I don't want to be an Octomom!

Having more than one baby at a time (multiple gestations--twins, triplets, etc) is the fear and desire of many couple struggling with infertility.  When scientist look at why couple don't pursue fertility treatments, fear of multiple gestations is one of the leading reasons (the other is fear of the cost--see my previous blog on the cost of fertility treatments).  However, I get asked on a daily basis whether it is possible to use a treatment or dosage that will give a patient twins rather than just one baby.  "If we could have twins, then we would be done!" is what I hear a lot.

We have all heard about the Octomom, but just how likely is a multiple birth with fertility treatment?  Well, it depends on the treatment.  Clomid or clomiphene citrate (see previous blog on Clomid) is a mild fertility treatment that is often the first treatment recommended for couples struggling with infertility.  It has about an 8-10% chance of causing twins and a less than 1% chance of higher-order multiples (triplets, quadruplets, etc).  Many facilities, such as ours, will monitor Clomid cycles with an ultrasound done a day or two before ovulation.  By measuring the follicles (the sacs containing the eggs that are developing that cycle), we can predict how many eggs are likely to ovulate.  The goal is usually 1 to 3 eggs ovulating, depending on the woman's age.  If a woman looks like she is going to have five eggs ovulating instead, let's say, we would recommend canceling the cycle and starting over at a lower dose.  This practice has really all but eliminated higher order multiple pregnancies from Clomid in our office.

The Octomom did IVF, but that isn't usually associated with a high risk of a multiple pregnancy, especially a high-order multiple pregnancy like octuplets.  This is because the doctor and patient control how many embryos are placed into the uterus at one time.  The American Society for Reproductive Medicine (ASRM) guidelines say that a woman who is 37 years old or less should have no more than 2 embryos transferred, a 38-40 year old should have no more than 3 embryos transferred, and a 41-42 year old should have no more than 5 embryos transferred (these are guidelines for good quality embryos and may be modified if the embryo quality is poorer).  If these guidelines are followed, the chance of triplets or more should be less than 1%.  Obviously, these guidelines were not followed with the Octomom.  However, most doctors do follow the guidelines.  You should definitely have a discussion with your doctor as to how many embryos they recommend transferring and what their clinic's multiple rates are, if you are considering IVF.

The treatment regimen with the highest multiple rate is using injectable medication (gonadotropins, see previous blog on the subject) with insemination.  This will often get 3-5 eggs ovulating, which can sometimes be the goal.  Every once in a while, though, 4 eggs ovulate, all 4 take, and you end up with quadruplets.  Therefore, this treatment regimen should be treated with caution and respect.  Very careful monitoring is necessary to avoid having too many eggs ovulate.  Cycles should be cancelled, if it looks like the risk of triplets or more is too high.  Younger women, especially those with PCOS (polycystic ovarian syndrome, see my previous blog on this topic), should be started on very low doses and watched carefully.  Even given careful cautious monitoring, it is still possible to end up with a multiple gestation.  Younger women may therefore want to avoid this regimen and go right to IVF.  The risk, in our hands, is less than 1%.  So even here you are not at tremendous risk for triplets or more.

What happens if you do end up with twins or triplets?  What exactly are the risks?  Well, let's start with twins.  The most common type of twin pregnancy produced by fertility medication is fraternal or non-identical twins.  This is a twin pregnancy from 2 separate eggs.  Identical twins are not more likely to happen with fertility medication.  The risk of miscarriage of twins in the first trimester is similar to single babies and depends more on the mother's age and therefore quality of eggs.  However, twins usually deliver before their due date.  The average delivery date for fraternal twins is 5 weeks before they are due.  This can lead to premature babies with medical complications. Overall, however, most twins do well. 

Triplet pregnancies are significantly more risky than twins.  90% of triplets are born prematurely.  This makes them much more likely to suffer problems like cerebral palsy (a condition with the inability to coordinate movements, learning problems, speech problems, etc), blindness, breathing problems, and problems with their intestines.  One study looking at triplet and higher order pregnancies found a 32% rate of minor neurologic problems and a 6% rate of major neurological problems.  The risks of death in the first month of life for triplets is ten to twenty times higher than with one baby.  All of these statistics get even worse for quadruplets or more, with the risk of losing all the babies before they are mature enough to survive becoming a major factor.  There are risks to you in a multiple pregnancy as well.  The chances of ending up with high blood pressure, diabetes, and anemia of pregnancy are higher.  Morning sickness tends to be even worse.  Bedrest for months is often needed, especially with triplets or more.  You are more likely to need a c-section and more likely to hemorrhage at delivery with multiples too.

As you can see, multiple gestations are not with risk.  The risks increase substantially as you go from twins to triplets, and beyond.  Most fertility centers, however, have worked very hard at reducing their rates of multiples as much as possible.  Not that you understand the risks, hopefully your desire for more than one baby at a time has also diminished.  If reducing the chance of multiples does not seem to be a goal of your fertility center, you may want to seek a second opinion.  With careful monitoring and by following the ASRM guidelines for the number of embryos transferred, your risk of being an octomom should almost non-existent!