posters and information booklets.

 

Patient attitude

Overall compliance with the policy was good (97.7%). Patients responded well to the policy change, having been provided with detailed information from the beginning of their treatment pathway and consistently throughout their cycle. 91.3% of patients felt that the information they were provided with was helpful and 94.2% felt that their views were listened to and incorporated into their plan of care (information from patient satisfaction surveys, 169 respondents).

 

Impact of the policy

  • The proportion of elective single embryo transfers has dramatically increased from 0% to approximately 32%. Concomitantly there has been an increase use of extended culture, with approximately 40% of patients now having embryo transfer on day 5. 
  • Clinical pregnancy rates have remained roughly stable at 35%, whilst the multiple birth rate dropped to an overall average of 19.2% for 2009.

 

Overall the target for 2009 has been comfortably met and assuming continued application of this policy and patient compliance the target of <20% for 2010 will also be achievable. However, monthly fluctuations in multiple birth rates do serve to highlight that there is scope for improvements to be made. 
 

Improvements / the next phase

During the last 12-18 months the results have been closely monitored. Two features were identified;

1. The high multiple birth rate for patients aged 35 years or less who had two cleavage stage embryos replaced (36.2%).

2. The high multiple birth rate for patients aged 36-38 years who had two blastocysts replaced (37.5%).
The aim for 2010 will be to transfer one good quality blastocyst in patients aged 35 or less by further increasing the use of extended culture. We now have improved confidence and success rates from blastocyst stage ET’s.

Furthermore, we have improved consistency between operators in grading and selecting embryos / blastocysts and the results from our blastocyst freezing programme are very encouraging. 

Patients aged 36-38 years who have two good quality blastocyst available will be strongly advised to have one blastocyst replaced and to consider freezing any surplus blastocysts.

Conclusion

Over the last 18 months our policy has had to be adapted to ensure the correct patients are selected for eSET. Pregnancy rates have not been compromised. The focus for this year will be to reduce double blastocyst transfers and to capitalise on the success achieved with frozen blastocyst stage transfers to improve cumulative pregnancy rates.

Vitrification offers the promise of improved survival rates, permitting the vitrification of single blastocysts.