Journal of Human Reproductive Science
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Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 93-95

Maximum number of embryos to be transferred in assisted reproductive technologies cycle: Ethics opinion

1 Editor, Journal of Human Reproductive Sciences; Clinical Director and Principal, Dr. Patilís Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
2 President Indian Society for Assisted Reproduction 2017-18; Director Gynaecworld the Center for Womenís Health and Fertility, Mumbai, Maharashtra, India

Date of Web Publication1-Aug-2018

Correspondence Address:
Duru Shah
Indian Society for Assisted Reproduction, Flat No. 23 A, 2nd Floor, Elco Arcade, Hill Road, Bandra (west), Mumbai Ė 400 050, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jhrs.JHRS_66_18

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Prevention of multiple pregnancies is of utmost importance as with multiple pregnancy-assisted reproductive technologies results shifts from success to complications. There is an increase in the maternal and neonatal morbidity and mortality with occurrence of higher order pregnancies. Therefore, restricting the number of embryos transferred either to one or two would reduce the occurrence of multiple pregnancy.

Keywords: Embryo transfer, ethics, infertility, in vitro fertilization, live birth rate

How to cite this article:
Patil M, Shah D. Maximum number of embryos to be transferred in assisted reproductive technologies cycle: Ethics opinion. J Hum Reprod Sci 2018;11:93-5

How to cite this URL:
Patil M, Shah D. Maximum number of embryos to be transferred in assisted reproductive technologies cycle: Ethics opinion. J Hum Reprod Sci [serial online] 2018 [cited 2022 Dec 1];11:93-5. Available from:

   Overview Top

There are significant harms from multifetal pregnancy for mother and fetus. This guideline balances the need to minimize the occurrence of multifetal gestation, particularly high-order multiples, with maintaining an acceptable overall pregnancy and live birth rates (LBRs) following in vitro fertilization with embryo transfer (IVF-ET).

In India, elective placement of multiple embryos is influenced by several factors including the absence of insurance and associated rules for ART practice, absence of legal guidance for the practice, financial conflicts of interest for practitioners and patients to have a pregnancy success, and societal norms. Moreover, no factors have yet been identified which reliably predict the occurrence of single or multiple pregnancy after single or multiple ET.

The impact of the number of embryos transferred on optimizing healthy live births from IVF requires evaluation of the clinical pregnancy rate, multiple pregnancy rate, and LBR correlated to the stage and number of embryos transferred. When multiple pregnancy is created, assisted reproductive technologies (ART) changes from the benefit of pregnancy success to maternal harm and neonatal complications. This makes prevention of multiple pregnancies of key importance.[1],[2],[3] Even twin gestations, while attractive to parents and health professionals wanting a successful pregnancy, have significant additional morbidity compared to a singleton pregnancy.

There is an increased incidence of maternal complications with multiple pregnancy including but not limited to: preeclampsia, HELLP syndrome, acute fatty liver, thromboembolism, postpartum hemorrhage, and increased mortality rates. Multiple pregnancies are also associated with increased incidence of lower LBRs, severe prematurity and its complications, small for gestational age babies, cerebral palsy, and infant mortality. These complications in the babies increase neonatal intensive care unit admission by almost fifteen times. Although multifetal pregnancy reduction can be performed, the procedure may result in unintentional loss of additional or all fetuses.[4]

Strict limitations on the number of embryos transferred, as required by law in some countries, do not permit individualization to each patient depending on the age, etiology of infertility oocyte and embryo quality, previous failures, variation in cleavage-stage or blastocyst transfer, efficiency of cryopreservation program and data analysis of each clinic.

According to the ASRM guidelines, the US National data from 2013 demonstrate that clinics that perform higher rates of elective single-ET in women aged <38 years have decreased rates of multiple gestation, with no significant impact on cumulative live-birth rates.[5],[6] There is no robust data presently from India on the number of embryos transferred and the occurrence of successful singleton or multiple pregnancies.

There can be conflicts of interest that need to be transparent in decision making for both health professional and patients and require careful counseling and consideration when deciding on the number of embryos to transfer. If only pregnancy rate is reported to patients, the health professional has a conflict because multiple transfers may result in a higher pregnancy rate although a lower or no different LBR. Patients have conflicts and vulnerability because their desire for a pregnancy often “at any cost” makes it harder for them to balance the benefits and complications of multiple pregnancy. The ethical requirement for careful truthful education and informed consent with counseling before transfer is critical for these procedures.


  1. Careful education and informed consent is required in the counseling process regarding options for transfer for all patients. Transparency regarding costs including costs of care for premature babies and potential complications of twin and higher order pregnancies needs to be part of the discussion
  2. Given the potential for harm (nonmaleficence) for mother and fetus of multiple transfers and multifetal pregnancy, patients with a favorable prognosis should be encouraged to receive a single ET. Favorable prognosis includes factors such as:

    • young age generally ≤35
    • good ovarian reserve
    • presence of one or more high-quality embryos available for transfer and cryopreservation
    • previous live birth after an IVF cycle.

  3. Encouragement to receive a single ET should be offered to women with preexisting medical conditions as multiple pregnancies would increase the morbidity and mortality
  4. The strategy for number of embryos transferred may vary according to age. Patients who do not meet criteria in recommendations 2 and 3 may have additional embryos transferred but not more than three embryos.[6] ASRM guidelines,[7] in 2017, have recommended that the patients must be counseled regarding the additional maternal and fetal risks of twin or higher order multiple pregnancy
  5. In donor-oocyte cycles, the age of the donor and age and health of the recipient should be used to determine the appropriate number of embryos to transfer
  6. Ongoing rigorous research and cumulative and transparent reporting of all outcome data is required in the India context for this area to further define the best clinical options balancing benefit and harm for mother and neonate.

   Conclusion Top

Each ART clinic should evaluate and report patient-specific, embryo-specific, and cycle-specific determinants to choose the number of embryos transferred to maintain acceptable pregnancy and LBR and also minimize the occurrence of multiple pregnancies. The preferred maximum is three embryos. Moreover, adequate and proper counseling of the couple regarding the pros and cons of transferring multiple embryos allows them to make an informed choice on the number of embryos to be transferred.


This report was developed by the Ethics Working Group of the Indian Society for Assisted Reproduction as a service to its members and other practicing clinicians. While this document reflects the views of members of that Committee, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment in all cases. This report was reviewed by the Ethics Committee of the American Society for Reproductive Medicine and their input was considered in the preparation of the final document. We acknowledge Joanna Cain, Former Chair of the 'FIGO International Ethics Committee' for participation during the development of the ethics opinion as an International Advisor.

The following members of the Ethics Working Group have contributed to the development of this document: Duru Shah, Madhuri Patil, Sujata Kar, Nalini Mahajan, Sadhana Desai, Ameet Patki, (Indian Society for Assisted Reproduction), Manohar Motwani (Private Practitioner), Sanjay Chauhan (Scientist F, ICMR-NIRRH), Hitesh Bhatt (Medico Legal Advisor), Amit Karkhanis (Legal Advisor), Anushree Patil (Scientist D, ICMR-NIRRH), Flavia Agnes (Lawyer and Activist), and Subarna Ghosh (Reproductive Activist).

We thank Abbott India Limited for their logistic support during the preparation of the Ethics Opinion.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Rao A, Sairam S, Shehata H. Obstetric complications of twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2004;18:557-76.  Back to cited text no. 1
Multiple gestation pregnancy. The ESHRE Capri Workshop Group. Hum Reprod 2000;15:1856-64.  Back to cited text no. 2
Santana DS, Cecatti JG, Surita FG, Silveira C, Costa ML, Souza JP, et al. Twin pregnancy and severe maternal outcomes: The World Health Organization multicountry survey on maternal and newborn health. Obstet Gynecol 2016;127:631-41.  Back to cited text no. 3
Stone J, Eddleman K, Lynch L, Berkowitz RL. A single center experience with 1000 consecutive cases of multifetal pregnancy reduction. Am J Obstet Gynecol 2002;187:1163-7.  Back to cited text no. 4
Mancuso AC, Boulet SL, Duran E, Munch E, Kissin DM, Van Voorhis BJ, et al. Elective single embryo transfer in women less than age 38 years reduces multiple birth rates, but not live birth rates, in United States fertility clinics. Fertil Steril 2016;106:1107-14.  Back to cited text no. 5
The Assisted Reproductive Technologies (Regulation) Draft Rules-2010. New Delhi: Indian Council of Medical Research New Delhi, Ministry of Health & Family Welfare Government of India; 2017.  Back to cited text no. 6
Practice Committee of the American Society for Reproductive Medicine. Electronic address:; Practice Committee of the Society for Assisted Reproductive Technology. Guidance on the limits to the number of embryos to transfer: A committee opinion. Fertil Steril 2017;107:901-3.  Back to cited text no. 7


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