Abstract
Despite the highest historical live birth success rates for couples undergoing in vitro fertilization (IVF), there has been an epidemic of iatrogenic twin and higher order gestation conceived from this treatment. Continued improvement in cryopreservation techniques have allowed preservation of supernumerary embryos for use in future cycles, and refinements in culture systems and embryo selection have resulted in the transfer of fewer embryos while maintaining favorable pregnancy rates. The voluntary transfer of a single high quality embryo, elective single embryo transfer (eSET), has significantly reduced multiple gestation rates and maximized the rate of singleton pregnancy without compromising overall success rates. Although eSET is the standard of care in several developed countries, utilization in the United States has been slow. States with mandated IVF insurance have seen decreases in preterm birth rates yielding down stream health care savings. Herein, the evolution and future applications of this practice to reduce the risk of iatrogenic twins is reviewed.
Highlights
Introduction of elective single embryo transferIn the late 1990s, significant improvements in in vitro fertilization (IVF) pregnancy success rates challenged the mantra that the transfer of higher numbers of embryos were required to obtain acceptable pregnancy rates
In the early 1980s, the rise in Advanced Reproductive Technologies (ART) success rates was synonymous with the transfer of multiple embryos and multiple gestation pregnancy
The past three decades have seen the emergence of IVF as the gold standard treatment for infertility
Summary
Since its inception in 1978, in vitro fertilization (IVF) has resulted in nearly 4 million births. IVF utilized unstimulated, natural cycles with laparoscopic oocyte retrievals and was fraught with inefficiencies and low pregnancy rates. Multiple embryos were transferred to maximize pregnancy rates. The debate surrounding the ideal number of embryos for transfer was born and has been ongoing for the past three decades [2]. In the early 1980s, the rise in Advanced Reproductive Technologies (ART) success rates was synonymous with the transfer of multiple embryos and multiple gestation pregnancy. In the early 1990s when the incidence of multiple gestations from IVF was 15–30 %, the delivery-related hospital expenses was up to four times more per child for multiple gestations compared to singletons [6]. The rate of twin gestation has plateaued and 36 % of all twins and 77 % of higher order multiples are still due to ART [7]. Annual expenditures for iatrogenic preterm deliveries totals twenty-six billion dollars of healthcare costs [8, 9]
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