Embryo Disposition Decisions

Lesson 1 of 4

Introduction to Embryo Disposition

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Introduction

When patients undergo fertility treatment, they often do so with a singular goal in mind—bring home a healthy baby. If they are successful, they may go after a second goal—bring home a sibling (or siblings).

For patients who have undergone IVF, this is often accomplished through the transfer of frozen embryos.

In this case, having “extra” frozen embryos is a great position to be in—it gives you an opportunity to have more transfers and thus more chances at bringing home a baby. However, when a patient feels their family building is complete or changes their mind about pursuing further treatment, the patient is faced with a decision about what should be done with their remaining embryos. This is known as embryo disposition.

Embryo disposition decisions are complicated by how the patient regards the embryos. Some patients view the embryos as a biological tissue; others see the embryos as future children with interests to protect. For some, a cryopreserved embryo represents a reminder of their fertility journey and the time, money, emotions, and energy that went into their creation.

Before we proceed further, we want to highlight that it’s critical to have an incredibly thorough discussion with your doctor and clinic, using their own data, insight, and perspective, before making any decisions on what to do with your remaining embryo(s). Seeking counseling with a qualified mental health professional can also be beneficial. This course is not a substitute for such discussions.

Background

The decision of what to do with remaining frozen embryos (or professionally known as final embryo disposition decision) is pertinent to many people undergoing IVF.

While there is no official count, conservative estimates place the number of frozen embryos currently in storage in the U.S. around a half million. Other experts believe the numbers are well over a million, not taking into account frozen embryos in storage globally.

It’s not uncommon for patients to postpone this decision, and ultimately, they choose to stop paying the clinic storage fees, at which point, the embryos may be considered abandoned. This creates a practical, legal, and ethical dilemma for the facility storing the embryos.

On the other hand, patients who do make an informed decision often express a feeling of relief and closure.

The Decision Making Process

At the start of an IVF cycle, embryo disposition decisions are usually presented on the initial IVF consent forms. At many clinics, there is very little education given about these options, and many experts feel that the topic is not being openly addressed early enough in the IVF process.

While introducing the topic earlier in the IVF process may be helpful, it’s important to note that__ most patients end up changing their minds__. What once felt like a comfortable option may feel less appealing as time goes on.

To illustrate the point, a small single center study showed that only 29% of couples kept with their initial disposition choice; the other 79% changed from their original intent.

Even though initial decisions are not set in stone, the decisions made on clinic consent forms can have a long-lasting impact, particularly if there is a legal dispute involving the embryos. We address this further in a later lesson.

Although changing your mind is common, it’s not necessarily easy. One study out of Canada surveyed patients who had embryos in storage for over two years. They found that 70% of patients were struggling with their embryo disposition decision. They also found the fear of regret and discordant wishes between partners to be significant factors in influencing their decision making.

This is a highly personal decision and several factors will probably come into play. Below, we cover a few factors you may wish to consider. Again, before making any decision about your embryos, it’s critical to have a detailed discussion with your doctor and clinic (leveraging their data and experience). This course is not a substitute for those discussions.

Stage in the Family Building Process

Many patients begin the family building process with a vision for how many children they’d like to have and sometimes wishes around age difference or sex.

Those feelings often evolve with the experience of raising children and as budgets, relationship dynamics, and career aspirations adjust. It’s also common for partners to have different views on the matter.

A key consideration in this decision is the degree of confidence all parties have around the desire to have more children.

If one or both partners feel there’s a non-insignificant chance they’ll want to have more children, then it may be wise to continue to pay to store embryos and leave open the possibility of a future pregnancy attempt.

Quality of Embryos

A critical determinant of whether future frozen embryo transfers will work is the underlying quality of an embryo.

Blastocyst vs Cleavage Stage

For instance, embryos that were frozen at the blastocyst stage are more likely to implant than embryos frozen at the cleavage stage (which can very much still work) as they’ve been given more time to demonstrate their durability.

You can see our dedicated lesson to the subject here.

Live Birth Rate by Stage of Development

Morphological Grading

Most every laboratory will grade embryos, and we have a detailed lesson on the value of such grades here. Grading is subjective; “lower quality” embryos can still very much make babies, and yet, there is still a correlation between embryo quality, female age, and the odds of success, as you can see below. Again, even “lower quality embryos” can still lead to births, but the odds do dramatically adjust, especially in the context of advanced female age.

Genetic Testing

Likewise, embryos that pass preimplantation genetic testing for aneuploidy (PGT-A) are far more likely to lead to a successful transfer than those that are “mosaic” (often depending on the form of mosaicism). Embryos deemed “aneuploid” seldom lead to a birth. Many (but not all) experts question the intuition of storing embryos revealed to be aneuploid.

We have a dedicated course where you can learn more about PGT-A & Mosaicism here.

PGT-A Transfer Hierarchy

If your embryos did not undergo PGT-A (previously known as either PGS or CCS), in some cases it may be possible to have them warmed, tested, and re-frozen. This is not always recommended, and it’s important to discuss the risks, trade-offs, and benefits with your doctor.

Ultimately, storing and relying upon embryos that could have been previously deemed unusable may create future challenges. Notwithstanding the pain of enduring failed future transfers, by the time one’s realized the embryos are not viable and another retrieval is needed, the odds of success may have shifted with age.

Impact of Age on IVF Success Rates

Cultural, Religious, or Ethical Factors

Hopeful parents often have a spectrum of views on their frozen embryos and what those embryos represent. While some may consider their embryos to be a simple combination of eggs and sperm, others regard the matter quite differently.

For some, cultural, religious, or ethical factors will lead them towards, or away from, specific final disposition decision options. Some patients have a clear perspective while for others, the decision needs to be examined more closely with the input of family, friends, mentors, clergy, spiritual guides, literature, and soul-searching.