Making Decisions When Uncertain in Embryology: Assessing the impact of patient and dispositional factors on blastocyst grading

Abstract

An estimated 60-80 million people suffer from some form of fertility issue, with many turning to Assisted Reproduction Technology for aid. Within this process, the selection of the most viable fertilised and developed embryo (blastocyst) for implantation into the uterus is critical. Selections are made by a trained embryologist based on how well the physical and morphological characteristics of the blastocyst map onto established grading criteria and have huge ramifications. On the one hand, if no blastocysts are judged to be viable, a pregnancy cannot be achieved, potentially preventing prospective parents from having children. On the other, there are health, financial, and emotional risks associated with implanting non-top quality blastocysts. While many blastocyst grading decisions are straightforward, there are inevitably cases in which the blastocyst's morphology does not provide clear guidance but where decisions must nonetheless be made. The current study represents a first empirical test of the factors that may be relevant to embryologist's decision making when blastocysts are on the borderline of being viable. Specifically, this study assessed whether three patient factors (maternal age, the presence of prior unsuccessful IVF cycles, and the availability of other viable blastocysts) or dispositional factors (dispositional embryologist Intolerance of Uncertainty and decision making style) predicted the decision to freeze a series of borderline blastocysts. One hundred and seventy practising embryologists were recruited around the world to complete an anonymous online study. After completing measures of dispositional tolerance of uncertainty and decision-making style, participants were presented with a series of eight 'decisional vignettes.' Each vignette presented relevant patient information including the three manipulated patient factors - higher/lower maternal age, presence/absence of prior unsuccessful IVF cycles, and presence/absence of other viable blastocysts - before an image of a blastocyst pre-selected for being unclear under current grading systems was presented. For each vignette, participants had to rate whether they would freeze the blastocyst and how likely they were to do so. Results indicated that lower maternal age, the absence of other viable blastocysts and multiple prior unsuccessful cycles were all associated with significantly higher freezing likelihoods. Furthermore, several of the manipulated patient factors interacted with one another to predict freezing ratings and there were further interactions indicating that certain 'types' of embryologist responded differentially to certain types of patient information. Taken together, the findings suggest that where the typical professional tools are providing insufficient guidance and the correct course of action is unclear embryologists will use clinical information relating to the patient to guide their decisions. However, while this information sometimes seems to be used to estimate likely reproductive success, the same clinical information sometimes seems to be interpreted in light of the specific decisional context (e.g., where the decision represents the patient's final chance). Thus, the same clinical information can be disregarded or reinterpreted, leading to decisions which diverge from what might be expected based purely on the probability of success. Future research should investigate decision making processes in embryology, particularly whether there are regional differences in freezing rates for borderline blastocysts, and further assess how patient information can impact blastocyst grades and decisions to freeze.