1. Elective Single Embryo Transfer (eSET); How Much Reasonable ? Rifat H. Gürsoy,M.D. Gazi University School of Medicine Dept. Of Ob/Gyn Reproductive Endocrinology & Infertility Division Ankara-TURKEY

2. Background Multiple embryo tranfer during IVF has increased multiple pregnancy rates (MPR) causing maternal and perinatal morbidity Elective single embryo transfer (eSET) is now being considered as an effective means of reducing this iatrogenic complications

3. Background Women undergoing treatment with IVF face to an approximately 20-fold increased risk of twins and 400-fold risk of higher order pregnancies

4. Background When compared with single births, twins have a 4-fold increased risk of mortality and for triplets the risk is 6-fold higher.

5. The Perinatal Mortality Rate in England (1995) General : 8.7 / per 1000 IVF singletons: 8.8 / per 1000 IVF twins :46.8 / per 1000 IVF triplets : 82.6 / per 1000 All IVF births: 22.6 / per 1000

6. Multiple Gestations Increased incidence of preterm births Handicapped infants –Twins : 1/13 –Triplets : 1/5 Higher malformation rates with IVF/ICSI

7. Obstetric Complications of Multiple Gestations Miscarriage Pregnancy Induced Hypertention Gestational Diabetes Premature Labour Abnormal Delivery Higher C/S indications

8. Economic Impact of Multiple Gestations The increased cost associated with prenatal care twin and higher order pregnancies The cost of the subsequent neonatal intensive care

9. Parenthood of Multiple Gestations Practical dificulties Residuel stress Demand of more resources Emotional stress

10. Strategies to Minimise the Multiple Pregnancies Multi-fetal pregnancy reduction (MFPR) Individualised embryo transfer policy Blastocyst transfer Elective single embryo transfer

11. Elective Single Embryo Transfer (eSET) Untill recently, eSET was not an optional in clinical practice, for fear tahat the overall success rates would decline, too far

12. Reason of This Presumption Published data of single embryo transfer where only one embryo was available No opportunity for selection of more suitable embryos exists Poor potential of the only available embryo (around 10%)

13. Single Embryo Transfer (Vilska,1999-Finland) PR (%) Only 1 embryo available 20.2 After selection 29.7 eSET + 1frozen/ thawed 47.3 (CPR)

15. DET vs SET, LBR

16. DET vs SET, CPR

17. DET vs SET,MPR

18. DET vs SET,Abortion

19. DET vs SET+FZET, LBR

20. DET vs SET+FZET,CPR

21. DET vs SET+FZET,MPR

22. DET vs 2 f-SET, LBR

23. DET vs 2 f-SET, CPR

24. DET vs 2 f-SET, MPR

25. DET vs 2 f-SET, Abortion

26. DET vs TET, MPR

27. CONCLUSIONS-I In a single fresh IVF cycle, eSET is associated with a lower LBR than DET There is no significant difference in CLBR following SET+1 FZET and the LBR following a single cycle of DET MPR are lowered following SET compared with other transfer policies

29. Registry European Society of Human Reproduction & Embryology (ESHRE) Australian & New Zealand Assisted Reproduction Database (ANZARD) The International Committee for Monitoring Assisted Reproductive Technology (ICMART) Canadian ART register Society of Assisted Reproductive Technology, USA (SART) Human Fertilization & Embryology authority (HFEA, UK)

30. # 47 348 (20.0%) SET - Avrupa 2005 ; Sweden (69.4%), Finland (49.7%), Belgium (48.0%), Denmark (32.6%), Slovenia (30.0%), Bulgaria (8.5%), US 2007 (2.8%), Avustralya (56.9%), Kanada (11%), Latin Amerika (6.5%), Japonya (54.8%) 69.4% 2.8%

31. CONCLUSIONS-II e-SET may be an effective policy regarding to lower the incidence of high order pregnancies But should not to be considered as the only and the sole choice