The couple's decision-making in IVF: one or two embryos at transfer?

M. Blennborn1,5, S. Nilsson1,2, C. Hillervik3 and D. Hellberg2,4

1 In Vitro Fertilization Clinic, S-791 82 Falun, 2 Centre for Clinical Research, S-791 82 Falun, 3 Dalarna University College, S-791 82 Falun and 4 Department of Obstetrics and Gynecology, Falun Hospital, S-791 82 Falun, Sweden

5 To whom correspondence should be addressed. Email: maria.blennborn{at}ltdalarna.se


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: The aim of this study was to evaluate the decision-making process and factors that contribute to the decision of IVF participants to choose one or two embryos at transfer. METHODS: Two hundred and seventy-four IVF patients equally distributed in males and females were personally interviewed using a semi-structured questionnaire which included 82 items. RESULTS: In the whole study population, previous childbirth [odds ratio (OR) 2.1; 95% confidence interval (CI) 1.9–3.6], and spare embryos to freeze (OR 23.6; 95% CI 11.2–54.5) emerged as the most important variables in patients who had one embryo transferred, while previous IVF treatments (OR 0.3; 95% CI 0.1–0.6) and the assumed increased pregnancy chance (OR 0.1; 95% CI 0.05–0.3) were the most important decision-making factors among those who had two embryos. The women were more satisfied with the information (83 versus 71%; P=0.02), and more aware of the risks with twin pregnancies (77 versus 66%; P=0.03) than the males. The women were also more concerned about their age. Knowledge about risks of multiple pregnancies was higher in females (77%) than in males (66%, P=0.03). CONCLUSION: The results of this study indicate that despite good information about the risks for complications with multiple pregnancies, many patients wish to have two embryos transferred. Spare embryos to freeze, improvement of pregnancy rate in single embryo transfer and young age of the woman are predictive of choosing single embryo transfer. However, the final decision must always be made in agreement with the physician.

Key words: double embryo transfer/IVF/patient's decision-making/single embryo transfer


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
One of the main complications in IVF is multiple pregnancies. Increasing awareness of maternal and fetal complications has led to a reduction in the number of embryos transferred in some IVF clinics (Gerris et al., 1999Go; Martikainen et al., 2001Go; Hamberger and Hazekamp, 2002Go; Gardner and Lane, 2003Go), but the frequency of twin pregnancies is still high. A multiple pregnancy is not only a high risk pregnancy, but can also be socially unacceptable for the parents (Pinborg et al., 2003Go). A reduction in the number of embryos transferred might, however, contradict the patient's desire to achieve a successful outcome of the IVF treatment and thereby increase the necessity for further IVF attempts.

Previous studies (Goldfarb et al., 1996Go; Grobman et al., 2001Go; Pinborg et al., 2003Go) have found a great desire among infertile couples to have twins, but have not evaluated the couple in the actual IVF situation.

Involvement of the patient in the decision-making concerning IVF procedures is desirable. The woman is young and otherwise healthy, and has generally undergone extensive diagnostic procedures. The patient has generally been childless for a long time. They have a good medical knowledge about infertility and have decided together to have a child. In many cases they are personally responsible for the expenses.

Decision-making in medical matters requires some conditions. The patient must have a capacity to understand and communicate. This is not limited to intellectual and cognitive processes, but also includes an ability to imagine possible consequences of different decisions. A second prerequisite is the ability to compare and weigh alternatives and their experienced consequences of different outcomes, and an ability to participate in probability reasoning. Finally, the patient must possess a set of goals for guidance through the decision-making process (Wicclair, 1991Go). From a medical standpoint the ultimate goal in IVF is the birth of a healthy singleton. However, this could be opposite to the patient's goal or wish (Grobman et al., 2001Go; Pinborg et al., 2003Go), which is our dilemma.

Psychological stress might decrease the decision-making capacity. Patients who undergo IVF treatment generally have poor scores on anxiety and depression scales and in tests that measure psychological well-being (Freeman et al., 1985Go; Eugster and Vingerhoets, 1999Go). Infertility as such is psychologically very hard to cope with and the IVF procedure might further increase the burden. This creates the necessity to provide correct information from the medical staff involved in the IVF process to facilitate the patient's decision-making together with the physician. The decision of having either one or two embryos transferred is of great importance. The aim of this study was to analyse which factors influenced women and men in their decision to prefer the transfer of one or two embryos after IVF and the impact of the environmental influence and support. The importance of identifying these factors lies in the fact that this knowledge can be used to counsel patients more effectively towards single embryo transfer in appropriate cases, i.e. when a reasonably high pregnancy rate can be predicted on the basis of the morphological profile of the embryo(s) and of the clinical profile of the woman.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Between November 2002 and March 2003, 160 couples undergoing IVF were asked to participate in the study. There was no patient selection based on the number of previous IVF cycles. Each week, the first consecutive 10 couples attending this private IVF unit were asked to participate in the study. For some patients the costs were covered with the public health insurance. The remaining couples during the same week were not asked or included in the study. One hundred and forty-two couples were enrolled in the study and the remaining 18 couples (11.3%) declined to participate, in general because of lack of time, such as having to catch a train or a flight. From the 142 couples in the study population, five men and five women were excluded as they stated that they did not participate in the decision of transferring one or more embryos. A total of 137 females and 137 males were thus available for analysis, giving a total number of 46 drop-outs (14.4%). Of the participants, 79.8% had their first (33.2%), second (29.9%) or third (16.7%) IVF attempt.

The patients received standard oral and written information about the IVF procedure and there was always a midwife accessible for questions and advice. The midwife had no direct counselling role, but when answering the patients she followed the general policy of the IVF unit. In about two-thirds of the population, external gynaecologists gave the first counselling and were responsible for the ovarian stimulation together with the physicians of the IVF clinic. Prior to embryo transfer, the responsible physician was informed about factors related to IVF prognosis, such as age of the female, embryo quality, IVF rank number and availability of embryos for cryopreservation. The information about overall clinical pregnancy rate (~35%) was given. Information about maternal and fetal risks in twins, and a possibly lower pregnancy chance after one embryo transfer, was also given. The IVF physician then suggested one or two embryo transfer. In general, the physician had a positive attitude towards one embryo transfer, but it was stressed that the patient should be involved in the decision.

The females and males were interviewed separately after embryo transfer, with the second member of the couple being interviewed immediately after the first. They were interviewed separately to avoid influence from the other partner, and were analysed as individuals. The semi-structured interview consisted of 82 items. Questions were asked on demographic and reproductive characteristics, providers of information, understanding of oral information, knowledge about embryo transfer, factors that influenced the decision, and the importance of having spare embryos to freeze. Interviews were conducted personally by one of the authors (M.B.). There were 14 open-ended questions, 17 semi-quantitative, and 51 unilateral questions. The interviews lasted for ~20–30 min.

The semi-quantitative questions allowed a choice of five answers, where 1 was ‘I completely disagree’ and 5 was ‘I completely agree’. The answers were dichotomized into ‘1–3’ and ‘4–5’ and analysed by {chi}2-test.

Questions and commentaries included demographic and reproductive characteristics. History of infertility, aetiology, duration and previous treatments was requested as well as a number of questions concerning the information they had been given. The patients were asked when they received information, from whom and at which stage in the IVF process. They were also asked whether the information had had any influence on the decision-making process.

The importance of information from the midwife, outpatient doctor, IVF doctor, media, patient organizations, partner and other sources were asked for.

Details about decision-making included when, why and how the decision was made. Influence by others was discussed. Open-ended questions specified knowledge about risks and benefits with one and two embryos transferred respectively and comments about the information given. The pregnancy rate and complications with multiple pregnancies and twins formed the main focus of these questions.

The outcome of previous treatments, controlled ovarian stimulation (COS), oocyte retrieval, fertilization rates and spare embryos to freeze was considered. Finally, the availability of the midwife and the IVF doctor during different stages of the IVF process was requested.

The results were calculated on JMP 3.1 statistical program (SAS Institute, USA). For crude comparisons, a {chi}2-test (likelihood ratio) was used for nominal variables and t-test for continuous variables. Multifactorial analyses by logistic regression (log likelihood test) were used when adjustment for possible confounding factors was made. In univariate analyses, odds ratios (OR) and 95% confidence intervals (95% CI) were similarly estimated by logistic regression. In Table V, variables were dichotomized into ‘4 or 5’, as compared to ‘1–3’ on five alternative answers where 1 was ‘of no importance’ and 5 was ‘very important’. Logistic regression without adjustments for confounders was used in these analyses.


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Table V. Different variables which were important for decision-making in 137 female and in 137 male IVF patients who chose either one or two embryos to be transferred

 

    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
One hundred and thirty-seven females and 137 males were eligible for analysis. One embryo was transferred in 113 (41.2%) cases and two embryos in 161 (58.8 %). For two couples, three embryos were transferred. They were included in the two embryo transfer group. There was no difference between private patients where 67/162 (41.4%) had one embryo transfer, as compared to 46/112 (41.1%) in those whose expenses were covered by public health.

Women who had one embryo transferred were younger (34.0 years) than those who had two embryos transferred (mean age 36.0 years, P=0.0001) (Table I). There were no significant differences in civil status, employment, smoking, other tobacco use and the use of pharmaceuticals between the two groups.


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Table I. Reproductive characteristics in 137 female IVF patients who chose one or two embryos, respectively, to be transferred

 
When reproductive characteristics of the females were compared, only previous IVF treatment was significantly associated with choosing two embryos. The outcome of COS seemed very important for the choice of one or two embryos at transfer. When the decision was made to transfer one embryo the most important factor was that there was at least one good-quality embryo to freeze (19% in the two embryo group as compared to 80% in the one embryo group). Similarly, among the males, previous IVF treatment [27 (48.2%) versus 63 (77.8%); P=0.0003] and spare embryos to freeze [37 (82.2%) versus 14 (20.6%); P=0.0001] differed significantly between those in the one embryo and two embryo groups respectively.

More than one-quarter of the whole study population said that they had not received information about the embryo transfer procedure (Table II). Understanding of information about the technical aspects of embryo transfer differed only marginally between the two groups of patients. A large majority in both study groups was completely satisfied with the information as compared to those who were ‘less satisfied’ (20%) or ‘not satisfied’ (4%). More females than males said that they had received information about the embryo transfer [113 (83.1%) versus 97 (70.8%); P=0.02]. The women were also more satisfied with the information as compared to the men [106 (83.5%) versus 77 (67.5%); P=0.004]. There were no other significant differences between females and males for the variables in Table II.


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Table II. Understanding of information about embryo transfer in 274 IVF patients who chose either one or two embryos to be transferred

 
Both study groups answered that the availability of medical staff was high. Almost 100% of the patients stated that the midwife was available during the IVF process in general, and during specific parts of the IVF treatment in particular. The corresponding figures for the physician were close to 90%. There were no differences between the two groups of patients studied.

The most important source(s) of information did not differ between the two groups. The midwife was most important for 39.8% of the patients, the IVF physician for 29.7%, the outpatient doctor for 29.3%, and for 35.4% of the patients the individual search for information was the most important source. There were no significant differences between the females and the males. The embryologist's judgement concerning the embryo quality was given by the IVF physician. Approximately two-thirds of the women had the COS performed by external specialists in gynaecology before coming to the IVF clinic for oocyte retrieval.

A strong opinion regarding the possible increased pregnancy chance per transfer with two embryos transferred was almost always present in the groups of patients that chose two embryos, while the group that chose one embryo was more worried about having twins (Table III). There was a good knowledge about complications associated with multiple pregnancy. Patients who chose one embryo made their decision later than those who chose two embryos.


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Table III. Knowledge about embryo transfer in 274 IVF patients who chose either one or two embryos to be transferred

 
The females were more aware of increased medical risks with twin pregnancies than the males [106 (77.4%) versus 90 (65.7%); P=0.03]. There were no other significant differences between females and males for the variables included in Table III.

The most important person in making the decision regarding one or two embryos was the partner, far ahead of the information provided by the medical staff (Table IV). This was particularly true for the one embryo group, although the difference was not significant after adjustments. The importance of the partner in decision-making was equal among the males and the females in the one embryo group. There was, however, a striking difference between the one embryo and two embryo groups when the participants were asked if it was a hard decision. It is clear that choosing one embryo was a difficult decision. Of those who had one embryo, more females (36.5%) than males (14.6%; P=0.008) thought it was a hard decision. One must, however, be cautious in interpreting some of these results because of the broad confidence intervals. When all females and males included in the study were compared, there were no significant differences for any variable in Table IV.


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Table IV. Decision-making about embryo transfer in 274 IVF patients who chose either one or two embryos to be transferred

 
Questions about the importance of 17 variables in decision-making regarding one or two embryos to be transferred were asked (Table V). Duration of infertility, the perceived possibility of becoming pregnant and the physicians' advice were important in both groups although the latter did not reach significance in the males. Most of the variables were equally important for both the females and the males, except for woman's age and the physician's advice that were more important for the women. The males were more concerned about the medical risks of twin pregnancies than the females. When all males and females were compared the difference was significant (P=0.05).

Low scores with no significant differences between the two groups (not shown in Table V) were observed for previous miscarriage, male age, costs, travelling distance and influence by friends, relatives, media and patient organizations. Significant differences between the two groups of patients studied were for two embryo transfer patients: a long duration of infertility, a relatively high age of the woman and the possibly higher pregnancy rate; for one embryo transfer patients: spare embryos to freeze and risk for complications with duplex pregnancy.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The main findings of this study were that certain variables were independently associated with the choice of having one, instead of two, embryos transferred. These variables were: having experienced a previous childbirth; being a comparably young woman; having no previous (failed) IVF treatment; and having spare embryos to freeze. A possible higher pregnancy chance was the most important variable for choosing two embryos. The increased risk associated with multiple pregnancy did not influence the two groups of patients significantly differently after adjustment for confounders, but the odds ratio was still >2.0 for the group of patients who chose one embryo. It is, however, interesting that the males, on one hand, were more concerned about the medical risks associated with twin pregnancies than the females. On the other hand, the females were more aware of the medical risks with a twin pregnancy. This is in agreement with the higher satisfaction of the medical information among females. It is tempting to speculate that the females are willing to take greater risks than the males if there is a higher chance per transfer of having a child.

Among the medical staff the midwife was the most accessible. The discussion with the partner was far more important than other information sources in making the decision, but equal in the two groups. A vast majority of the patients felt that they themselves were taking the decision about the number of embryos to be transferred, and 60% of our study population had two embryos transferred. Grobman et al. (2001)Go studied women in an IVF clinic and found that 67% of 200 responders desired a twin pregnancy. Pinborg et al. (2003)Go mailed a questionnaire to IVF mothers who had already conceived. They found that mothers with twins preferred twins, but also that 62% of mothers with singletons would have preferred to have twins. It is obvious that we face a challenge on the road to one embryo transfer.

One strength of this study was that females and males were interviewed separately. Thus, we avoided communication which would allow for the male and the female to give the same answers. This is rarely possible with a self-administered questionnaire. Other strengths were that the personal interview allowed for explanation of questions, minimizing the responder's interpretation of a question, and that the study was large. However, personal interviews may also induce weaknesses in a study. The respondent might perceive the opinion of the interviewer and could be eager to provide the ‘right’ answers.

The purpose of the present study, to investigate how decision-making comes about, also differs from previous similar studies (Goldfarb et al., 1996Go; Grobman et al., 2001Go; Pinborg et al., 2003Go), which focused on the couple's desire for twins.

Participation of the patient in decision-making in medical care is regarded as desirable for many reasons. Among the most important reasons are patient satisfaction and outcome of medical interventions. From areas other than IVF it has been shown that patient involvement in decision-making gives better compliance (Brody et al., 1989Go) and outcome of treatment (Greenfield et al., 1985Go). This is true for conditions where there is no obvious choice of treatment (Hallenbeck, 2002Go), as is the case when deciding whether to transfer one or two embyros. The decision-making process of the patients comes to the clinicians' attention when patients disagree with their recommendations. We are pleased that a large majority of the patients, especially among those who received one embryo, consider that it was their decision and at the same time consider the physicians' advice, where an important part was the embryologists' judgement of the embryo quality. We want to stress that in the end the responsible physician must take the decision on the number of embryos that shall be transferred, but that the above situation is desirable. We are, however, surprised that more than one-quarter of the population felt that they did not have any information about embryo transfer. We suspect that some patients meant the technical procedure, as a larger proportion of the patients answered that they felt they could choose the number of embryos themselves.

This is the first study that analyses IVF patients' decision-making at specific stages in the treatment. Patients with a low prognosis might disregard the information about risks with a multiple pregnancy and focus on the increased chances of pregnancy with two embryos transferred and vice versa. Which risk in having a multiple pregnancy is acceptable for the patient? Which difference in treatment outcome between having one or two embryos transferred is acceptable for a particular patient? When do benefits (low pregnancy complication) outweigh risks (not becoming pregnant after this particular transfer)? These questions are very important when seen in the light of recent IVF techniques to improve the results with single embryo transfer. Memories of past experiences might make the patient choose a treatment that is shorter, even if it is more intense or risky (Redelmeier et al., 1993Go). In the IVF situation a patient might choose two embryos when the last treatment was a failure as it gives a greater chance of having a child even if a duplex pregnancy is associated with more complications and there is a statistically increased risk for the child.

The interaction between patients and medical staff might differ. A large majority of the patients wishes to make a shared decision (Strull et al., 1984Go; Deber, 1994Go). Young, female and well-educated patients are more prone to be involved in the decision (Health Services Group, 1992Go). These characteristics are true for patients undergoing IVF treatment. A patient's competence in decision-making declines in stressful situations (Buchanan et al., 1986). Anxiety and depression scores as well as other psychological scores are increased both in infertile patients as such (Kentenich, 1989Go; Wischmann et al., 2001Go) and in IVF patients (Kentenich, 1989Go; Mori et al., 1997Go).

During 2003, after this study was conducted, The National Board of Health and Welfare in Sweden issued ‘regulations’ which stated that one embryo should ‘in general’ be transferred. Two embryos may be transferred under certain circumstances, e.g. where the woman has a low pregnancy chance, such as old age, many previous IVF failures and very poor quality of the embryos. Although this is not law, it provides a strong incentive towards single embryo transfer. Our counselling was of course influenced by the discussion of single embryo transfer and the expected regulations. Efforts to increase the present pregnancy rates with single embryo transfer are of paramount importance.

This study has shown that some of the main obstacles for IVF patients to accept single embryo transfer would be a possible lower pregnancy chance per transfer, which might be evident by information or associated with a previously failed IVF attempt, a comparably older woman and no spare embryos to freeze. Perceived awareness of risks of multiple pregnancies was equal in patients who chose one or two embryos. The influence of the medical staff was high in both groups of patients. In our study population the information seemed to be sufficient. Cryopreservation of embryos was very important for those who chose single embryo transfer. Finally, patients of lower ages are more prone to choose one embryo transfer. We believe that when the physician makes the final decision it is his/her responsibility to consider one embryo transfer as the method of choice and perform two embryo transfers only in special circumstances, for instance when the patient has a poor prognosis. The complexity of factors that influence the patients' decision-making shown by this study may help the medical staff in general, and the responsible physician in particular, to give necessary and qualified information to the couple.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
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Submitted on August 31, 2004; resubmitted on November 16, 2004; accepted on January 17, 2005.