Surrogacy Questions: How Many Embryos Should I Transfer?

All pregnancy comes with risk but with multiples the risks are increased. Multiples pregnancies are harder on the surrogate and the babies have increased risk of complications… and probably 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 multiples full term (versus a first time mother).

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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 the surrogate could end up on months of bedrest. This would increase expenses.

Also, the risks of multiple births are six times more probably 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 only transfer one. Always discuss your feelings regarding twins/triplets as even with transferring one embryo, you still carry the risk of multiples if the embryo.

If all parties are comfortable with selective reduction, another option is 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 however 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.

I personally feel it’s best 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 had planned 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 chance of surrogate mother quitting).

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

  • Transferring two you have around 45% chances of having twins and 5% of triplets and 1% of quadruple.
  • Average birth weight is 2,5 Kg for things and 1,7 Kg and for triplets.
  • Average gestational age is 35 weeks for twins and 32 for triplets.
  • % of pregnancies delivered before week 32: 12% for twins and 36% for triplets.
  • % of babies in need of NICU: 25% for twins and 75% for triplets.
  • Average time in NICU: 18 days for twins and 30 days for triplets.
  • 20% of triplets have a major handicap.
  • 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.

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