Multiple Pregnancy after ART: The View of the Guru

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Dr. Hugo Verhoeven: “My name is Hugo Verhoeven, I’m from the Center for Reproductive Medicine in Dusseldorf, and I’m reporting from the 17^th European Congress on Perinatal Medicine in Porto, Portugal.  I am on the Editorial Board of OBGYN.net, and I have the exceptional honor of talking today to Professor Louis Keith who is Professor of Obstetrics and Gynecology at Northwestern University in Chicago and President of the Center for Study of Multiple Births, also in Chicago.  Good afternoon, Louis. I’ve known you for twenty years and realize that in the field of multiple pregnancies you are the number one guru.  That is the reason why I decided to have this interview with you, because I think you have the best overview of multiple pregnancies from the endocrinological, reproductive, medical, obstetrical, and neonatal sides. We know that the incidence of multiple pregnancies is exploding worldwide and that one of the main reasons is the improving results of artificial reproductive techniques and the introduction of those techniques into more and more countries.  We realize that being specialists in reproductive medicine that we are producing problems, and we have no idea what those problems are going to be during pregnancy, during delivery, and then when real life starts.  I know that you have some thoughts about the lack of responsibility of many doctors who see reproductive medicine just as a possibility to make money, to achieve high pregnancy rates, and to be number one in their specialty without taking care of the problems that they are producing.  Tell me something about those thoughts.”

Professor Louis Keith: “Hugo, first I’d like to comment on a misconception and that is that all of the problems are due to the reproductive specialists, I don’t think so.  Aside from the fact that women are aging when they want to get pregnant, we have to consider that many of them go to their generalist when they want to become pregnant.  In many countries, mine for sure, a generalist cannot only prescribe the classic drug, clomiphene citrate, but they can also give injections of menotropin and other medications of extremely powerful nature.  I don’t think anybody has an idea how big this contribution is to the worldwide epidemic, and that’s the first thing that I want to emphasize.  While I agree with what you say, I think it is too simplistic a statement in the sense that the ART guys aren’t the only people who are doing it.”

Dr. Hugo Verhoeven: “Let’s go back to the problem of education or the training of doctors who are doing ovulation induction.  It is my opinion that only specially trained people should have the possibility to do ovulation induction.  Is this also your opinion?”

Professor Louis Keith: “I agree with you totally because it is clear that people without that training are part of the group that I just mentioned, the ones who are contributing to the epidemic.  People of my age did not have that training.  Let’s use clomiphene as an example.  When clomiphene was first introduced, it was tested in the offices and clinics of the very few people who were already well established in a practice of infertility.  They watched their patients like hawks, and carefully monitored the doses.  This literature is now twenty to thirty years old, and whether or not we should rely on it today, I have serious doubts.”

Dr. Hugo Verhoeven: “Could it be that the reason why specialists in reproductive medicine are producing so many multiple pregnancies is that there’s a lack of information?”

Professor Louis Keith: “That’s only part of it.  The patient who goes to a specialist in reproductive medicine essentially goes for one reason and that is to get pregnant.  Once the pregnancy is achieved, the responsibility is shifted totally to the office of the obstetrician.  Once the obstetrician takes care of the woman, for better or for worse, near term, at term, or pre-term, his responsibility is finished.  It is the pediatrician and the neonatologist who have the ultimate responsibility to take care of the products of the office of the assisted reproductive technologist who gave the mother the medicine.  When you think about what we heard here in the last two days, it is clear that with the increased rate of neurological handicaps and cerebral palsy that are associated with the high rate of pre-term delivery and low birth weight, the story continues not only for the lifetime of the children.”

Dr. Hugo Verhoeven: “You are the President of the Center for Study of Multiple Birth, what is this Center and what are you providing for doctors or patients?”

Professor Louis Keith: “The Center was started some twenty years ago by my identical twin brother Donald and myself in recognition of the fact that we had survived the rigors of pregnancy and childhood, that we were both reasonably intelligent and didn’t have any major neurological deformities or physical deformities, and the fact that we realized this wasn’t the case for everybody.  So we started the Center for the Study of Multiple Birth, which was the first American umbrella organization to deal with multiple births.  We have a charter from the state of Illinois with three main reasons for existence.  The first is research, the
second is public education, and the third is service.”

Dr. Hugo Verhoeven: “How can you share your experience and your information with doctors and patients, and how can they contact and ask you whether they can do something for you?”

Professor Louis Keith: “Originally it was by phone and written mail but now we have a website.  The other day I looked at it and we had had 43,000 hits, the address is www.multiplebirth.com.  We’re also on most of the search engines, and in addition, I get hundreds of e-mails a year from doctors, mothers, school children, and teachers who want information.  Our website is unique in that we have links to every other twin organization in the world that has a website.  We have a huge list of resources around the world including Europe as well as the United States, and this list is being updated as we speak.  By the time this gets into OBGYN.net, it will updated.”

Dr. Hugo Verhoeven: “You wrote and co-edited a book that is going to be the bible for reproductive specialists, obstetricians, neonatologists, and maybe also for patients interested in the topic - it’s called ‘Iatrogenic Multiple Pregnancy.’  Tell me something about the contents of the book.”

Professor Louis Keith: “You have mentioned it in a very complimentary way, I’m proud of this book because, it represents forward thinking.  Actually, if you remember it was you who made the suggestion to my co-editor, Dr. Isaac Blickstein, when we were at dinner in Dusseldorf, that there was an enormous knowledge deficit about all of the aspects of iatrogenic multiple pregnancy.  It wasn’t that you couldn’t go to the PubMed or to the National Library of Medicine and get any one of a number of articles.  You could get hundreds of articles which were giving you the point of view of a specific doctor on a specific topic.  There was no monograph that covered the waterfront, as it were.  So, at that dinner we wrote it out on napkins and took it to Mr. David Bloomer of the Parthenon Publishing Company and he agreed to publish it.  At this very meeting he brought us copies of the page proofs that will be on the bookstall stands at FIGO in Washington, the first week of September.  Of course, anybody who is writing or listening to this on the Internet can contact the Parthenon Publishing Company in London or in New York, for more information.”

Dr. Hugo Verhoeven: “Or they can contact the website of the Center for the Study of Multiple Births, www.multiplebirth.com.” Professor Louis Keith: “Yes, either way.”

Dr. Hugo Verhoeven: “My final question relates to the fact that in some countries of the world, IVF treatment or infertility treatment is paid by the government.  In other countries, the patients have to pay for treatment themselves, such as is the case in the United States.  However, as soon as the lady is pregnant and she is expecting a multiple pregnancy, then the real costs are coming to the patient.  Who is taking care of those costs?”

Professor Louis Keith: “Obviously I can’t speak for every country in the world, and it certainly differs country by country.  At these meetings, we heard from Elizabeth Bryan and Jane Denten from the Multiple Foundation in London how poor the assistance was from the state for mothers of multiples even when those children were severely handicapped.  I’m not talking about assistance in the home with diapers and with wheelchairs and special vans to get the children to a school if they have cerebral palsy.  I’m talking about cash assistance to make life a little bit easier.  These English ladies say there is essentially none in England.  Now, in the United States, not only do we have a lack of cash assistance for the running of the household but the long-term costs are invariably picked up by the taxpayer.  Many times the cost is very high.  I’ll give you an example, I know of a specific case that happened in Chicago.  Quadruplets were born after clomiphene citrate, the mother went to a public hospital and had her delivery, and three of the four children were severely handicapped.  The husband left, and the mother and her children went on public assistance.  That means - the state of Illinois is paying all expenses for that family which means the renting of the apartment, the money for the food, the money for the clothes, and the money for the medical care. It’s probably similar in Germany, in the sense that if a child has to go to a specialized school, you don’t ask the parents to pay for the ramp to go from the parking lot to the front door of the school.  The state, through the Ministry of Education, builds the facilities not only for the ramp but for the washroom and for the special attendant.  However you look at it, the public pays.”

Dr. Hugo Verhoeven: “So what is the conclusion?”

Professor Louis Keith: “The conclusion, I think, was articulated by you today.  All efforts must be made to reduce the number of iatrogenic multiple pregnancies.  Will we ever be 100% successful – no!  But should we therefore do nothing – of course we shouldn’t.  We should do everything we can, and it may very well be that five years from now, and I’m speaking as a general obstetrician, fewer of the generalists will be prescribing these drugs as the public becomes more aware that these are really very potent and ideally should be prescribed by people with training.  In conclusion, it is axiomatic that every woman who comes to you with a problem of infertility has in her mind one child.  Moreover, the human uterus is not meant to carry a litter and finally the
human being doesn’t do well when it tries to do such a thing.”

Dr. Hugo Verhoeven: “Thank you very much for this interesting statement.  Thank you once again.”