• What is this leaflet about and who is it for?

    This leaflet is for couples undergoing In Vitro Fertilization (IVF), Intra-Cytoplasmic Sperm Injection (ICSI) or Fresh/Frozen Embryo Transfer (FET) and to provide them guidance on the safest number of embryos to transfer to the uterus which will reduce the risk of multiple pregnancy.

  • What is ‘Single Embryo Transfer’ (SET)?

    SET is where a single embryo is replaced into the uterus following fertilization. At the planning stage, the clinician will advise you of the risks of multiple pregnancies. You will both need to sign a consent form relating to your treatment. Patients should be aware that even when only one embryo is replaced, it is still possible for a multiple pregnancy to occur as an embryo can occasionally divide to create identical twins. 23.6% of pregnancies from assisted conception are twins compared to only 1.5% of naturally conceived pregnancies. Indeed, the risk of monozygotic (identical twins) is at least 2 fold higher after IVF compared to natural conception with an average of 2%. The risk is particularly higher after blastocyst (day 5 or 6 embryo) transfer.

  • Why are we being asked about this?

    Couples in your situation often consider that having 2 healthy babies in a twin pregnancy is the best outcome of treatment, but there are risks in a twin pregnancy and you need to be aware of them. The overall chance of twin pregnancy remains significant if 2 embryos are replaced. All clinics are now required by the regulators, (HAAD) to reduce this multiple pregnancy rate. We are thus giving you some information here to help you decide whether to have one, two or three embryos transferred.

  • Why are multiple pregnancies a problem?

    Multiple pregnancies are the single biggest risk to the health of children conceived by IVF, ICSI or FET as many more twins are unwell when they are born than singleton babies but a minority of twins may suffer health and developmental problems for many years. There is also a greater risk to the mother’s health in a multiple pregnancy.

  • What is the risk to the mother of a twin/ triplet pregnancy?

    Almost all complications of pregnancy for the mother are increased in a twin pregnancy.

    This includes:
    • Higher rate of miscarriage
    • Risk of hypertension is higher 4 - 20 times (high blood pressure)
    • Risk of pre-eclampsia (Hypertensive disorder affecting mother and child) is 3 times higher
    • Risk of pregnancy-related diabetes is 2-3 times higher
    • Needing hospitalization for last weeks of pregnancy (delivery)
    • Needing a Caesarian section / induced labour / instruments to aid delivery
    • Haemorrhage (severe bleeding) as result of placental abruption (early detachment of the placenta) and postpartum hemorrhage
    • Risk of mother’s death is twice (although rare)
    • Higher incidence of depression as a result of coping with more than one baby
    • Higher rates of marital problems
    • Greater financial considerations
    • Taking care of the twins, even if they and you are fit and well, is much more difficult.
  • What is the risk to the baby of being a twin or triplet?
    This includes:
    • Twin-to-twin transfusion syndrome when one baby takes all the blood from the other.
    • Abnormal amounts of amniotic fluid especially for twins that share a placenta.
    • Cord entanglement
    • 7 times higher risk of neonatal death (shortly after birth).
    • 4 times higher risk of perinatal death (still born). The chance of a baby dying between 24 weeks of pregnancy and 7 days after birth (perinatal mortality rate) is singleton (one baby) 6.9 in 1000 and for twin (two babies) is 27.2 in 1000.
    • 4 times higher risk of cerebral palsy (brain damage which impairs control of muscle movements). The chance of a baby having cerebral palsy in singleton (one baby) 2.3 in 1000 and twin (two babies) is 12.6 in 1000.
    • 2 times higher risk of disability e.g. learning disability, language delay, attention/ behavioural problem.
    • Over 50% are born prematurely (under 37 weeks) at low birth weight linked to higher risk of adult disease.
    • 10 times higher risk of admittance to neonatal special care unit for breathing/ feeding problems.
  • Who should have a single embryo transfer?

    Women with the greatest risk of twins are 35 or younger and are having their first treatment. This does not mean that twins do not occur in women over 35 years but it is less likely. We can give you a realistic estimate of your risk of twins when we know more about your embryos. That will not be until at least 3 days after the eggs are collected.

    There is information below about our recommendations for embryo transfer. It gives several options because the individual recommendations that we give to you may change as we see your embryos develop.

  • What is the change in pregnancy rate if I have only one embryo transferred?

    Evidence shows that if you have only one embryo transferred and you have other eggs/embryos frozen and transferred later if required, your overall chance of a baby is not reduced.

  • When will we get information about our embryos and when will we be told?

    We will call you on the day after egg collection (Day 1). We will let you know how many eggs have fertilised normally. We will call you before 1 pm, 2 days later (Day 3) to let you know if we recommend monitoring your embryos for a further 2 days before transfer (Day 5).

    You need to be prepared to come in for embryo transfer that day (Day 3). If you are advised to come in on Day 5, we will give you a time, when we call you.

  • What is the transfer policy?

    We will look at the embryos 3 days after egg collection (Day 3), the decision about what to do then is not based on a rigid policy and we might vary it depending on your specific circumstances and your views. Generally, if you are 35 years or younger and you have at least 2 top or good quality embryos on Day 3, we recommend growing them for a further 2 days so that we can select the best embryo to transfer. Otherwise we will recommend transferring your embryos on Day 3. We will discuss this with you when you attend for the embryo transfer.

  • How many embryos do we recommend to be transferred?
    Day 3

    You may have either 1 or 2 embryos transferred depending on your specific circumstances. These will be discussed with you.

    Day 5

    If you have at least one blastocyst on Day 5, we will only transfer one blastocyst. This is to reduce the risk of twins. If you have embryos on Day 5 that have not yet reached the blastocyst stage, you may have 2 or 1 embryos transferred as you wish.

  • What do I do before coming in for embryo transfer?

    Have your breakfast/lunch as usual then come to the hospital at the time decided. Please do not wear perfume or strong deodorants as strong smells can be detrimental to your embryos.

  • What happens when I am admitted?

    There may be a little time between your arrival at the hospital and being called for your transfer. Take this time to relax. When called for transfer we will ask you to change into theatre gown and remove your outside shoes and put on theatre shoes/slippers.

  • What happens when the embryos are transferred?

    Immediately before your procedure, the embryologist will tell you about your embryos. We will confirm with you again the number of embryos you wish to have transferred. We will confirm your name and check it against your embryos with the embryologist. The procedure usually only takes a few minutes and is usually quick and painless.

    We use a moderately full bladder for embryo transfer. This helps in 2 important ways. It allows good ultrasound visualization of the catheter which helps with smooth and proper transfer of the embryos to the best location, and it also unfolds the uterus to a more accommodating angle, making the process smoother and less traumatic for the uterine lining and the embryos.The catheter is loaded with the embryos and the doctor passes it through the cervical opening up to the middle of the uterine cavity. Abdominal ultrasound is used simultaneously to watch the catheter tip advance to the proper location.

    When the catheter tip reaches the ideal location, the embryos are then "transferred" to the lining of the uterine cavity by the doctor. After the embryos are transferred, the catheter is slowly withdrawn and checked under a microscope for any retained embryos. Mostly the procedure is straightforward. However, sometimes it may take longer to pass the catheter into the womb. After the embryo transfer procedure, the catheter is checked to confirm that the embryos have gone. Occasionally one or more may have stuck inside the catheter and the procedure has to be repeated.

    You may go home straight afterwards as resting or lying down does not improve the success rate. You may also empty your bladder!

  • After the embryo transfer

    We advise you to lead a normal life without doing anything too strenuous. There is no need to abstain from sexual activity after the embryo transfer. There is nothing more you can do at this stage to help the embryos to implant. Please don’t hesitate to call the hospital if you have any problems. Remember, we are here to support you throughout your treatment.

  • How soon to do a pregnancy test after IVF?

    About 9-11 days after the transfer (9 days for day 5 transfer and 11 days for day 3 transfer), we do a blood test to find out if you are pregnant. If embryo implantation has occurred, HCG hormone will be detectable in the mother's blood at that time.

    We don't recommend doing a urine pregnancy test after IVF. The reason is that there are a lot of falsely negative results. We have seen many beautiful babies born after the female partner called us to say that she took a home urine pregnancy test that was negative. A blood test is needed because it is much more sensitive and reliable

  • How does the embryologist decide which embryos are of good quality?

    There is no absolute test that tells us whether or not an individual embryo can make a baby. The embryologist will look at the embryos each day and assess how quickly each embryo is dividing and whether all the cells are dividing evenly. We always transfer the best quality embryos to give the best chance of a pregnancy

  • Is there evidence comming there is no benefit to having two or three embryos replaced?

    Almost all multiple twin pregnancies from assisted conception treatment are caused when 2 embryos are transferred and both the embryos implant into the womb (non-identical twins). Data from european countries such as Sweden shows that routinely replacing one embryo tells us that this does not jeopardise patients’ chances of success if targeted at those patients with the highest chance of becoming pregnant. The multiple pregnancy rate dropped to around 5% but the overall pregnancy rate stayed virtually the same.

  • What is the embryo transfer policy at Burjeel Center for Reproductive Medicine?

    Our aim is not to reduce patients’ chances of conceiving, but to reduce the number of patients who are conceiving with multiple embryos as there are significant and serious risks associated with multiple pregnancies. The overwhelming evidence both from international and national studies undertaken and by analysis of our own pregnancy data show that patients most at risk of multiple pregnancies are younger patients with good quality embryos. For these patients, having one embryo replaced does not lower the chances of success, but rather means they are more likely to have a healthy singleton pregnancy rather than a potentially risky twin pregnancy

    As embryo quality is not known until the day of transfer, the final decision may sometimes be deferred until then. Therefore patients fitting the criteria below will have one fresh embryo replaced to reduce the chances of a multiple pregnancy:

    1. All patients undergoing their first IVF or ICSI cycles who are 35 years of age or less with at least 2 good quality embryos or one good quality blastocyst stage embryo.

    2. All patients with medical history which increases the risks associated with multiple pregnancy will also be advised to have only one embryo replaced.

    These conditions include, but are not limited to:
    • Uterine abnormalities, previous multiple ceasarian sections.
    • Recurrent miscarriage.
    • Prior mid trimester (after 12 weeks) miscarriage.
    • Prior preterm labour / stillbirth / neonatal death.
    • Diabetes; Hypertension / history of pre-eclampsia.
    • Inflammatory bowel disease.
    • Any chronic medical condition.

    3. The risk of multiple pregnancy is lower with frozen embryo transfer.

    4. Patients who had a live birth from a previous IVF cycle are advised to have single frozen embryo transfer.

  • Making the decision

    We understand that this is a stressful time and there are strong emotional and financial pressures on patients undergoing fertility treatment and that the overwhelming desire is to maximise the chances of having a family. However the common idea of twins being an “instant family” and a good outcome to treatment needs to be challenged, as the reality can sometimes be very different. At Burjeel Center for Reproductive Medicine, we put the welfare of potential children first, giving them the best chance to be born healthy and full- term singleton babies.

    By providing this information, we hope that patients can consider carefully the risks involved with multiple pregnancies when deciding the number of embryos they wish to have transferred. We realize this may not be an easy choice so if you have any questions, please ask a member of staff who will be happy to help you.

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