Implementation of elective single-embryo transfer (eSET) policy – a nursing perspective

Published: 27 February 2013

Forum member Val Peddie, a fertility nurse specialist and research midwife at the University of Aberdeen writes on the role of nurses in promoting the elective single-embryo transfer policy

Background

The primary focus and ultimate end-point of in-vitro fertilisation (IVF) programmes is undoubtedly the generation of encouraging pregnancy rates. In 2005, the Human Fertilisation and Embryology Authority (HFEA) commissioned an expert group to address the increasing multiple pregnancy rate in the United Kingdom (UK). Natural progression led to the commissioning of the “One at a time” multidisciplinary stakeholder group, which continued the valuable work of the expert group, reviewing the literature, national data, health and psychosocial outcomes of twins born as a consequence of IVF.

In 2009, the combined evaluation and recommendation was for the regulator to set a national threshold for multiple pregnancy rates (five to ten per cent) to be achieved by step-wise progression. The fertility sector is not immune to cultural change; March 2004 witnessed an amendment in policy (Code of practice: sixth edition), with the maximum number of embryos to be replaced (in women under 40) reduced to two; and while this transition drastically reduced triplet pregnancies, it did not have the same impact on twin pregnancy rates.

The role of the fertility nurse

Fertility nurses are increasingly at the forefront of patient care. Many are assuming increased responsibility in clinical decision-making and gaining additional skills in procedures such as pelvic ultrasound and embryo transfer. In Aberdeen, this has presented significant opportunities - and immense job satisfaction - for nurses engaging couples in the decision-making process, particularly about the number of embryos to transfer. In January 2009, the HFEA set the maximum multiple pregnancy rate at 24 per cent. Overall, this was realistically achievable, and we experienced compliance from both staff and patients in the context of elective single-embryo transfer (eSET).

While IVF outcomes and patient satisfaction can be measured numerically, there can be no substitute for engaging couples in what many consider to be the most crucial part of the treatment programme. Multidisciplinary involvement is also dependent on consistency of information delivered, and development and utility of clinical algorithms (for patient and embryo selection), which should be frequently audited in response to policy, pregnancy and multiple pregnancy rates.

When the sector reduced the maximum multiple pregnancy rate again in January 2010, this time to 20 per cent, it required further modification of our algorithms, in an attempt to maintain our pregnancy rate while reducing our multiple pregnancy rates. These were on the increase in the 37-39 years age group; most of whom were receiving double embryo transfer (DET) on day three.

It is essential that nurses understand both national and local data in order to ensure that they can give couples accurate and current information for their personal situation, on which they can base their decision, thereby giving fully informed consent. Fertility nurses encounter various opportunities to promote and disseminate information about the positive attributes of single-embryo transfer (SET).

Patient information evenings - which are normally attended by couples prior to embarking on treatment - are one such example. Nurses can refer to the One at a time website and leaflets such as those distributed by Infertility Network UK (INUK) - both of which are invaluable resources of information for patients.

Nurses are also in a position to use positive reinforcement of the eSET policy throughout the entire treatment process: at each scan appointment; when the number and size of ovarian follicles are determined; through to oocyte collection and the embryo transfer procedure itself.

Issues to consider

While the definitive default position should always be eSET (for good prognosis patients), the decision is not always explicit. In cases where one or more good quality blastocysts are available on day five, there exists an overwhelming clinical case for eSET, and very few would argue the case in point.

However, the success of eSET and its cumulative pregnancy rate is also dependent on good quality embryos, with the capacity for survival and robust cryopreservation/vitrification programmes. Disparate commissioning and funding of IVF services has further created the potential for a “financial divide” in the decision-making process, with those funded by the NHS in a better position to agree and consent to eSET compared with those who are self-funding, and may only be able to afford one cycle of treatment. Further financial investment, and indeed, female age, needs to be considered (in the context of cryopreservation/ vitrification of single-embryos).

In addition, decisions around the time of embryo transfer may not always be clearly defined by clinical algorithms and/or scientific circumstances. For example, in cases where couples have only two good-quality embryos available on day of transfer, the decision is not always morally and ethically determined. Individual (and on occasion, tragic) circumstances can further complicate the decision-making process, and nurses frequently act as patient advocate, sharing appropriate personal and social history with medical and embryology teams in situations where there remains some ambiguity.

As a result, and irrespective of multidisciplinary engagement with the eSET policy, on occasion, fertility nurses will find themselves “empathising” with a rationale that supports the request for double-embryo transfer (DET).

Nevertheless, accepting and respecting professional roles (and boundaries), and confidence in the entire multidisciplinary team “buying” into the process is key to the successful implementation of the eSET policy.

Fertility nurses are best placed for communicating the risks and benefits around the number of embryos to be transferred clearly to couples, in a language they understand, and patient perception of eSET should also be sought to help inform the decision.

Finally, the way in which the information and data are presented, coupled with compliance and trust in the regulatory functions, will ensure the successful implementation and maintenance of eSET programmes, and most importantly, improve obstetric outcome for mother and baby.

How nurses can engage with policy, while promoting best practice in the context of eSET: notes on the Aberdeen experience

Patient information evening

Provision of accurate information which reflects current policy (local and national). Reference slide highlighting the “One at a time” initiative’s web address.
Infertility Network UK information leaflets, local information sheets (embryo transfer policy and embryo freezing) distributed.

First consultation

Discussion with medical and nursing staff of individualised care in the context of number of embryos to be replaced (based on local algorithm) - recorded and countersigned in medical records.
Positive reinforcement of information which has already been provided at the patient information evening.

Multidisciplinary team meetings

Held three times weekly to discuss patient progress and confirm the number of embryos to be replaced (progress cross-referenced with algorithm).

Day of oocyte collection

Following the procedure (and when the number and maturity of oocytes is known), the embryologist consults with the patient and reinforces the eSET policy (where appropriate). Local information sheets (embryo transfer policy and embryo freezing) distributed again.

Day of embryo transfer

The embryologist and the nurse or doctor carrying out the procedure discuss embryo number and quality. Refer to algorithm at this stage.
Discussion with couple prior to procedure.
If the couple meet the criteria for elective single-embryo transfer, and following discussion with embryologist and nurse/doctor they request double-embryo transfer, they are asked to sign a disclaimer.

Engage with activity of professional bodies

Engage with the Royal College of Nursing, the British Fertility Society and the Royal College of Obstetricians and Gynaecologists.
Be aware of nurse representation in the context of “One at a time” initiative and the Multiple Births Stakeholder Group.