Single embryo transfer & advanced maternal age: how to succeed?

Esther Marbán, MD
Gynecologist & Fertility Specialist , Clinica Tambre
From this video you will find out:
  • What is the definition of advanced maternal age?
  • What are the effects of advanced maternal age on pregnancy?
  • How does age influence a woman’s ovarian reserve?
  • What is the correlation between oocyte euploidy and maternal age?
  • Is single embryo transfer always recommended in patients of advanced maternal age?

Should patients of advanced maternal age only transfer a single embryo?

During this live session, Dr Esther Marbán, Gynaecologist & Fertility Specialist at Clinica Tambre, Madrid, Spain talked about advanced maternal age and explained why single embryo transfer is recommended. Dr Marbán walked through her past patient’s success story from the diagnosis to the pregnancy.

Dr Marban started by defining advanced maternal age, which is considered getting pregnant at 35 years old or older. We know that the egg quality and also the ovarian reserve decrease as age increases, and the chances of carrying a baby with chromosomal disorders such as Down syndrome also increase. When we talk about advanced maternal age, it’s essential to consider the fetal and maternal risks. A higher risk of miscarriage, stillbirth and abnormal growth is related to age, and the maternal risks include high blood pressure, diabetes and premature birth. That’s the reason it’s recommended, if possible, to have a single embryo transfer to avoid those risks that are even higher if we talk about twin pregnancies.

Advanced maternal age & single embryo transfer – real-life case

The case presented by Dr Marban was about a couple in their 40s, the female was 41 years old, she didn’t have any previous IVF attempts, no diseases or current medication at that moment, and her medical family history showed that the patient’s grandmother from her father’s side suffered from breast cancer. Her partner was 42 years old, had no diseases or current medication, and he didn’t have any family history, so we started the diagnosis.

  • 41-year-old female with a male partner, low ovarian reserve, no previous IVF attempts, male factor

When we checked the partner’s semen, we found that he had oligozoospermia with a concentration of 8.1 million per millilitre and a total concentration of 28 million, the total motility was 62%, and the morphology was completely normal. He also performed a testicular ultrasound and a Doppler that came back normal, we also tested the karyotype, which was completely normal, with 46 chromosomes 1 X and one Y chromosome according to a normal karyotype in a male. We also did the infectious disease screening, and we also tested the DNA fragmentation, which also came back normal.

We did the DNA fragmentation test to check if there is any kind of DNA damage in the sperm. When we find a high rate of single-stranded DNA fragmentation, it could be related to a lower fertilization rate of the eggs that we will retrieve afterwards. Apart from that, when double-stranded DNA fragmentation is found, we may find a higher chromosomal alteration in the embryos, and it’s also possible to have a lower rate of developing embryos into blastocyst as a result. DNA fragmentation may be related to a lower implantation rate. What can we do in such a case? We always recommend stopping smoking and drinking alcohol, and we recommend reducing our tea, and coffee intake, it’s also recommended to take antioxidants and turmeric, which are quite powerful antioxidants and could help us in reducing DNA fragmentation. We also use a specific technique during fertilization called Chip Fertile, which reduces the chances of selecting a fragmented sperm to fertilize the eggs.

Regarding the female patient, we tested her ovarian reserve, and her AMH was 0.5 ng/ ml, we did a vaginal scan, and her AFC was 3 follicles in each ovary, we also tested the karyotype, which was also normal. Smear test results and the infectious diseases came back normal, as well as the blood cell count and the clotting. The TSH level was 2.3.

Protocols & procedures

The diagnosis in this specific clinical case was a male factor and a low ovarian reserve because of that, we decided and recommended our patients to undergo an IVF treatment with PGT-A, in case we had a good and euploid embryo to transfer just 1 embryo due to her age. We performed ICSI, which is a procedure where a single sperm cell is injected into the cytoplasm of the mature egg, we use a tiny needle called a micropipette, it was necessary to use a microinjector to do that procedure, and we also needed to prepare the eggs and sperm properly.

We retrieved 8 eggs, 5 of them fertilized properly, and we had 2 embryos developing into the blastocyst stage. We did the PGT-A testing, we do the embryo biopsy on day 5 or day 6 of the development of the embryo. The idea is to select chromosomally healthy embryos, and it’s known that it increases the chances of having a healthy baby because it reduces the risk of having a miscarriage, especially in patients older than 40 years old. In such patients, the risk of miscarriage is quite high, and it also increases the probability of pregnancy per transfer, so that’s another good reason to recommend a single embryo transfer in these patients. It also reduces the duration of the treatment on the number of cycles needed because, in the end, we are selecting a good quality embryo, and also a healthy embryo, so the chances of implantation of that embryo are higher. Both embryos were biopsied, 1 of them was a euploid embryo which was transferable and chromosomally healthy, and one was aneuploid.
The euploid embryo contains 23 pairs of chromosomes which is a completely normal embryo, while an aneuploid embryo could have gain or loss of genetic material, and that’s the reason those embryos are not recommended to be transferred. They could end in a miscarriage or in an affected fetus, which we always want to avoid.

Further tests

We also suggested doing EndomeTRIO test to maximize the implantation rate as there was just 1 transferable embryo. This test has to be performed in a mock cycle, we decided to do it with estradiol and subcutaneous progesterone, it could also be performed in a natural cycle, but the mock cycle should be the same as the one that we are using for a real embryo transfer.

We did an endometrial biopsy to check the window of implantation, which is called the ERA test, we also did EMMA test to check the microbiome, and we checked the pathogenic bacteria causing chronic endometriosis, which is called the ALICE test. Both results of EMMA and ALICE were completely normal, so there was no chronic infection in the uterus, but we found that she had a pre-receptive endometrium which means that the window of implantation, which is the moment when the endometrium is more receptive for eventual embryo transfer was not in the normal and correct place in this patient. The test showed that she needed some more hours of progesterone and at least 1 more day of progesterone. It was recommended to do the embryo transfer with 146 hours of progesterone, so with that test, we were able to personalize the embryo transfer, which is what we wanted.

The patient underwent the endometrial preparation for the frozen embryo that we had, she also used estradiol (6 mg every day for 12 days), and we tested endometrium that had a thickness of 8 millimetres, and no-dominant follicles in the ovaries were found. We did luteal phase support with subcutaneous progesterone of 25 milligrams, it was 1 vial every 12 hours for 6 days before the embryo transfer as the ERA test result revealed.

We did a B-hCG test 11 days later, which came out positive, and now the patient is currently 35 weeks pregnant. The non-invasive prenatal DNA test was also performed as a recommendation of our genetic laboratory, even though we knew that the embryo was chromosomally healthy. It’s recommended to do a non-invasive prenatal DNA test to be as sure as possible that the baby is doing fine because, in the end, we are not taking the cells from the embryo, we are just taking the cells from the external part of the embryo, and we know that the relationship between the external cells and the inner mass cells that could be the embryo in the future are quite accurate, but it’s also important to be as sure as possible that the baby is also okay. The test came back normal, and no fetal or maternal complications have been found so far.


  • accurate diagnosis and specific tests are essential for a correct assessment and proper treatment
  • an important examination of both male and female factors
  • IVF and PGT-A help to increase the implantation rate reduces the miscarriage rate and shorten the time to get pregnant, selecting a chromosomally healthy embryo to transfer
  • the endometrial assessment also plays a role in personalizing the embryo transfer in these patients
  • in advanced maternal age patients, SET (single embryo transfer) is recommended to reduce risks during pregnancy, such as prematurity preeclampsia and diabetes
- Questions and Answers

I am 38, and my first IVF cycle produced 12 follicles. Only one egg was retrieved, and this did not make it past day-2. I was told I had cysts that are formed. In my next round, I have been recommended mild IVF. I have a fibroid that is 10 centimetres outside my uterus. Would you recommend single or double embryo transfer?

Normally, I recommend a single embryo transfer, so it is true that in the past, we knew that if we transferred 2 embryos, maybe 1 embryo could help the other embryo to implant. Nowadays, it’s known that if the embryos are good quality ones, in the end, we are increasing a twin pregnancy. Especially if you have a fibroid in the uterus, it’s outside, so it’s not supposed to affect implantation, but in the end, if you have that fibroid, I would also recommend just doing a single embryo transfer.  

In general, we always recommend doing a single embryo transfer if the embryos are of good quality.

I’m 40, and I have 2 frozen embryos when I was 40. Do you recommend other IVF procedures before I proceed with the transfer, given that at 40 most embryos can be genetically abnormal? The embryos have not been tested. Also, do you recommend implanting 1 at a time or both of them at once? The frozen embryos are day-3, I was told it is best to freeze day-3 embryos if I only have a few. They told me that they were grade 1 embryos. What chance do these embryos have to reach the blastocyst stage?

We know that approximately 50% of the embryos that starts developing on day-1 reach the blastocyst stage. However, this is in general, so it’s impossible to know how the embryos may develop from day-3 to day-5. We already know that in most cases, when a male factor occurs, it could affect embryos from day-3. If there is any problem with the sperm, it’s quite typical that the embryos stop their development from day-3.  That’s the reason we normally recommend culturing them for all our patients. It’s about getting an idea of how the embryos are developing. That way we can transfer the embryo that could have good chances of implantation, if possible.

Regarding transferring 1 or 2 embryos, as I’ve mentioned before, it’s true that the implantation rate in patients over 40 are not high, but I would recommend doing a single embryo transfer anyway because if there is any chance of having a twin pregnancy at that age, it’s not good news. If possible, I would suggest doing a single embryo transfer. I would say that is recommended almost for all patients, but especially for patients of advanced maternal age.

We have 2 tested (normal) frozen embryos after 3 egg retrievals. My lining is thin due to D&E in February. Any recommendations to help improve the lining? We are considering PRP this month, I’m 39, I was diagnosed with unexplained infertility.

Some procedures may affect the endometrial lining, it’s difficult to make it grow, but it’s possible to use different protocols. We can add aspirin, pentoxifylline to try to make the endometrium thicker.

We have different protocols, including estradiol, and it’s also possible to perform a mild stimulation in the ovaries so that all the hormones that those ovaries will produce could also impact the lining and help that lining be thicker.

My biggest problem regarding embryo transfer has been thin endometrium and its quality. It does not grow to have a trilaminar structure, even though I have used 8 mg of Progynova per day. Do you have any suggestions on what could help to achieve a trilaminar structure of endometrium? 

It’s important to consider performing additional tests in patients with thin endometrium. It would be good to do a hysteroscopy to make sure there are no other issues with the uterus. Sometimes, we find that the cavity is not big enough, or there are other alterations in the uterus, etc. It’s significant to double-check that. If that is fine, as I’ve mentioned before, we can do stimulation with low doses of gonadotropins to try to make it thicker. Apart from Progynova, it’s also possible to use the protein vaginally, and sometimes we need to add aspirin in lower doses, also Pentoxyphiline or vitamin E. We try to add different medications that may affect endometrial lining. However, it is true, sometimes it’s difficult to make the endometrium grow, but we do have different ways of improving that.

If a woman ends up getting pregnant naturally before going in for IVF, is there anything she can take to maintain that pregnancy, such as progesterone? Any recommendations when progesterone levels are low?

Normally, when a woman gets pregnant spontaneously, the progesterone level should be normal otherwise, that pregnancy wouldn’t develop. occur. In patients with previous miscarriages, we sometimes use progesterone to support the luteal phase a bit. Also, progesterone could affect uterine contractions. In general, when a patient gets pregnant, we just need to do the scans but nothing special because we know if a miscarriage is happening, we can’t do anything to avoid it. It’s possible to use progesterone in a very specific group of patients, but not in general.

What are the rates of single versus double embryo transfers in patients over 40? Is single embryo transfer always recommended?

It depends on the quality of the embryos, on the personal history of that patient, the number of previous attempts, etc. It’s also important to know if the embryos are blastocyst or day-2, day-3 embryos. Many factors could affect the implantation and the implantation rate. In general, if we have a good quality embryo, especially if that embryo has been previously tested with PGT-A, I would recommend doing a single embryo transfer. If we are talking about an embryo on day-3, maybe of not very good quality, and if it’s the third attempt, I would possibly be more flexible, and we would transfer 2 embryos. However, there is a very small group of patients where it would be recommended. In our clinic (Clinica Tambre), we always try to have embryos on the blastocyst stage, and it’s quite typical to transfer just 1 embryo despite the embryo not being tested.

How often does a single embryo split?

It’s not a common situation, but of course, it’s another reason why we recommend just transferring 1 embryo. I don’t remember any patients in the last year that had a situation like this, but of course, it may happen.

What is the suggested vitamin E dosage per day if I would use it to boost the growth of the uterine lining?

We normally recommend between 400 and 800 mg every day, so the most typical dose is 400 mg of vitamin E every day.

I’m doing acupuncture to help with a thin lining, how can we prove this is helping if I’m taking vitamins at the same time?

The main problem with acupuncture is that we don’t know the effect it may have. There are no major clinical studies done to prove that. The main reason is that when a patient undergoes acupuncture, it’s quite typical to have many other treatments at the same time, and it’s not easy to know the specific effect that the acupuncture may have in the future and for the treatment. At our clinic, our patients can try acupuncture if they want to, and it helps them to be more relaxed. I’m not sure that it could affect the eventual endometrial thickness. I would also recommend changing the protocol the doctors are using or adding aspirin or vitamin E to help the endometrial growth, but I’m not so sure that acupuncture could play a role in that specific situation.

Is PRP (plasma rich platelet) a good therapy for ovarian rejuvenation for women with low AMH and high FSH?

We are now using the PRP in patients with problems with endometrium, we are doing a study to try to see if PRP may help patients with having a better endometrium, and we are waiting for the results. All therapies on ovarian rejuvenation are not used in our daily practice, they are used in a very specific small group of patients, and it is still done for clinical studies. There is no clinical evidence that PRP could help in that kind of patient, but of course, we need to wait for the eventual results of studies. Possibly, in the future, we will have some information that it can help, especially in young patients with low AMH value.

Can you use vitamin E and aspirin both at the same time?

That’s perfectly fine, and actually, it’s the way we always do because we try to push that endometrium to be thicker and do the transfer as soon as possible.

If my last 2 IVF attempts did not work out at the age of 43, to have a chance to conceive naturally is likely 0, right? The doctors are recommending going for an egg donor, but for now, I am not ready for it.

It’s quite likely that the embryos you had were aneuploid, and that’s their main reason. If egg donation is not an option for you, which is something understandable, and you would like to repeat embryo transfer, you could do PGT-A on the embryos. If your ovarian reserve is low, we sometimes recommend doing a dual stimulation. It means doing the first stimulation, retrieving the eggs and 5 days later, at the same time as the embryos are being tested, start a new stimulation to get more eggs and more embryos. It’s recommended for patients when we expect a low response because of their low reserve. The chances of having healthy embryos at that age are indeed around 10% maximum, so we should be realistic in that way, and it’s possible to try again, but we need to realize the chances are not very high.

Any other vitamins you’d suggest taking to help with lining? I’m taking vitamin D, vitamin E, prenatal vitamins and fish oil?

We know that vitamins may help our general health, but the one that has shown to have some effect on the endometrium is vitamin E. Apart from other treatments such as aspirin, sometimes we also use Viagra to try to have like a better blood flow in the uterus, and when we face a patient that has a problem with the endometrium, we try to use as many protocols as possible to try to make that endometrium grow. The prenatal vitamins, fish oil, also vitamin D, do not affect the endometrium. They may help with helping your body to be in the best condition, but they don’t impact the endometrium.
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Esther Marbán, MD

Dr Esther Marbán has been part of Clínica Tambre’s medical team since 2010. She is a gynaecologist specialized in Human Reproduction with a brilliant academic career. In fact, she obtained a special honourable mention in her Master’s Degree in Human Reproduction that she completed during 2009-2010 (organised jointly by the Spanish Fertility Society and the Faculty of Medicine of the Complutense University of Madrid). Dr Marbán is known for her restless and proactive personality and her innate talent for empathizing with people which she proves every day by working with patients.
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