1. #hfeaconference2014 26 February 2014 Andrew Riddle Medical Director Person Responsible, Nuffield Health Woking Hospital Key factors of a successful strategy

2. ACE 2014 Oral Presentation Successful establishment of eSET criteria with multiple pregnancy rate reduced to below 5%

3. Original Criteria (prior to 2011) Developing Criteria (2011-2012) Current Criteria (2013 onwards) <37All patients ≤402 or more TQE on day 2 or 3 9 TQE5 TQE1 TQE and multiple average quality embryos Previous unsuccessful attempt when TQE transferred 4 TQEor Consider patient history Long discussion with patient3 TQEIf >40 consider blastocyst based on previous history 3 How have our blastocyst criteria developed? Increase in blastocyst transfers from 6.4% in 2011 to 72.1% in 2013

4. How have our eSET criteria developed? 4 Original Criteria Consider for any patient <37 TQE to replace 1st cycle Any previous pregnancies If spare embryos suitable for freezing Current Criteria Consider for any patient <41 If the morula or blastocyst is good quality 1st or 2nd cycle Any previous pregnancies

5. Pregnancy rates eSET vs. DET: Year 4 Patient ageeSET preg. rate eSET multiple preg. rate DET preg. rate DET multiple preg. rate Under 3541.41.537.933.4 35-3734.82.833.924.9 38-3931.81.329.523.2 Other35.11.928.327.0 All ages38.81.632.929.2

6. Preg. rates blastocyst eSET vs. DET: Year 4 Patient ageeSET blastocyst preg. rate eSET multiple preg. rate DET blastocyst preg. rate DET multiple preg. rate Under 3544.61.644.040.3 35-3738.72.042.029.4 38-3935.71.538.828.7 Other39.52.036.332.8 All ages42.31.740.535.2

7. Overview of National trends Pre-policyYear 1Year 2Extended Year 3 Year 4 Proportion of transfers that are eSET(%) 4.911.315.919.726.1 Proportion of transfers that are blastocyst transfers (%) 13.020.630.338.848.2 Multiple pregnancy rate (%) 26.624.121.319.516.5 Multiple live birth rate (%) 23.621.419.217.415.6? Overall pregnancy rate (%) 30.332.131.632.632.9

8. Clinic data: % eSET fresh cycles Y1: Jan 2009 to end March 2010 Y2: April 2010 to end March 2011 Y3: April 2011 to end September 2012 Y4: October 2012 to end September 2013

9. Clinic data: % blastocyst transfers fresh cycles Y1: Jan 2009 to end March 2010 Y2: April 2010 to end March 2011 Y3: April 2011 to end September 2012 Y4: October 2012 to end September 2013

10. Clinic data: % CPR, MPR, MBR Y1: Jan 2009 to end March 2010 Y2: April 2010 to end March 2011 Y3: April 2011 to end September 2012 Y4: October 2012 to end September 2013

11. Clinic data: CUSUM plot multiple births Multiple pregnancy rate by pregnancy, for all IVF, ICSI and FET cycles For period: Oct 2012 – Jan 2014 (as of 02/02/14) Number of births

12. Year 4 centre performance: funnel plot Multiple live birth rate by live birth, for all IVF, ICSI and FET cycles For period: Oct 2012 – Sep 2013 (as of 09/01/14) at 10% Number of births

13. With Thanks to: Aimee Hetherington Rebecca Fabian Caroline Franklin All the team at Nuffield Health Woking Hospital Acknowledgements

14. Any questions? #hfeaconference2014

15. Andrew has replicated the practice in Sweden and achieved almost identical results in terms of MBR, but with a higher pregnancy rate using a blastocyst based programme. Table discussions What are the key factors of this successful strategy?  What did you need to put in place to ensure that the majority of patients would be able to take part in a blastocyst transfer programme?  What proportion of your patients have blastocysts for transfer What are the trigger points for review/audit? Feedback… Discussion

16. Thank you. #hfeaconference2014