FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health.

Committee Statement.

Introduction

In recent years there has been a dramatic increase in multiple pregnancies throughout the world. For example, some countries have reported a doubling of twin pregnancies and the quadrupling of triplets over the last twenty years. The relative increase in higher order pregnancy has been even greater.

Undoubtedly, the main factor has been the use of ovulation inducing drugs and of multiple embryo transfer in the treatment of infertility. The increase in twin pregnancies may also be attributed in part to a trend towards increased maternal age at conception.

The need for infertility treatment has also been rising sharply due to factors which include the trend towards pregnancy at later ages, and the impact of sexually transmitted diseases.

Multiple pregnancy has very serious implications for the mother and her offspring, for the family and the community, and for health service resources. To give examples: the maternal mortality may be increased 3 fold for twin pregnancy and even more for triplet pregnancies; with triplets as compared with singletons the incidence of birth weight < 1,5 kg has been reported to be increased 75 fold, the perinatal mortality raised 9 fold, and the incidence of cerebral palsy 16 fold. The parenting required for triplets has been estimated at 197 hours per week. The resulting physical and emotional stress commonly leads to psychological problems within the family. In addition the financial cost to the health service and community, as well as to the family may be 100 to 200 times greater than with a singelton pregnancy.

Every effort should be made to prevent infertility. Further research is required. Women require education on the consequences of delaying pregnancy until late in their reproductive lives. They should also be made aware of the risk of infertility associated with sexually transmitted disease, such as chlamydial infections, and other risk factors.

Obstetrician-gynecologists have an important responsibility to make both the public as well as their patients aware of the many hazards associated with multiple pregnancy, especially with triplets and higher order pregnancies. In addition, they must make them aware that the high risk nature of multiple pregnancies requires an expertise that may be beyond that available in some rural or smaller town areas.

Research and education is urgently required to improve the technologies of assisted reproduction. Reduction in the incidence of iatrogenic multiple pregnancy and the problem of increasing monozygosity are important areas of study.

The misuse of drugs for the induction of ovulation is responsible for at great deal of iatrogenic multiple pregnancies. Therefore, those using these drugs should be familiar with the indications for their use, their adverse side effects, ant the methods of monitoring and preventing iatrogenic multiple pregnancy.

Obstetrician-gynecologists using assisted reproductive technologies, whether by the induction of ovulation or the transfer of pre-embryos (in all stages of development including blastocysts), should aim to achieve singleton pregnancies. Under optimal conditions, not more than two pre-embryos should be transferred although circumstances of age and other clinical considerations may warrant three or, in exceptional circumstances, four. International and national professional bodies have a responsibility to issue recommen-dations for good practice with a view to reducing the incidence of iatrogenic multiple preg-nancy. There is a need for accreditation or certification of centres in order to ensure a uniformly high standard.

The risks for both mother and her resulting children with triplet and higher order pregnancies are sufficiently great to justify consideration by the couple and their medical advisers of the use of fetal reduction.

In order to monitor and regulate professional practice, audit of the use of these technologies should include not only the fertility success rate but also statistics on the incidence of mul-tiple pregnancy, the use of fetal reduction, the maternal and perinatal mortality and morbidity, the incidence of preterm delivery and low birth weight, and the occurrence of long term disabilities among the offspring. International, national and local centre statistics should be available to couples wishing to use these services.

Couples seeking treatment for infertility must be fully informed of the risks of multiple pregnancy both to the woman and to their potential progeny. These risks are so numerous, complex, and potentially far reaching that they should be fully explained and also given in writing. Counselling should also be abailable from an experienced paediatric member of the perinatal team. Proper informed consent should be obtained for the use of ovulation inducing drugs and other assisted reproductive technologies.