When is De Novo Selection (DNS) In Vitro Fertilization (IVF) indicated?

Indications for De Novo Selection (DNS) In Vitro Fertilization (IVF)

De Novo Selection (DNS) IVF is primarily indicated in cases where there is a need to minimize multiple pregnancy risks while maintaining optimal pregnancy outcomes, particularly in patients with good prognosis factors where elective single embryo transfer (eSET) is recommended.

Primary Indications for DNS IVF

DNS IVF refers to the selection of embryos for transfer without prior fertilization history or specific genetic testing. The main indications include:

1. Patients with Good Prognosis Factors

• First-time IVF patients with favorable prognostic factors
• Younger women (under 35 years)
• Good ovarian reserve
• Good quality embryos available for selection

2. Specific Clinical Scenarios Where eSET is Strongly Recommended

• Donor oocyte cycles: DET should be avoided at all costs due to clearly increased pregnancy complication risks 1
• Donated embryo transfers: Single embryo transfer strongly recommended 1
• Gestational carrier cycles: eSET is strongly recommended to minimize risks 1
• Blastocyst transfers: Due to higher monozygotic twin potential of blastocysts and high risk of complications with multiple blastocyst transfers 1

3. Patients with Medical Contraindications to Multiple Pregnancy

• Pre-existing medical conditions that would be exacerbated by multiple gestation
• History of pregnancy complications that would be worsened by twins or higher-order multiples
• Uterine anomalies that may increase risks with multiple gestations

Decision Algorithm for DNS IVF vs. Multiple Embryo Transfer

1. Assess patient prognosis factors:

   • Age (younger patients are better candidates for eSET/DNS)
   • Embryo quality (high-quality embryos favor eSET/DNS)
   • Previous IVF outcomes (failed cycles may influence decision)

2. Consider embryo development stage:

   • Blastocyst transfers should use eSET due to higher implantation rates and increased risk of monozygotic twinning 1

3. Evaluate medical risk factors:

   • Presence of conditions that increase risks with multiple pregnancy
   • History of pregnancy complications

Benefits of DNS IVF with eSET

• Reduced multiple pregnancy rates: Significantly lower risk of twin and higher-order multiple pregnancies
• Improved maternal outcomes: Lower rates of pregnancy complications including pre-eclampsia, gestational diabetes, and emergency cesarean section 1
• Better neonatal outcomes: Reduced prematurity, developmental delays, and neonatal mortality 1
• Comparable cumulative live birth rates: When combined with subsequent frozen embryo transfers, eSET achieves similar cumulative live birth rates to DET 1

Cautions and Considerations

• Risk of ectopic pregnancy: The risk increases with the number of embryos transferred (up to 20-fold), making eSET safer 1
• Poor prognosis patients: Even in patients with poor prognosis factors (advanced age, poor-quality embryos, previous failed cycles), evidence does not support that DET improves cumulative live birth rates 1
• Patient counseling: Patients should be informed about risks and benefits as part of shared decision-making, including short and long-term medical risks, and social and economic factors 1

Special Considerations for Specific Fertility Treatments

• Unexplained infertility: IUI with ovarian stimulation may be considered before moving to IVF in couples with unexplained infertility and good prognosis (>30% chance of spontaneous pregnancy) 1
• Male factor infertility: ICSI should be reserved for severe male factor infertility; conventional IVF is preferred for non-severe male factor cases 2

DNS IVF with eSET represents the current best practice for most patients undergoing IVF treatment, balancing the goal of achieving pregnancy while minimizing the risks associated with multiple gestations.