Surrogacy Questions: How Many Embryos Should I Transfer?

One of the critical conversations that you will have with your fertility clinic is the decision of how many embryos to transfer during an IVF cycle.

All pregnancy comes with risk but with multiples, the risks are increased. Multiple pregnancies are harder on the surrogate and the babies have increased risk of complications… and therefore, you need to answer one of the most common surrogacy questions: How many embryos should I transfer?

The decision to transfer more than one embryo should be between the doctor, surrogate mother and intended parents. Usually, only one is transferred with a first attempt, especially if the egg is from an egg donor or the intended mother is under 35 or if a Preimplantation Genetic Screening has been done. Women who have had full-term pregnancies before are more likely to carry multiple full terms (unlike a first-time mother).

Although transferring more than one can increase the chances of having two babies (saving the cost of 2 surrogacy journeys), it does increase the chances of the surrogate ending up in months of bed rest. This would increase expenses.

Also, the risks of multiple births are six times more likely to be born prematurely than single babies. It increases the risk of their babies spending time in the NICU (which is especially worrisome for international intended parents).

There is also a saying in surrogacy “don’t transfer more than you are willing to carry”.

If you feel very strongly that you do not want to take the risks of carrying two or more, you should transfer only one. Always discuss your feelings regarding twins/triplets, as even with transferring one embryo, you still carry the risk of multiples if the embryo splits.

If all parties are comfortable with selective reduction, another option is to transfer multiple embryos, to increase the chance of pregnancy and then reduce to the number you are comfortable with. Some have ethical/moral concerns with doing this but it is a personal choice. It does also come with risk, the risk to the remaining baby (or babies) and the entire pregnancy as well. You should consider long term health problems due to prematurity, as breathing issues, cerebral palsy and other physical and/or learning problems.

It’s better to assess each arrangement individually… patient history, embryo quality and the parties’ feelings on all the issues.

Sometimes, IPs decide to put in 4 embryos and have it in mind to reduce if needed. Transferring multiple embryos does have benefits, such as:

• Increases chances of pregnancy success.
• Reduces cost (multiple cycles and surrogate mother cost).
• Saves time (instead of multiple cycles with one embryo/SET).
• Less medication (surrogate cycles 1-3 times instead of 3-5).
• Emotional Impact (repeated negative 1 embryo cycles are draining emotionally and increase the chance of surrogate mother quitting).

Before making your decision, you should also consider the following figures for multifetal pregnancies:

• Transferring two, you have around 45% chances of having twins and 5% of triplets and 1% of quadruple.
• The average birth weight is 2.5 Kg for twins and 1.7 Kg for triplets.
• The average gestational age is 35 weeks for twins and 32 for triplets.
• The percentage of pregnancies delivered before week 32: 12% for twins and 36% for triplets.
• The percentage of babies in need of NICU: 25% for twins and 75% for triplets.
• The average time in NICU: 18 days for twins and 30 days for triplets.
• 20% of triplets have a major handicap.
• The risk of death in the first year is increased 7 times (with respect to a singleton) for twins and 20 times for triplets.
• Twin pregnancies are harder on the surrogate and triplets much harder.
• The risk of preeclampsia is 6% for twins and up to 12% for triplets.

The transfer of one or more embryos, it is a choice everyone needs to make for themselves, but people need to be aware of the consequences (medical and economical). For international intended parents, hospital bills are a real risk and there is no “good” insurance available against the hospital bills for a multifetal pregnancy.

• Risk of death in first year is increased 7 times (with respect to singleton) for twins and 20 times for triplets.
• Twin pregnancies are harder on the surrogate and triplets much harder.
• Risk of preeclampsia is 6% for twins and up to 12% for triplets.

Transfer one or more embryos, it is a choice everyone needs to make for themselves but people need to be aware of the consequences (medical and economical). For international intended parents, hospital bills are a real risk and there is no “good” insurance available against the hospital bills for a multifetal pregnancy.