Multiple Pregnancies after ART: The View of the Obstetrician

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Dr. Hugo Verhoeven: “I’m Hugo Verhoeven from the Center for Reproductive Medicine in Dusseldorf, Germany. I am on the Editorial Board of OBGYN.net, and I’m reporting from the European Congress on Perinatal Medicine in Porto, Portugal. It gives me great pleasure to introduce Professor Isaac Blickstein, the Editor-in-Chief of the Israel Journal of Obstetrics and Gynecology working at the Department of Obstetrics and Gynecology at the Kaplan Medical Center in Rehovot, Israel. Dr. Blickstein is the Chairman of the Working Group on Multiple Pregnancy of the International Society of Twin Studies and a world authority on multiple pregnancies. Good morning, Professor Blickstein.”

Professor Isaac Blickstein: “Good morning.”

Dr. Hugo Verhoeven:  “The overall multiple pregnancy rate is exploding worldwide and one of the reasons for that is certainly the worldwide introduction of new techniques in ART and, of course, the improving pregnancy rates. You are an obstetrician and among the ones who have to solve the problems that specialists in Reproductive Medicine are producing, and you have some special thoughts about that. I heard you at this meeting criticizing the way specialists in Reproductive Medicine are thinking about the outcome of their treatment and that most of them ignore the problems that you and the neonatologists have . So let us talk a little bit about your thoughts on this topic.”

Professor Isaac Blickstein: “Thank you very much for approaching me on this question. I would like to start with an overview of what happens in reality. We are witnessing a change in society, many years ago women first married, produced children, and then looked for a career. However, society and culture changed over the years; women now finish their career first and then think of marrying and producing children. At that time of their reproductive age, they might encounter problems in getting pregnant. We are fortunate that the technology is here to meet the requirements of women and, indeed, infertility treatment changed tremendously over the last fifty years . One can look at infertility as a disease that should have a treatment, and as you know in medicine all treatments have side effects. One major side effect of infertility treatment is perhaps hyperstimulation syndrome which is life threatening. I am, however, interested in the point of producing more children than necessary, which has an enormous impact on perinatal mortality and morbidity. Admittedly, all methods of reproductive technologies are highly costly. They cost a lot of money, cost a lot of energy from the patients, and in addition, the cost of sophistication required by the experts of reproductive medicine. At the endpoint, if they don’t produce results, they have no existence; it subsequently became an existentialistic aspect. If you don’t produce results, you have no survival as a center, you have no survival as a group of physicians or laboratory technicians that earn a a lot of money, and expend a lot of money on fertility. Of course, the cost is different in many countries so the cost of a fertility treatment might be between $5,000-$10,000 in the States and might cost nothing in Israel where treatment is free.”

Dr. Hugo Verhoeven:  “It doesn’t mean that’s it’s free, that it doesn’t cost anything, it costs…”

Professor Isaac Blickstein: “It costs to the society.”

Dr. Hugo Verhoeven:  “Exactly.”

Professor Isaac Blickstein: “But the patient that spends the money and their energy on doing that are fortunate in Israel to get it free of charge which is the limit of course in the States and in some other countries that have to produce results within a few cycles. So for that reason all that matters is the pregnancy rate and, admittedly, this is good thinking for the patient. The patient wants a child; if the side effect is a multiple pregnancy sometimes the patient will regard that as a compensation for long lasting infertility. They are happy that they have two or three children after they are longing for a pregnancy for several years, however, many are not aware of the risks associated with a multiple pregnancy. It has been shown extensively in the literature by many researchers that infertility treatment is associated with increased risk of multiples and therefore associated with increased morbidity and mortality. The contribution of ART, for example, has been estimated to increase the rate of cerebral palsy of the spastic quadriplegic type, meaning that the baby or the infant is not moving except for his head and eyes, by 8% in the United States only because of ART. “

Dr. Hugo Verhoeven:  “Let’s go back to the cost of treatment because I think that’s very important. Even if the patient has to pay for the infertility treatment herself, it is the society who is going to pay for the consequences. If the lady gets a twin pregnancy and has to pay herself, society may have to take care of the handicap child for maybe 30, 40, or 50 years. So that is something that should be kept in mind very clearly and pointed out, because not many people realize that it’s not just getting pregnant but the complete pregnancy and the complete life of those disabled children - this costs enormous amounts of money.”

Professor Isaac Blickstein: “Yes, money is one thing but I think it’s more than money because what costs society is the loss of working power of the parents. They have to commit their lives to treat or to take care of a handicapped child and for the society it is important to understand that the risks are enormous. When one balances the risks associated with multiple pregnancy as compared with singleton pregnancy, one should reach the decision very easily : the goal of infertility treatment should be a singleton pregnancy. We know about the difficulties, the enormous energy, talent, and sophistication involved in modern ART but we can define that iatrogenic multiples have two types - the avoidable and the unavoidable. If you only give ovulation induction, you cannot actually control the number of multiple pregnancies unless you are canceling the cycle. If you go and use protocols that do not produce good follicles, then you do not get good pregnancy rates, but this is unavoidable. On the other hand, transferring embryos is a decision made by governments, societies, doctors, and by the patients themselves and these are avoidable multiples.”

Dr. Hugo Verhoeven:  “That is an interesting point, so who do you think should have priority - the government, the policy of the hospital, the thoughts of the doctor, or the patient? Would you say that if the patient wants to have five embryos back and accepts the risk of triplets , you should say okay that’s the patient decision or do you think that the decision or the thoughts or the responsibility of the treating doctor is the most important? That is my feeling, that many doctors are not thinking enough about their responsibility treating infertile patients.”

Professor Isaac Blickstein: “This is mainly an ethical question, it’s not a medical question. In regarding infertility and the ethics, the well-known dictum “primum non nocere” - first of all do not do any harm - implies that, infertility can be regarded as an unethical treatment because there is some harm involved in infertility treatment. However, we use plastic surgery to change a patient’s nose which is not a life saving procedure, and patients are submitted to dangers of anesthesia and dangers of the surgery because we are living in a dynamic society which has different demands nowadays. The center of those decisions is the patients, no doubt, but only if they get a real informed consent. They should get all the information regarding the success and the risks of multiple pregnancy, the possibility of having a handicapped child, the tremendous efforts in keeping a multiple pregnancy going on, the risks associated with a multiple birth, and the tremendous effort in raising those children later on. Then, they may have other thoughts and be in conflict with the doctors that would aim for a higher fertility rate but not in expense of having a multiple pregnancy as a side effect.”

Dr. Hugo Verhoeven:  “But you, as probably the number one in research in the field of mortality and morbidity in twin pregnancies, what is your message to doctors performing reproductive medicine?”

Professor Isaac Blickstein: “Try to make everything necessary for a single fetal pregnancy. This means even canceling cycles, this means lower fertility rates, and this means considering a multiple pregnancy as a bad outcome. Then if you calculate your success rates, you should show off your single pregnancy success rates, and the overall success rates are not important as the singleton pregnancy success rates.”

Dr. Hugo Verhoeven:  “You are one of the Editors of a new book that is, in my opinion, going to be the bible for doctors performing reproductive medicine, for obstetricians taking care of women carrying a multiple pregnancy, and for the neonatologists. Could you give some pre-information of the content of this book?”

Professor Isaac Blickstein: “First of all, Hugo, thank you. You were one of the catalysts in writing this book. We thought about this problem that should have a background textbook, the Iatrogenic Multiple Pregnancy, which is the epidemic of affluent societies. This side effect of infertility treatment, should receive the proper proportion. That’s why we embarked on this project starting with describing the biology of iatrogenic multiple pregnancies, trying to give some guidelines on how to avoid a multiple pregnancy. We tried to educate doctors caring for the iatrogenic multiple pregnancy from the beginning to the end , including pregnancy observation and follow-up, to educate parents about the risks of the iatrogenic multiple pregnancy. We were discussing medical/legal aspects of those treatments and the religious aspects of those problems. I think that by using the "inserts" system in this book, which you Hugo also contributed very nicely to, we could update our book to February 2000. This is exceptional in most textbooks that lag at least two years of update. This gave us the opportunity to have all important papers published by February 2000 incorporated in this volume.”

Dr. Hugo Verhoeven:  “So this book is not going to be the bible just for doctors but maybe also for pregnant and even non- pregnant patients to get up-to-date information on the topic of multiple pregnancy.”

Professor Isaac Blickstein: “Sure, we wrote it in a medical language of course. We did not write it as in women’s magazines or parent’s magazines because our prime targets are the doctors and the medical profession. However, we provided glossaries with explanation of all our treatments and side effects of the medications. It is highly illustrated with many graphs, figures, and a lot of photography. It is easy to comprehend even by the lay person, and I think it might prove being a very effective method of educating those couples before embarking on a infertility treatment.”

Dr. Hugo Verhoeven:  “So when is the book going to be available?”

Professor Isaac Blickstein: “As far as I know by September it will already be in the shops.”

Dr. Hugo Verhoeven:  “Professor Blickstein, thank you very much for this interview.”