Reproductive endocrinology and infertility are rapidly evolving fields of medicine replete with controversies. As a patient you have to make life-changing decisions despite the absence or scarcity of reliable information. Our goal is to give you the facts and issues without bias and without pretending that we or anyone else has all the answers. We think our approach is more honest and fun.
How many embryos should you have transferred? Is more always better? How many children do you want to have? Can you handle twins? Is multi-fetal pregnancy reduction an option for you? Are you taking your future children’s health fully into account when making these decisions?
You have decided to get pregnant with donor eggs. Who are you going to tell? Are children conceived with egg donor gametes entitled to the knowledge of their origins? Are your parents and relatives ready to accept your decision? Is privacy of your reproductive choice just a slogan? Can you keep it a secret for a lifetime?
What are the pros and cons of blastocyst transfer? Who is the best candidate for day 5 to 6 versus day 2 to 3 transfer? How do embryologists keep eggs, sperm and embryos from each patient separate? How frequent are lab mix-ups? How do we guard against them? You had a tubal ligation but now you want to have children. What are your options? What are the chances of success and the costs?
The Dilemma of Twins and Embryo Transfer
Multiple pregnancies are a potential problem for the children and the parents but they have been hard to avoid with IVF. Traditionally, the success of IVF has hinged upon availability of more than one embryo for transfer. Currently about 25% of IVF pregnancies are twins. Higher-order multiple gestations (triplets or greater) have become much less common than several years ago. Despite widespread concern about the health risks of multi-fetal pregnancies, single embryo transfers remain uncommon except when embryo testing is performed. Despite the official policy favoring single embryo transfer, many infertile couples express strong desire for twins.
Most twins are fraternal, i.e. they arise from 2 different embryos and have separate placentas. Identical twinning occurs in 1.5% to 4.5% of IVF pregnancies and occurs when a single embryo splits into two. IVF twins deliver on average three weeks earlier and weigh 1,000 gm less than IVF singletons. While IVF singletons are smaller than non-IVF singletons, IVF twins do as well as spontaneously conceived twins. Triplet (and greater) pregnancies deliver before 32 weeks (7 months) in almost half of cases.
The most important complications associated with multi-fetal pregnancy are preterm labor and delivery, pre-eclampsia, and gestational diabetes. Prematurity accounts for most of the risks associated with multiple gestations. Poor fetal growth and discordant growth among the fetuses also result in perinatal morbidity and mortality. Obstetrical complications, such as placenta previa, placenta abruption and postpartum hemorrhage are more common in multi-fetal pregnancies.
Multi-fetal pregnancy reduction (where one or more fetuses are selectively terminated) reduces, but does not entirely eliminate, the risk of these complications.
Fetal death rates for singleton and twin pregnancies are 4.3 per 1,000 and 15.5 per 1,000, respectively. Identical twins that share the same placenta have additional risks such as twin-to-twin transfusion syndrome which occurs in up to 20% of cases. Twins sharing the same placenta have a higher frequency of birth defects compared to fraternal twins and appear to occur more frequently after blastocyst transfer.
The major lifelong consequences of prematurity include cerebral palsy, blindness and chronic lung disease. It is unclear to what extent multiple gestations themselves affect neuro-behavioral development in the absence of these complications. Rearing of twins may generate physical, emotional, and financial stresses, and the incidence of maternal depression and anxiety is increased in women raising multiples. At mid-childhood, prematurely born offspring from multiple gestations have lower IQ scores, and multiple birth children have an increase in behavioral problems compared with singletons. It is not clear to what extent these risks are affected by IVF as such.
While most consumers and reproductive endocrinologists agree with the goal of avoiding triplets and higher order multi-fetal pregnancies, many patients not only accept, but in fact desire, twins. Thus a major discrepancy has evolved between the avowed goals of patients and public health officials such as the CDC. The reasons why patients desire twins despite knowledge of the above risks is grounded not in ignorance but in valid reasoning. Since most patients have no insurance to cover the IVF cost, getting twins seems like a bargain. The added obstetrical and pediatric expenses, on the other hand, are usually covered benefits under their health insurance policies, so they are of more concern to epidemiologists and economists than to subscribers. In Europe, where IVF is a covered benefit, clinics and patients are under intense government pressure to accept transfer of single embryos.
Age is another valid reason why so many consumers hope for twins. For many women in their late 30s and early 40s, it may be possible to establish one pregnancy through IVF but repeating that feat a couple of years later may prove impossible. Finally, single embryo transfer is the only strategy that reliably reduces IVF twin rates but most patients are unwilling to accept the reduction in live birth rate resulting from a single embryo transfer. Embryo testing/PGS achieve a high live birth rate through transfer of a single genetically normal blastocyst while avoiding the risks of twins.
Where does the Alta Bates IVF Program stand on this issue? We are proud of the progress achieved in lowering the rate of triplets, but when it comes to twins we remain sympathetic towards our patients’ preference for twins as a reasonable family-building approach. This individualized policy is consistent with both patient autonomy and the fact that so many of the women we see fall into the older age group.
As the graph below illustrates the frequency of multi-fetal births, portrayed as the area between the blue and red curves, markedly declines with the woman’s advancing age.
The Disclosure Decision
When people first learn that they cannot have a child using their own eggs or sperm, they are often overwhelmed by a sense of loss. Many patients feel that their dream of becoming a parent using their own genes has been taken from them. At the Alta Bates IVF Program we acknowledge the pain of not having a genetic link to a child and understand the need to grieve for this profound loss. After you have gone through the grieving process and feel ready to resume building your family using donated gametes, we are here to guide you through this novel terrain.
Sperm and egg donation are good choices for couples who believe that families are created by love, commitment and responsibility, that parenting requires active involvement and nurturing and that relationships are more important than genetic ties as the force which holds a family together.
After choosing gamete donation, many questions come to mind: Do we tell our child(ren)? When and what do we tell our child(ren)? Do we tell friends and family? It is common for couples to be initially concerned about revealing the use of donor eggs or sperm to their offspring. They may worry that the child could be confused about his or her identity, and possibly fail to bond with or even reject his or her parents due to the lack of a genetic link.
Parents may be concerned that their child(ren) will be stigmatized by others and fear that the social acceptance of gamete donation is not as widespread as one might wish. Some couples believe that secrecy will protect their child and that disclosure may hurt their family bonds. Other would-be parents value the privacy of their reproductive choices and see little benefit in disclosure.
In actuality, both openness and secrecy affect families in unpredictable ways. In this complex area no definitive studies can ever be applicable to all situations. Although privacy has been the standard of practice for decades, there has been a recent shift toward openness. The Ethics Committee of the American Society for Reproductive Medicine has come to advocate informing children of their donor origins “to protect the interests of the offspring.” In several western European countries, including Sweden and the United Kingdom, children conceived with donor gametes are entitled by law to find out the identity of the donors upon reaching maturity.
Secrets tend to produce stress and tension in families and may negatively impact the parent-child bond. Genetics play an important role in a person’s developing physiology and psychology, and withholding factual genetic information might hinder an individual from making good medical decisions.
Ultimately, disclosure remains one of the many difficult decisions faced by parents in the course of raising children, and people have unique feelings about this subject. At the Alta Bates IVF program we pass no judgment on your decision. Our role is to wholeheartedly support you in whatever approach is best for your family.