A recent review by the European Society of Human Reproduction and Embryology (ESHRE) examined the best approach to embryo transfer in IVF and ICSI, analyzing thousands of studies. The conclusion was clear: single embryo transfer (SET) is more beneficial than double embryo transfer (DET) for all patient groups.
At a two-day workshop in Prague, experts discussed the challenges fertility clinics face when advising patients who believe transferring two embryos increases their chances of IVF success and family-building. The workshop, organized by ESHRE’s Ethics and Law, Psychology and Counselling, and Safety and Quality in ART groups, highlighted strategies to guide clinicians in choosing the safest treatment while respecting patient values.
One key discussion point was balancing patient autonomy with medical evidence, which overwhelmingly supports SET for better outcomes for mothers, babies, and families. SET has been linked to safer deliveries, better long-term child interactions, and a higher chance of full-term births.
Dr. Rekha Pillai, a consultant gynaecologist at Newcastle Upon Tyne Hospitals NHS Trust, explained that SET should be the standard whenever multiple embryos are available. She stressed that SET does not reduce the cumulative live birth rate (CLBR) compared to DET. The risk of multiple births with DET is significantly higher, and SET should be the choice for patients at risk of ovarian hyperstimulation syndrome (OHSS) or for gestational carriers.
Patient factors such as age, infertility duration, and ovarian response should not drive the decision to opt for DET, according to the ESHRE guidelines. However, Dr. Pillai acknowledged that counseling patients on this issue is a “mammoth task,” requiring sensitive discussions about clinical judgments and personal values.
Ethical concerns were raised by Dr. Heidi Mertes from Ghent University, who argued that SET is preferable from both ethical and cost perspectives. She questioned whether mandating SET interferes with patient autonomy. Dr. Mertes emphasized that clinicians should ensure patients are fully informed about the risks of both SET and DET so they can make well-informed decisions.
Higher costs are often associated with DET, which may lead patients to opt for it if insurance covers pregnancy and neonatal costs but not ART. Therefore, policies encouraging SET on health grounds are crucial.
In terms of safety, Dr. Mertes cited evidence that DET may even increase the risk of death compared to SET. However, she also acknowledged that some patients view twins as a positive outcome, and in certain cases, exceptions to the SET rule could be justified with robust informed consent.
A Europe-wide survey conducted by ESHRE and Fertility Europe revealed that most patients prefer a singleton pregnancy due to its lower risks. However, 32% of respondents wanted twins, with the goal of having more children sooner. Still, only a quarter of those desiring twins felt healthy enough to carry two babies.
A debate on the pros and cons of SET versus DET featured Samuel Santos-Ribeiro, who presented data suggesting that transferring two embryos in separate cycles (2xSET) might soon be more successful than DET. His unpublished data showed a 53% CLBR for 2xSET compared to 39% for DET, with more children born overall.
Dr. Christos Venetis defended DET, acknowledging that ESHRE does not advocate banning it but noted that a blanket SET policy could overlook the emotional and financial strain on patients. Research shows that 40% of patients do not return for another IVF cycle after a failed attempt, often due to the cost and psychological toll.
The workshop concluded that ensuring the highest standards of care in IVF is essential to maximize success and minimize risks. Effective patient communication is critical to reducing the incidence of multiple pregnancies and improving IVF outcomes.
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