by: Juha Tapanainen, professor, Oulu University Hospital and Aila Tiitinen, professor, Helsinki University Hospital
Single embryo transfer (SET) has become common and every day practice in all Nordic countries. The first randomized study in 2001 (HR 16:1990, 2001) and several other studies thereafter have shown the effectiveness of SET. A recent study from Finland showed that elective SET with cryopreservation is more effective and less expensive than two embryo transfer, and the incidence of multiple births is reduced more than two-fold (HR 24:1632, 2009).
In Nordic countries, SET is practiced in 60-70% of the cycles and even 100% in some clinics. Since 2004, elective SET has been the norm in Sweden as a result of legislation. In Finland, the multiple pregnancy rate in IVF/ICSI has decreased to less than 10%, but still accounts for 20% of all multiple pregnancies. The application of elective SET has raised the question of how clinical results of ART should be presented and compared. For instance, if the outcome is presented as pregnancy rate/aspiration, the results in Finland and Sweden are not even close to those of some other countries in Europe, but when cumulative pregnancies are taken into account these two countries are higher (cumulative delivery rates/aspiration 33.4% and 31.8%).
The Nordic registers, together with the individual person identification systems, provide a unique basis for epidemiological studies with follow-up of infant and maternal health after ART. In order to implement recommendations by ESHRE, the Committee on Nordic ART and Safety (CoNARTAS) has been established. The aim of this task force is to provide a continuous Nordic monitoring system and database containing data on all ART pregnancies, deliveries and children born after ART in Norway, Sweden, Finland and Denmark. CoNARTAS will provide good opportunities to evaluate how the implementation of elective SET affects the health of newborns.
An important issue which has developed is the reimbursement of ART treatments. In Denmark, the authorities have amended legislation governing IVF funding, which would result in ART treatments no longer being covered by public health services. In Denmark, there is the highest level of ART treatment in Europe (2500 IVF cycles per million population, yearly) and nearly 5% of all children are born as a result of ART. We will see in the near future whether this amendment, which would be detrimental for childless couples, will be implemented.