Gambling with twins, triplets and more.

June 7, 2010Carole 2 Comments »

My lab was optimized to produce twin pregnancies because we almost always transferred two embryos on day 5. Statistically,  if you came to us and got pregnant (and more than 60% of our patients did the first time), you had a 50% chance of twins. Patients loved this because they got “two for the price of one”.  I get it. IVF is very expensive and generally unpleasant so who wouldn’t want to complete or make serious headway in their family building in one attempt?

Transferring more than one embryo does increase the chances of getting pregnant in the same way that two lottery tickets increases the  chances you’ll win. The difference is that you don’t just “win” once, you can get pregnant from each embryo you transfer. And sometimes, there’s a bonus baby, because embryos can and do split creating identical twins from one embryo transfer. That means that  even a single embryo transfer can result in twins. As ART improves, we make embryos more like nature intended and they implant better, the more likely we are to get multiples.

But twins usually turn out okay, right? They do, except when they don’t. We saw our patients until about 12 weeks, then off to the obstetrician. Every year, without fail, a number of patients would lose their twin pregnancies completely or have a preterm birth with complications after they were referred to the OB. Every year. Without fail. Sometimes nurses are asked to attend the funerals of the fetuses that were delivered mid-way in the pregnancy, too soon to survive. This really bothers me because it is avoidable. The March of Dimes has an excellent website page on preterm labor. Preterm labor is more likely in twins, triplets and higher order multiples. Interestingly, March of Dimes lists being pregnant with a singleton from IVF as a risk factor for preterm birth. Statistically, IVF patients are more likely to suffer from pre-term labor and miscarriages anyway. Being pregnant with more than one increases that risk.

What are the possible bad outcomes from multiple gestation pregnancies? A multiple gestation pregnancy is more likely to result in fetal or maternal death, congenital malformations, pregnancy complications and loss of the pregnancy. Long term studies of families who are raising twins or higher order multiples find that there is an increased risk of psychological, social or economic difficulties. Raising more than one infant at a time is a strain.

What is driving this push for more than one? Lack of insurance coverage is part of it. European IVF programs have been more successful in selling single embryo transfer to their patients because the burden of the cost of IVF is more likely to be shared with government healthcare, making the out-of-pocket costs to European patients much less. The average cost of a straightforward IVF case is approximately $12,000 in the US, with regional fluctuation. That’s a lot of money for most people. If you can only afford one attempt, better maximize the chances for success, right? Sure, unless you are one of the unlucky ones who gets pregnant with more than one and something bad happens.

Another factor is that you are the customer and we want to make you happy. Getting you pregnant makes you happy, even with twins. If you get unhappy later in pregnancy, you probably won’t blame us but will blame your obstetrician. Not getting pregnant makes you very unhappy. If you are unhappy, you might not come back for a second attempt and you might tell your friends that we don’t know what we’re doing. The customer is always right. Except, in this case, sometimes your clinic is not doing you a favor by letting you have it your way. Sometimes, doctors need to tell their patients, “No, one embryo is all we can safely transfer”. In an article published in the European Society for Human Reproduction and Embryology’s journal Human Reproduction, the topic of avoiding multiple pregnancies is hotly debated. This article concludes that physicians fail their patients by not fully educating their patients and by not saying “NO” to transferring multiple embryos.

One way of dealing with this difficult customer problem is to let the patient know that they can always have multifetal reduction if they end up with too many fetuses. Fetal reduction is a medical procedure in which a long needle is inserted through the mother’s abdomen and into the fetal heart to introduce an agent to stop the heart. This procedure is only performed by a few doctors in the whole country so you have to travel to get this done. Being faced with the choice of fetal reduction means that you, the fertility patient who has been trying for eons to get pregnant now have to ask yourself, do I selectively abort one or more of these precious fetuses so that I increase my chances of bringing one live healthy baby home? Is this grossly unfair or what? I think that having to consider this choice falls under the category of “Worse things than not getting pregnant”.

It will be duly noted in your chart that multi-fetal reduction was discussed and you understood and you chose to go ahead anyway. So in the end, it’s all on you. You might have thought that you were given the green light for two (or three) to transfer- no problem. Your medical chart may reflect a more conservative approach. Advanced maternal age is used to justify increasing the number of embryos transferred per attempt to optimize the chance of getting pregnant. It’s definitely true that since embryos from older eggs are more likely to have problems like aneuploidy, resulting in no pregnancy or early pregnancy loss, transferring more increases your odds that one will implant and go the distance. But realize that it’s all only a best guess and the more you put in, the more chances you have to win–and lose, if you get too many.

Remember the choice and consequences really and truly fall on your shoulders in the end. I know it is difficult for someone struggling with infertility to even imagine having the opposite problem, but fertility patients have more multiple births than the general public because when ART interventions work, they really work. You may have to do some research on this topic on your own because not all fertility clinics excel at patient education. However, in my opinion, the very best doctors tell patients everything, even the facts that they don’t want to hear and also say “NO” sometimes because these doctors are looking at the risk of the worst outcomes, not just making their patients happy in the short term.

© 2010 – 2015, Carole. All rights reserved.

2 Responses to this entry

Join the discussion