Twins in Demand Through IVF?

Despite some couples' desires, doctors counsel against trying for twins through in vitro fertilization.

From the WebMD Archives

Forget "Octo Mom." The hot debate among in vitro fertilization (IVF) patients and their doctors isn't about having lots of babies at once. It's about trying for twins. Patients who want twins point to the high costs of IVF, their ticking biological clocks, and their frustration and exhaustion from lengthy fertility struggles. They ask, why not have two at a time?

Leslie Glass says she did want twins when she turned to IVF.

Her reasoning: "It was so expensive and I knew that this would probably be it for us," Glass tells WebMD. "If we get twins, all the better, because whether we had twins or one, it's still $22,000. So if this is it, then let's just complete the family."

But doctors say it's risky.

Compared to having one baby, twins and other multiples are more likely to have serious -- and even life-threatening -- health problems, including preterm birth, low birth weight, and birth defects.

"[Patients] are so focused on getting pregnant in any way, shape, or form that the concerns with multiples are secondary," Alan Peaceman, MD, professor and chief of maternal-fetal medicine at Northwestern University Feinberg School of Medicine, tells WebMD.

"Sometimes, they just don't understand how bad 'bad' can be," Peaceman says.

And just like that, one of the most intimate decisions an adult can make -- how many children to have -- becomes a medical, ethical, and personal minefield that can pit patient against doctor. Here are the pros and cons from each side of the debate.

IVF Cost, Insurance a Factor

It's rare for IVF patients to bluntly request twins, and few ask for triplets or more, but many mention a desire for twins, IVF doctors tell WebMD.

That happens "all the time," says Mark Perloe, MD, medical director of Georgia Reproductive Specialists in Atlanta.

Suheil Muasher, MD, medical director of the Muasher Center for Fertility and IVF in Fairfax, Va., agrees.

"A good number of my patients would kind of joke about it and say, 'We would like to have twins,'" says Muasher. "Most of the time they don't demand it, but it is something desirable for them."

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Perloe and Muasher practice in states where insurance companies aren't required to cover IVF. That leaves patients to shoulder IVF costs themselves.

Those costs can add up quickly.

The average U.S. cost for one IVF cycle is about $12,500, says Elizabeth Ginsburg, MD, president of the Society for Assisted Reproductive Technology (SART) and the medical director of assisted reproductive technologies at Brigham and Women's Hospital in Boston.

"For some people, they can afford it once and that's it," Ginsburg tells WebMD. But IVF doesn't always succeed in the first cycle.

The Glasses spent $22,000 out of their own pockets for three rounds of IVF.

"We're still paying for them," Glass says of her twin daughters. "We didn't go in there and say, 'We'd like twins.' It was, 'We can't get pregnant, we need your help, this is the only way we can do it.'"

Even in states where insurance covers IVF, some patients still want twins. Ginsburg hears that from women nearing the end of their childbearing years, people who think twins are "cute," and people who want two kids but only one pregnancy. "They feel like it's just very efficient that way," Ginsburg says.

Medical Risks of Multiple Births

Health experts -- including all the doctors interviewed for this story -- don't approve of trying for twins because it's a risky undertaking. Those risks include:

  • Infant death: Twins are five times more likely than single-birth babies to die within a month of birth.
  • Preterm birth: Twins and other multiples are much more likely than single babies to be born early. According to the CDC, 60% of all U.S. twins born in 2006 were born prematurely, compared to 11% of single babies. And 12% of twins were born very preterm (before 32 weeks of gestation), compared to about 2% of single babies.
  • Low birth weight: Twins and other multiples are more likely than single babies to be born at a low birth weight. The CDC reports that about 58% of U.S. twins born in 2006 were born at low birth weight, compared to 6% of single babies. And 10% of twins were born at very low birth weight, compared to 1% of single babies.
  • Birth defects including cerebral palsy are more common in babies born prematurely.
  • Risks to the mother: Women pregnant with more than one baby are at higher risk for preeclampsia, gestational diabetes, and bleeding before or after delivery, compared to women carrying one baby.

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Of course, many twins are born on time and are healthy.

For instance, while the infant death rate among twins is much higher than the rate for single babies, the vast majority of infant twins don't die. CDC records show that about 30 out of 1,000 U.S. twins born in 2006 died during infancy, compared to six per 1,000 single babies.

So it's not that all twins are headed for complications. But their odds aren't as good as single babies.

"The good news is that most of the time with twins, and maybe even with triplets, people end up with normal, healthy babies. But there are significant number of bad outcomes," says Peaceman.

And those bad outcomes become more common with increasing numbers of babies. So twins are riskier than single babies, but less risky than triplets, quadruplets, or more.

Because of the relative risks, most doctors discourage trying for twins or other multiples.

"Anybody who comes in asking for multiple births, we will dissuade and try to get them thinking correctly," Perloe says. Muasher says he tells his patients that "the best outcome that I would like to hope for is to have one healthy baby."

Doctors can't guarantee twins at the onset of IVF, anyway. SART and the American Society of Reproductive Medicine (ASRM) have guidelines about how many embryos should be transferred to an IVF patient, based on her age, reproductive history, and embryo quality. But not all embryos that are transferred result in live births, and even if only one embryo is transferred, that embryo could split, leading to twins.

In short, the outcome of IVF isn't totally within the patient's or doctor's control.

The risk of premature birth is the top concern for Phyllis Dennery, MD, FAAP. As chief of the neonatology division at Children's Hospital of Philadelphia, she sees firsthand the complications that can occur with twins and other multiples.

Dennery explains that the more embryos there are in a uterus, the greater the chance of preterm birth and its complications, such as immature lungs, brain, gut, and bleeding in the brain.

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"It may be costly to do IVF, but it is very costly -- emotionally and otherwise -- to have premature babies who are in the hospital for a long time or who have problems that may span beyond the first few months of life. … It is a difficult thing to think about when you don't see it in front of you. It's only when that baby's born and things are the way they are that people go, 'Wow, I didn't realize.'"

Amanda Gifford, 26, had her twins, Ethan and Abigail, who were conceived through IVF, eight weeks early. And that was after 11 weeks of bed rest after going into preterm labor when she was 20 weeks pregnant.

Gifford and her husband, Kenneth, weren't trying for twins. But the two embryos that their IVF doctor had transferred implanted, resulting in twins.

"Go find out what it's like to have a preterm baby and decide if that's something you can risk, because it's a lot of heartache," Amanda Gifford says. Now 9 months old, Ethan and Abigail are doing "pretty well, but I still worry about them every day. They're behind with gross motor [skills], which is to be expected" because of their preterm birth, Gifford says. "As a parent, you just constantly worry -- what if they have long-term complications?"

Education the Key?

IVF patients often change their minds about wanting twins when they learn about those risks. "I think it's really an educational issue," says Ginsburg.

That's what reproductive endocrinologist Ginny Ryan, MD, and colleagues found in 2007 when they studied 110 couples who got IVF at the University of Iowa's clinic in Iowa City.

Surveys showed that when the patients first came to the clinic, 29% said twins were their most-desired IVF outcome. After reading a pamphlet and talking with a doctor about the risks associated with multiples, that figure dropped to 14%.

Still, doctors say that even after learning about the risks, some patients have a hard time taking that in.

"That's just human nature," Ryan says. "When you've been undergoing infertility treatments for years, there's such a focus on just getting pregnant that it's harder to look at the bigger picture as far as what's going to happen in the pregnancy, what's going to happen after the pregnancy. It's just this real kind of tunnel vision towards getting pregnant. And I can understand that."

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Gifford and Glass can relate to that. Both say that before having their twins, they had wanted their IVF doctors to transfer three embryos in the hopes of at least having one baby -- and they're glad their doctors refused.

"There's times when people say, 'Put 'em all in, I'm tired, this is my last shot.' And they're there to keep you from doing things like that," Gifford says.

Muasher, an IVF specialist for nearly 30 years, says he's seen a shift over the years as patients become more aware about the risks of triplets and higher-order multiples -- but not twins.

"You don't get much argument when you talk to them about triplets. Twinning ... they still see that as a desirable thing," Muasher says.

The CDC reports that the twin birth rate climbed 70% between 1980 and 2004, but leveled off between 2005 and 2006 at a rate of 32.1 twins per 1,000 U.S. births.

"I get that all the time when I'm out -- 'Oh, I wish I had twins, I hope I have twins.' Be careful. It's not easy. You wouldn't change it, but it's no joke," Glass says.

Glass says the first year with her twins was "really, really difficult," even though the twins were healthy.

That sounds familiar to John Moore, MD, FAAP, chief of pediatrics at the Carilion Clinic in Roanoke, Va.

Moore, who follows research on twins and multiples, is the father of healthy twin girls who will turn 5 this summer. He notes that even healthy, full-term twins are still stressful for parents.

"It's a lot harder than people like to think it is," says Moore.



"People need to realize that when the babies are born, that's kind of the beginning of the process with multiples, not the end," says Moore. "Twins can be fun. There's nothing better than coming in at the end of the day and having two children jump on you at the same time. By the same token, there's nothing worse than having crying in stereo."

WebMD Feature Reviewed by Louise Chang, MD on March 25, 2009

Sources

SOURCES:

Leslie Glass, mother.

Alan Peaceman, MD, professor and chief of the division of maternal-fetal medicine, Northwestern Feinberg School of Medicine.

Mark Perloe, MD, medical director, Georgia Reproductive Specialists, Atlanta.

Suheil Muasher, MD, medical director, Muasher Center for Fertility and IVF, Fairfax, Va.

Elizabeth Ginsburg, MD, president, Society for Assisted Reproductive Technology; medical director, Assisted Reproductive Technologies, Brigham & Women's Hospital, Boston.

Amanda Gifford, mother.

Ginny Ryan, MD, associate, division of reproductive endocrinology & infertility, University of Iowa College of Medicine, Iowa City, Iowa.

Phyllis Dennery, MD, FAAP, chief, division of neonatology, Children's Hospital of Philadelphia; professor of pediatrics, University of Pennsylvania School of Medicine.

John Moore, MD, FAAP, chief of pediatrics, Carilion Clinic, Roanoke, Va.

CDC: "Births: Final Data for 2006."

Ryan, G. Fertility and Sterility, August 2007; vol 88: pp 354-360.

March of Dimes: "Multiples: Twins, Triplets, and Beyond." American Society for Reproductive Medicine: "Patient Fact Sheet: Complications and Problems Associated with Multiple Births."

Sources

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