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Fady I. Sharara, MD, FACOG
Prevention of Multiple Pregnancies in IVF
Virginia Center for Reproductive Medicine

Prevention of Multiple Pregnancies in IVF

Invitro fertilization (IVF) is now an integral and established treatment for infertility, and the number continues to increase (currently accounting for more than 1% of all children born in the US). While the pregnancy rates with IVF have improved steadily since the 1980s, so has the number of multiple pregnancies (especially triplets or more).
Despite strict guidelines on the number of transferred embryos in many countries, and recommendations in others such as the US, the number of multiple pregnancies continues to increase, or at least remains elevated.
While there has been a successful effort at curtailing higher-order multiples (such as triplets or more) by having only two or three embryos transferred, the number of twin pregnancies has not decreased. The problems associated with multiple pregnancy are many (whether IVF or natural), and include preterm labor, prematurity, hospital admissions, low birth weight, perinatal death, long term disabilities such as cerebral palsy, learning and neurologic deficits, resulting in significant health care expenditures. The maternal risks include, among others, an increased risk of gestational diabetes, pre-eclampsia, and hemorrhage. These risks also hold for twins, so twins are not “twice the fun”.
It is important to realize that the vast majority of triplets or more occur in the setting of ovulation induction/artificial insemination (IUI) and not in IVF, because unlike IUI, one can control the number of transferred embryos with IVF. The risks associated with ovulation induction/IUI compared to IVF have led many programs to move faster towards IVF.
Because of the nature of IVF coverage in the US (there is a lack of insurance coverage in many states, such as Virginia), patients and clinicians feel the pressure to maximize the chance for a pregnancy by transferring more embryos. The biggest barrier to having a single embryo transfer (SET) has been patient acceptance. Patient acceptance is growing steadily in western Europe and Australia, but remains a big challenge in the US, where the motto “I need to get pregnant first and then worry about how many I have” holds.
In a recent study, patient acceptance for SET for those women who were counseled about the risks of multiple pregnancy increased from 32% to 87% as long as the pregnancy rates with SET were not lower than those of a double ET. Currently, more than 50% of young women in some programs in Europe and Australia are undergoing SET.
In our program, 80% of patients polled preferred a twin pregnancy. Recently, efforts to decrease the incidence of multiple pregnancies, especially twins, have been gaining traction. Such efforts include strict laws or guidelines regulating the number of embryos transferred, especially in women under 35 years old where only 1-2 embryos should be transferred (preferably only one in good prognosis patients), use of extended culture systems, and most importantly the elective use of single embryo or single blastocyst transfers. Prospective patients contemplating IVF should have a detailed discussion with their physicians about limiting their exposures to multiple pregnancy. Educating prospective parents about the risks of multiple pregnancies (even twins) is the most important aspect of reducing those risks.
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