The use of outcomes-based data in reducing high order multiple pregnancies: The role of age, embryo score and ovum donation

Abstract

Objective: This report demonstrates the efficacy of clinic-specific guidelines in reducing the incidence of high order multiple pregnancy(ies) (HMP) from in vitro fertilization (IVF). Design: IRB approved retrospective analysis of IVF outcomes from two united IVF programs (1995–9), with followup analysis (2000–01) based on the information gained from 1995–9. Materials/Methods: During 1995–9, 777 clinical pregnancies resulted from 1740 IVF embryo transfers (ET)s in two united IVF programs. Good outcomes for an IVF cycle were defined as singleton or twin deliveries and bad outcomes as no delivery, miscarriages, need for multifetal reduction, triplet, or quadruplet pregnancies. The IVF cases under study were retrospectively analyzed by logistic regression using multiple variables. The utility of the historical information generated from 1995–9 for determining the optimal number of embryos to transfer in order to reduce the incidence of HMP was evaluated in 2000–2001. Results: The best outcome for donor egg (DE) <35 yrs old, DE >35 yrs old and non-DE cycles <35 yrs old were achieved with the transfer of two (57.7%), three (43.2%) and three (43.2%) embryos, respectively. The highest risk for HMP was associated with the transfer of three or more embryos in DE cycles <35 yrs old which accounted for 23.9% of all HMP. Logistic regression revealed that age <35 (p <0.0001), embryo score (ES) (p <0.0001), and donor egg (p = 0.0262) significantly affected the good/bad rate. The ES correlated with the percentage of good outcomes/cycle (GR) in a linear fashion as defined by the equation (GR = 3.3 + 2.0 ES) within the range 4 <ES <26 (r = 0.91). Follow up analysis revealed the near complete elimination of HMP with DE IVF- one triplet for 2000–1. Furthermore, a 52% reduction (p = 0.001) in HMP from 9.1 (71/777) to 4.4% (25/569), in the absence of change in the overall pregnancy rate (PR) for DE (58.4 (153/262) vs 59.3% (99/167)) and non-DE cycles (41.5 (608/1452) vs 44.5% (470/1056)), was noted in 1995–9 compared to 2000–1, respectively. This reduction was accomplished primarily, but not exclusively, in DE cycles. Finally, among physicians experiencing the greatest reduction in HMP (7.6 in 1995–9 to 2.7% in 2000–1, p = 0.02), no significant reduction was noted in clinical PRs (39.9 to 37.9%) over the two study periods, respectively. Conclusions: Heightened awareness of clinic-specific high risk categories (age, ES, and DE) during patient informed consent for IVF-ET resulted in a significant reduction (52–64%) in HMP without significantly reducing the clinical PR. A standardized national embryo scoring system incorporated into the SART data collection system may provide useful information to IVF patients and potentially help reduce the incidence of HMP without compromising the PR. Supported by: IVF Research Fund, Division of Reproductive Endocrinology and Infertility, University of Utah Health Sciences Center.