Whilst reading the Commentary by Norbert Gleicher recently published in BioNews (1), we were surprised and saddened that the same arguments given at the ESHRE (European Society of Human Reproduction and Embryology) annual meeting (2) last summer in Barcelona, were repeated without a clinical counterpart. ESHRE wishes to reaffirm its response to Gleicher last July; the complications of twin pregnancy outweigh the benefit, even if one accepts Gleicher's premise that most of our patients want more than one child.
These patients have already learnt the hard way that life often presents unpredicted obstacles, in this case the infertility for which they are seeking treatment. Most would prefer a healthy child (and also less risk for the mother-to-be and her future family), and realise that to achieve this, they may well have to review their life plans. Indeed, this is one of the very good reasons why counselling should be available in fertility clinics, and the Human Fertilisation and Embryology Act wisely advises counselling in the UK. In the same setting, one can only applaud Sandy Starr's comments (3) about the injustice to our patients with the remaining postcode lottery, forcing patients into the private sector (4, 5).
When Gleicher presented to ESHRE's annual meeting last year, we acknowledged that what he said was an interesting challenge to the move to reduce twin births after IVF. His study correctly noted, as all IVF doctors affirm, that most twin pregnancies will have a good outcome, and that his intention was not to scare those who already have embarked on a twin pregnancy.
However, he failed to comment on the conclusions of the study he quotes from Helmerholst, which says: 'With a twin pregnancy they may be relatively advantaged compared with other twin gestations, but this is poor consolation for the much greater risks of twin pregnancy overall. Virtually all perinatal and infant morbidity occurs more frequently in twins than in singletons.'
Any obstetrician will confirm that twins can have huge obstetric complication risks: 2-3 times higher risk of preeclampsia, and post partum haemorrhage, even after using Gleicher's hypothetical correction factor, and 5-7 times the chance of being born prematurely. Extreme prematurity is accompanied by a significant increased risk of cerebral palsy and that is not an intended outcome for any parent or their child. His assertion that women want two children and that some even want triplets attests to the general ignorance of these risks.
Gleicher also omits to consider increased late losses of multiple pregnancy. The saddest outcomes that we see in practice are those twin pregnancies where women go into very premature labour or lose both babies at around 25 weeks or less. The disappointment and grieving that accompanies this loss is profound and cannot be calculated in dollars or pounds.
When one looks at studies of families who have had twin or triplet pregnancies they have significant stresses, even to the extent that some have given their babies up for adoption because they are unable to cope. It is not reasonable to equate two single-spaced pregnancies with twins; being up all night with newly born twins, the doubling of the initial outlay costs, and the significant stresses of bringing up two toddlers are all material. Added to this, in the older age mother, as acknowledged by Dr Gleicher, a significant number may request prenatal diagnosis to avoid age-related genetic abnormalities. In twin pregnancies the risks of the procedure are much increased, and dealing with the outcome is more complicated.
Because of the emotional stress of infertility, most prospective parents under-estimate the difficulties of raising multiple children, even if they are all healthy. Understandably this stress is further intensified if one or both of the children are affected by any of the complications which commonly surround premature births. Furthermore, if babies are affected by any of these complications, the stresses may last a lifetime rather than be limited to the period surrounding delivery. This is not to mention the financial cost to the parents, and to healthcare systems involved in caring for the mother during a complicated pregnancy and the children whether in the short or long term after birth.
We should also not forget that Dr Gleicher speaks as someone who lives and works in the US, where there is little if no public funding for both fertility treatment and the consequences of multiple births which may last a lifetime.
Whatever the hypothesis, which may be interesting for doctors to mull over and discuss, there are significant risks to multiple pregnancies, and we should not be generating them deliberately. IVF babies also deserve the best start in life.