Embryo Development, Grading and Selection Copy —
Training activity: 4

Details

Make clinical decisions regarding the number of embryos to be transferred for a variety of patients

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• HFEA and professional body regulations and guidance
• Multiple births minimisation strategy
• Factors that influence the clinical decision
• Patient involvement in decision making
• Risks of multiple pregnancy

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to making clinical decisions regarding the number of embryos to be transferred for a variety of patients.
• Consider how the learning outcomes apply, specifically in relation to evaluating embryo quality and development, interpreting and reporting results, and communicating effectively with patients and the multidisciplinary team.
• Discuss with your Training Officer to gain clarity of what is expected of you in relation to the clinic’s specific guidelines balancing success rates and minimising multiple births.

What is your prior experience of this activity?

• Think about what you already know about factors influencing embryo transfer decisions, such as maternal age, embryo quality, and multiple birth minimisation strategies.
• Consider possible challenges you might face during the activity, such as navigating conflicting factors (e.g., patient preference vs. risk of multiple pregnancy) or applying decisions for atypical patient cases.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example, if the patient insists on transferring a number of embryos exceeding local clinical or regulatory guidelines.
• Acknowledge how you feel about making critical decisions that directly impact patient risk and outcome.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as integrating diverse clinical and embryological data to formulate a recommendation.
• Identify the specific insights you hope to gain into the ethical and clinical complexity of multiple birth minimisation in practice.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of embryo selection or counselling activities.
• Identify important information you need to consider before embarking on the activity, such as the specific criteria or algorithm used by the clinic for determining embryo number (e.g., patient age, previous cycle outcomes, embryo grade).

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst determining the appropriate number of embryos for transfer?
• Are you encountering situations such as:
  • Patient preference strongly conflicts with clinic guidelines regarding the risk of multiple pregnancy, challenging your justification.
  • Atypical clinical factors (e.g., a specific uterine anomaly or previous unexplained cycle failure) complicate the standard decision-making algorithm.
  • Borderline embryo quality makes selecting the single best embryo difficult, requiring immediate risk vs. benefit analysis.

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to justifying the recommended transfer number?
• Consider the steps you are taking in the moment, such as immediately consulting the multiple birth minimisation policy and involving the supervising clinician to co-present the recommendation.
• How are you feeling in that moment? For instance, are you finding it difficult to balance risk factors with clinical success rates? Is it affecting your confidence in justifying the final decision?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully justifying the decision based on risk policy and regulatory guidelines? Or are you needing support because the decision requires ethical review or override due to complexity or patient refusal?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for integrating complex clinical data into a clear transfer justification?

On action

What happened?

• Begin by summarising the key steps you took when making clinical decisions regarding the number of embryos to be transferred.
• Consider specific events, actions, or interactions which felt important, such as how you integrated patient factors (e.g., age, previous cycles) with embryo quality to formulate a recommendation or how you communicated the recommendation to the clinical team.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, re-evaluating the single embryo transfer recommendation when a patient factor suggested a higher risk of non-implantation.
• How did you feel during this experience, e.g., acutely aware of the responsibility to balance multiple birth risk against pregnancy chances?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding clinical decision-making and risk assessment. What strengths did you demonstrate, e.g., adherence to the multiple births minimisation strategy and guideline interpretation?
• What skills and/or knowledge gaps were evident, e.g., difficulty quantifying the relative risks of transferring one vs. two embryos in borderline cases?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in evaluating embryo quality and development to inform clinical decisions and applying legislation/guidelines?
• Identify any challenges you experienced, such as navigating complex clinical history details that conflicted with standard guidelines, and how you reacted to this. This might include needing to seek advice or clarification on scope of practice regarding deviating from the standard protocol for embryo number selection, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to strengthening your data integration for transfer decisions.
• What will you do differently next time you approach making embryo transfer decisions, for instance, by proactively reviewing the clinic’s specific data on success rates stratified by age and embryo grade?
• Do you need to practise any aspect of the activity further, such as calculating risk ratios based on clinical criteria or key learning outcomes related to interpreting and reporting embryology results?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of clinical decision-making since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, if a subsequent need to strictly adhere to new clinic policy limiting embryo transfer number forced you to re-evaluate your decision-making.
• Considering what you understand about multiples birth risk statistics, patient heterogeneity, and ethical justification for single embryo transfer (SET) now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your data integration and justification for embryo number based on further learning and experiences? For example, how you proactively integrated a decision support tool that combines local success rates with regulatory criteria into your assessment process.
• Has discussing ethical dilemmas in SET or the impact of multiple births on maternal/foetal health with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where transferring too many embryos led to multiple pregnancy refined your understanding of the critical importance of risk assessment.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent risk assessment and regulatory application experiences, contributed to your overall confidence and ability in justifying and communicating the appropriate number of embryos for transfer, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated skill in balancing clinical risk (multiples minimisation) against prognostic factors now enables you to confidently assess clinical presentation and cycle details to recommend the number of embryos to transfer during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to embryo transfer decision-making and patient justification? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer immediately when patient insistence conflicts with clinic/regulatory guidelines regarding the number of embryos, recognising the need for senior authority to manage protocol deviation.
• Looking holistically at your training journey, how has this initial clinical decision-making experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to evaluating embryo quality and development to inform clinical decision? For example, how this foundational experience has supported your development in reviewing the multiple birth rate and multiple births minimisation strategy for the clinic.

Relevant learning outcomes

#	Outcome
# 1	Outcome Evaluate embryo quality and development to inform clinical decision.
# 3	Outcome Interpret and report embryology results.
# 4	Outcome Communicate embryo grade and clinical decisions effectively with patients and the multidisciplinary team to enhance the overall patient experience.