Summary

U.S. fertility doctors more commonly guide their IVF patients to transfer multiple embryos per transfer, but that pattern is shifting. Amidst the debate of whether the patient or doctor makes this crucial choice, doctors clearly help drive these decisions and overwhelmingly their recommendations are followed. At the same time, over a quarter of patients do not believe they are given sufficient education to make a decision and nearly a fifth of patients report being educated only immediately before transfer. And 39% of patients were not apprised of the risk to their offspring of a multiple-embryo transfer and 23% were not apprised of the risk to themselves. Disparities in education can be found depending upon the patient’s age and level of reimbursement and clearly correlate to a difference in decision-making.

Context

Multiple-embryo transfers carry dramatically higher risk of multiple gestation which drives higher risks to both mother and offspring

In fairness, these absolute percentages may seem small to some, but carrying multiple fetuses leads to premature-birth, and low-birth weight, in 57% of cases for twins and 97% of cases for triplets. Nearly a third of all twins will end up in the NICU.

Why does that matter? For one, low-birth weight and premature offspring suffer from significant emotional and cognitive disadvantages. JAMA investigated 18 studies on the subject and all 18 agreed.

For this reason, countries like Sweden, Japan and Australia have largely migrated away from multiple-embryo IVF transfers to single-embryo IVF transfers. Conversely, in the U.S. upwards of 70% of IVF cycles still involve elective multiple-embryo transfer, according to the CDC. We know of no studies in the last decade that investigate what patients are told in this process and how that influences their decisions.

Methodology

We surveyed 413 U.S. IVF patients who were eligible for single or multiple-embryo transfer. 53% of patients were treated within the last 18 months. Patients were asked a variety of questions about how they were educated on the topic of single versus multiple-embryo transfer, the extent to which their doctor made a recommendation, their ultimate choice, as well as demographic data on age, geography, level of fertility insurance, year treated and whether they had undergone PGS testing. We used a multi-variate regression analysis isolating on these factors with a 95% confidence interval to determine statistical significance. Resulst were not broken out by Day 3 vs Day 5 embryo stage.

Observations

Doctor Recommendations

Over 90% of patients say their doctor made a recommendation on the number of embryos to transfer and roughly half of those were guided towards multiple-embryo transfer. All the same, it is clear doctors have begun shifting their priorities towards single-embryo transfer.

We noted that patients living in states with weaker IVF insurance mandates, or who had not received PGS testing, were far more likely to be guided towards transferring multiple embryos. Meantime, younger patients (who are generally better candidates for single-embryo transfer) treated as recently as 18 months ago are still as likely to be directed towards multiple-embryo transfer as single-embryo transfer.

Clinician Influence

The clinician’s recommendation on the number of embryos to transfer tightly correlates with what ultimately transpires. Generally, to this point doctors assert it is the patients who drive these decisions.

In fact, most fertility patients consider their doctor to be an equal, or more-than-equal, decision maker in this process. We should point out that with each passing year it seems patients consider this decision more theirs to make.

Patient Perception of Discussion and Timing

Despite the importance of the subject matter, nearly 26% of patients regarded their discussion with their clinician to have been “somewhat or not-at-all” sufficient and over one-fifth report their only discussion transpired immediately before embryo transfer. Importantly, those patients who ultimately underwent a multiple-embryo transfer were significantly less likely to have been given enough time to make a decision.

Uneven Dissemination of Information

Patients were not provided consistent levels of information in formulating a decision. Most startlingly is the degree to which patients were not told about the risk to themselves (23%) or to their offspring (39%) of a multiple gestation birth. We consider this a first-order issue.

Clearly what patients were told about the risks and benefits of each procedure correlated with the number of embryos they elected to have transferred. When women were told of the risks to themselves of a multiple-embryo transfer, they were significantly more likely to elect for a single-embryo transfer. Women who were told that multiple-embryo transfers had higher rates of success on first transfer more often chose multiple-embryo transfer.

We noticed a patient’s age and the location where they were treated correlate with what information they were given. For instance, younger women were better educated on the risks to both mother and offspring, possibly in an effort to dissuade this population from multiple-embryo transfer. Women treated in states with stronger reimbursement (e.g. Illinois, Massachusetts, New Jersey, Maryland) were more likely to be educated on the challenges of raising twins. Older patients were more likely to be told of the theoretical benefits of multiple-embryo transfer than their younger counterparts.

Conclusion

In the minds of patients, clinicians clearly wield tremendous influence over the decision of the number of embryos to transfer. While many patients consider the nature and timing of their discussions sufficient, a non-insignificant minority do not. As we work to better understand why multiple-embryo transfer remains stubbornly high in the U.S., we would be wise to pay closer attention to how and when patients are being educated on the tradeoffs for their treatment options.

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