Within Assisted Reproductive Technologies (ART), In Vitro Fertilization (IVF) involves the retrieval, testing, and implantation of an embryo. However, the determination of the number of embryos to transfer during the course of IVF treatment may depend on a variety of factors. The American Society for Reproductive Medicine (ASRM) provides guidance on the clinically appropriate number of embryos for transfer based on a review of the available peer-reviewed published literature studying how to optimize live birth rates with ART while minimizing profound medical complications stemming from multiple (i.e., twin, triplet, or quadruplet) pregnancies. Multiple gestation leads to an increased risk of complications in both the individual carrying the pregnancy and the fetuses.

MET Prior Authorization Policy:

Transfer cycles for a single embryo transfer do not require prior authorization. If a provider believes that transfer of multiple embryos is indicated, they must seek prior authorization before initiating the transfer cycle.

Cleavage Stage Embryos

No authorization shall be granted for the transfer of multiple euploid cleavage-stage embryos.
No authorization shall be granted for the transfer of multiple “favorable” cleavage-stage embryos.
No authorization shall be granted for the transfer of multiple cleavage-stage embryos in “favorable” scenarios (see below).
“favorable” scenario: any one of the following: fresh cycle with expectation of one or more embryos available for cryopreservation; prior pregnancy after a prior transfer with sibling embryos; available additional frozen embryos.

For patients 38 years old and above, consideration may be made for the transfer of 2 and no more than 3 cleavage-stage embryos after review of provider attestation and member clinical history.
For patients 41 years old and above, consideration may be made for the transfer of 2 up to and no more than 4 cleavage-stage embryos upon review of member clinical history and provider attestation.

Blastocysts

No authorization shall be granted for a multiple embryo transfer involving a euploid blastocyst.
No authorization shall be granted for multiple non-PGT blastocysts.

Consideration for transfer approval of two non-PGT screened blastocysts may be made for patients 38 years old and older.

A request for multiple embryo transfer of no more than two blastocysts may be approved outside of the guidelines above if the enrollee has a history of three failed single embryo transfers with the same cohort and the medical record indicates the individual is at no greater risk for complications stemming from a multiple pregnancy than the average patient.

Documentation

1. Obstetric medical history, including the number of prior pregnancies and gamete source of prior pregnancy, compared to the current requesting attempt; pregnancy outcomes; and history of pregnancy loss.
2. Providers must provide an attestation confirming they provided counseling and guidance to the patient in accordance with ASRM guidelines for multiple embryo transfer.
3. Embryology medical records identifying the type, grade, and quality of embryos to be transferred.
4. Medical records evidencing transfer history and medical history, including conditions that may put the patient at high risk of pregnancy complications (e.g., cardiac disease or history of preterm delivery).
5. Origin of the current cohort of embryos (e.g., donor).

References

1. Practice Committee of the American Society for Reproductive Medicine and the Practice Committee for the Society for Assisted Reproductive Technologies. Guidance on the limits to the number of embryos to transfer: a committee opinion. Fertility and Sterility. September 2021.
2. American College of Obstetricians and Gynecologists. Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231. Obstetrics & Gynecology. June 2021.
3. Practice Committee of the Society for Reproductive Endocrinology and Infertility, Quality Assurance Committee of the Society for Assisted Reproductive Technology, and the Practice Committee of the American Society for Reproductive Medicine. Multiple gestation associated with infertility therapy: a committee opinion. Fertility and Sterility. March 2022.
4. Lemos EV, Zhang D, Van Voorhis BJ, Hu XH. Healthcare expenses associated with multiple vs. singleton pregnancies in the United States. American Journal of Obstetrics and Gynecology. December 2013.
5. Mejia RB, Capper EA, Summers KM, Ten Eyck P, Van Voorhis BJ. Elective transfer of one embryo is associated with a higher cumulative live birth rate and improved perinatal outcomes compared to the transfer of two embryos with in vitro fertilization. Fertility and Sterility Reports. November 2020. Demonstrated that optimal cumulative live birth rate outcomes are achieved with single embryo transfer, whether blastocyst or cleavage-stage embryos, even when PGT is not employed: “The association of ieSET with a higher CLBR [cumulative live birth rate] and markedly improved perinatal outcomes outweigh the relatively minor increase in time to pregnancy.”
6. Pirtea P, De Ziegler D, Tao X, Sun L, Zhan Y, Ayoubi JM, Seli E, Franasiak JM, Scott RT Jr. Rate of true recurrent implantation failure is low: results of three successive frozen euploid single embryo transfers. Fertility and Sterility. January 2021.
7. Lou H, Li N, Guan Y, Zhang Y, Hao D, Cui S. Association between morphologic grading and implantation rate of euploid blastocyst. Journal of Ovarian Research. January 2021.