Given rapidly changing practices in the IVF arena, it is becoming increasingly implausible to reliably interpret current national reports expressing IVF outcome statistics as birth rate per initiated treatment cycle, per egg retrieval procedure or per embryo transfer procedure performed. …AND here is why:
- There has with good justification been a strong move to perform embryo transfers on day 5-6 (blastocyst-ET) rather than on day 3. Such practice has inevitably resulted in more and more women (especially older women and those who have diminished ovarian reserve-DOR) failing to reach embryo transfer.
- The growing trend of freezing and “stockpiling (banking) embryos” for future use, coupled with the expansion of preimplantation genetic testing (PGT) with of full blastocyst karyotyping (-e.g. NGS), in most cases requires delaying ET to a later cycle (Staggered IVF) for frozen embryo transfer (FET) in order to have test results available for embryo selection.
- There is presently a wide center-to-center variation in the number of embryos being transferred at a time. This is sometimes due to patient insistence, but all too often is done in an attempt to bolster IVF success rates. The result has been an unacceptably high multiple birth rate.
- Currently, in my opinion, oversight by the Society for assisted Reproduction (SART) is lacking when it comes to insuring the accuracy of IVF success rates reported by different clinics, thereby creating an uneven playing field and skepticism about reported results.
I believe that when it comes to the annual reporting of IVF outcome statistics, the time has come to consider adopting a simpler, more reliable, less costly and more verifiable method, one that at a glance would compare standards of IVF services on a “level playing field”. In my opinion, this could best be achieved by focusing primarily on the viable pregnancy rate (those that have advanced beyond the 10th week of pregnancy) per transferred embryo. The data would be further sub-classified on the basis of the woman’s age and by the type of procedure performed (e.g., age, fresh cycles, frozen embryo transfers (FET), egg donation, etc.)….see the Table below.
Expressing IVF success/competence in terms of outcome per (each) embryo transferred, would not only likely lead to a drop in the number of embryos transferred per ET procedure and accordingly help reduce the unacceptably high national multiple birth rate, but would also facilitate oversight of reported results and thereby provide consumers with an ability to readily evaluate and compare proficiency on a level playing field.
The College of American Pathologists (CAP) is charged with overseeing all IVF laboratories and in the process of so doing, tracks the fate and disposition of all gametes and embryos propagated. Using such oversight and data, it would, it would be a simple and inexpensive exercise to individually and collectively link the origin, and disposition/ destination of all eggs/embryos and in the process validate reported rates.
Since the difference between the ongoing IVF pregnancy rate beyond the 10 weeks and birth rate is insignificant, I decided to test this new approach that focuses on the ongoing pregnancy rate per embryo transferred (PRPE). The preliminary data shown below is for all patients I personally treated at Sher-IVF from January 2018 to March 2019, thereby allowing confirmation of viable pregnancies by ultrasound examination at 10 weeks, prior to my departure from SIRM , a few months later.
I fully recognize that recent changes in the reporting system used in SART/CDC annual reports, which expresses outcome in terms of the number of IVF cycles initiated and per egg retrieval (ER) performed, were adopted to provide a full accounting of the amount of work that goes into propagating each IVF pregnancy. While such intent is laudable, the fact is that such data presentation, while clarifying one aspect of the picture will often obscure another. For example, in cases where the use of preimplantation genetic testing and stockpiling of PGT-normal embryos (banking) in older women and those with diminished ovarian reserve (DOR) often represents the ideal approach, it could understate success and discourage adoption of state of the art practices. This is because such patients of necessity require the uncoupling of the ER and ET. Moreover, in many such cases, several IVF cycles would be required to access even one or two “competent”/euploid embryos for transfer. Clearly, the current approach of expressing success as a function of each IVF cycle initiated or per ER procedure performed would unfairly, understate the quality of care (and the success rate) for those clinicians who in the very best interest of their patients elect such an approach and might even disincentive some from doing what is right in this context.
I would like to express my sincere appreciation to Levent Keskintepe and Dayana Elizalde for assisting in the collection and compilation of this data.
SHER-IVF: OUTCOMES BEYOND 10 WEEKS (JANUARY 2018-MARCH 2019)
|FRESH IVF CYCLES (n=224)|
|# Egg Retrievals||n=69||n=79||n=40||n=9|
|# Embryo Transfers (ET)||n=29||n=12||n=4||n=3|
|# Positive beta- hCG tests (%)||23(79)||7(59)||3/4||1/3|
|Pregnancies (>10w) per ET procedure (%)||20 (69)||4(33)||3||1|
|Pregnancies (>10w) per embryo transferred -PRPE (%)||20/50 emb (40)||4/15 emb (26)||3/9 emb (33)
|FROZEN EMBRYO TRANSFERS-FET (n=204)|
|# Embryo Transfers (ET)||n=60||n=67||n=72||n=5|
|# Positive beta- hCG tests (%)||38 (63)||36 (54)||27 (37)||3/3|
|Pregnancies (>10w) per ET procedure(%)||29 (48)||25 (37)||19 (26)||3|
|Pregnancies (>10w) per embryo transferred -PRPE (%)||29/101 emb (29)||25/93 emb (26)||
19/104 emb (18)
|3/7 emb (43)|