Clinic E tells their story

Clinic profile

• IVF Unit within an NHS hospital setting dealing with 600 new referrals with infertility each year.
• 450 fresh IVF cycles per year: 60% self funded, 40% funded by the NHS.
• Live birth rate per cycle started around the national average in 2009.

Pre-January 2009

Unit has had a philosophy of care sensitive to multiple pregnancy rates for some years. The fertility clinic and the receiving maternity services are geographically isolated and thus all neonatal problems are looked after within the same hospital setting. Neonatal transfers of necessity entail significant journeys.

Policy change (January 2009)

With the introduction of the Policy change the Unit held several meetings with all staff to discuss the development of a multiple births minimisation strategy. 

All were aware of the clinical issues but there were concerns that a drive to reduce multiple rates would adversely affect our overall live birth rates. Patient acceptance was an unknown and there was a concern that some might move to other units where a less rigorous promotion of SET was in place.

It was important though that all staff agrees the policy and consensus in approach agreed. Consistency of message to patients at all stages in the pathway of care, including pre-IVF assessment and treatment was fundamentally important.

Patient attitude

Written information concerning eSET was sent prior to the first appointment at the clinic to all patients. The policy was outlined in detail at an information evening session for prospective patients and reinforced in discussions at a subsequent clinic appointment with each individual couple.

The information covered issues of risks for mothers and babies associated with multiple pregnancy. It was emphasised that eSET was not suited for all and information on embryo selection techniques was supplied. Links to web-based resources were also supplied including particularly the One-at-a-time web site.

Laboratory changes

An algorithm based on female age, embryo quality and numbers was developed. This was intended to guide clinical and laboratory discussions and decision making.

Impact of the policy

In the first year of the policy 37% of our patients were recommended eSET. Of these 77% accepted the advice and had a single embryo transferred. 28% of these had a clinical pregnancy none of which were multiples.

The patients who declined the recommendation of eSET had a 45% pregnancy rate but 40% of these were twin pregnancies. In patients who were not recommended eSET 29% conceived and 21% of these had twins.

The overall multiple birth rate as a % of all births was 18%. The pregnancy rate overall was 30%.

Comment

The high acceptance rate of eSET suggests that our patients are compliant with the policy. The difference in pregnancy rates where DET is performed mirrors others’ experience.

The cumulative effect of cryopreservation cycles on top of the eSET cycles need to be emphasised. The maintenance of reasonable overall pregnancy rates despite the promotion and uptake of eSET is encouraging but the high multiple rate in those declining eSET is worrying.

The multiple pregnancy rate in those who were not recommended eSET is also an issue. Our techniques for defining the patient at risk of a multiple pregnancy still require to be refined.

Future improvements

Our recent data has shown consistent fresh cycle pregnancy rates.

The quality of cryopreservation practice needs to be maintained to underpin our multiple births minimisation strategy. If there are fluctuations in embryo survival or reduction in extended culture rates  this will lead to a reduction in cumulative pregnancy rates and will be a disincentive for some to accept eSET. Increased DET’s will lead to a return to high multiple rates.

Conclusion

The unit is generally happy with the introduction of eSET but we need to refine patient selection criteria for single embryo transfer and continually improve on embryo culture and cryopreservation practice to maximise cumulative live birth rates. The target of 15% for the next year will be challenging.