The Miracle of Multiple Births:Is it always ‘happily ever after’?

Babies born small and early are at a greatly increased risk for developmental problems. Are fertility doctors explaining these risks to women desperate to conceive? For the woman who has been trying desperately to conceive, the words "You're pregnant!" seem like the most beautiful ever spoken. For those women and their partners who have struggled through months, perhaps years, of assisted reproduction techniques — egg harvesting, IVF (in vitro fertilization), GIFT (gamete intrafallopian transfer), ICSI (intraCytoplasmic Sperm Injections), and other technologically sophisticated ways of making sperm plus egg equal baby — the notion of delivering twins, triplets or even quadruplets can be both thrilling and overwhelming. But a recent study published in The American Journal of Public Health found that a significant increase in multiple births between 1981 and 1997 has contributed to higher overall rates of preterm delivery and low birthweight in several nations. From 1981 to 1997, a dramatic increase in triplet rates was found in all participating countries (U.S., Canada, France, England and Wales), with the United States holding the greatest increase — 358 percent. The rise in twin births during the same period increased by 39 percent in the United States and by between 28 percent and 45 percent in Canada and the European nations, respectively. Every year in America, almost half a million babies are born prematurely, with the rate of prematurity having risen from 9.8percent in 1985 to about 12 percent today. Advances in fertility treatment have led to this substantial increase in twin, triplet and higher-order multiple pregnancies; and because these pregnancies rarely go full term, we are seeing a higher overall rate of prematurity and low birth weight in spite of programs and policies designed to lower the rates of preterm birth. This has potentially serious consequences, since premature newborns, who account for an estimated 70 percent of perinatal deaths, are also at greater risk for long-term health and developmental problems. Researchers predict that the rising number of multiple births will increase the burden on health and neonatal services in North America and Europe, since there will be more children surviving with special health care needs.

Problems for preemies Science is still attempting to ascertain the myriad ways in which prematurity affects the development of a child's physical health, cognitive abilities and behavior. Overall, premature infants have a higher incidence than full-term infants of subnormal physical growth, medical and neurological or developmental problems. The severity of these problems appears to be directly correlated with birth weight and gestational age, with the smallest, youngest infants having the most profound impairments. Complications that can seriously affect a preemie's development include intrauterine growth retardation, infection, severe asphyxia, neonatal brain disorders including meningitis and intracranial hemorrhage, or seizures. One study, which appeared in the New England Journal of Medicine, assessed 308 extremely preterm infants (before 26 weeks gestation), and found that 49 percent met criteria for severe disability, with 19 percent having severely delayed development and the other 30 percent having some combination of physical and developmental problems. Cerebral palsy is the most frequent neurological abnormality seen in premature, low birth weight babies, with approximately 20 percent of babies weighing less than 1,000 grams (2 lbs, 3 oz.) manifesting some signs and symptoms of the disorder. Twins alone are thought to occur for 5 percent to10 percent of all cases of cerebral palsy. Along with prematurity and low birth weight, causes of neurologic impairment in infants born of a multiple pregnancy include intrauterine fetal demise (one twin dies before delivery), twin-to-twin Transfusion syndrome, and growth abnormalities. The findings of a 10-year longitudinal study of preterm infants, which were presented at the American Psychological Association's annual convention in 2000, found that 61 percent of children born prematurely but not suffering from debilitating physical conditions still showed signs of subtle cognitive, social and behavioral delays. These delays were frequently not recognized until the child reached school age. The preterm children were more likely than their full term counterparts to score lower on intelligence tests and to have learning disabilities, behavioral problems or other specific deficits which required intervention from school professionals. Other studies have suggested that children born prematurely, especially boys, are at increased risk of attention deficit hyperactivity disorder (ADHD). A news release issued by the National Institutes of Health in January found that babies born just two to four weeks prematurely, or those born even moderately undersize for their age, are at risk for minor delays in development. Researchers found that infants who were from one to four weeks premature were likely to experience a delay in one or two developmental milestones for a given age category, from birth to 47 months of age. In all probability, the researchers concluded, children will reach these milestones when they are slightly older, with no negative effects from the delay. However, a cumulative effect might result when a child who faces other risks for developmental delays is born prematurely. The news, however, is not all bad. Data presented at the American Academy of Pediatrics annual meeting last year showed that babies born with extremely low birth weights are doing better than in past years due to improved treatment shortly before and after birth. The study tracked more than 7,000 preterm babies born in the 1990s, who weighed between 500 to 1,000 grams at birth, and found that the children born in the latter part of the decade were less likely to develop cerebral palsy, blindness or other medical or neurological impairments. Overall, of the babies born in 1993-94, (at 22-26 weeks of gestation) 64 percent suffered impairments, while, of infants born that early in 1997-1998, less than 50 percent were impaired.


Are parents making informed choices? Yes, advances in obstetric and neonatal care are helping to increase the odds that preemies and low-birth weight babies will be able to lead normal or near-normal lives. But the babies most at risk of neurological impairments remain those born smallest and earliest — and this often means twins, triplets, or higher-order multiples. Are fertility experts discussing the possibility of developmental or medical problems with their patients who are desperate to get pregnant? According to Mariann Rubin, C.S.W., a board member of RESOLVE of Long Island (a national infertility organization) and a psychotherapist who specializes in reproductive and adoption issues: "Most fertility doctors will inform their patients who are undergoing IVF about the possibility that, if the treatment is successful, they may be confronted with a multiple pregnancy. Counseling is generally recommended, and women and their partners are asked to think about the chance that there will be a high-level multiple pregnancy (more than four fetuses)." Because continuing a high-level multiple pregnancy could lead to a very high risk of extreme prematurity and low birth weight with its associated problems, choosing selective reduction, a procedure in which the number of fetuses are reduced, may actually offer the best chances of saving any of the fetuses. Many experts suggest that a quadruplet pregnancy should be reduced to twins, which is, of course, a painful decision for a woman who has undergone so many invasive procedures in her quest to become a mother. Rubin says: "Fertility doctors will spend time with prospective parents discussing the ramifications of a multiple pregnancy in terms of the mother's and the babies’ physical health, but very few will talk about the possibility that these much wanted children might end up with serious impairments which could affect the quality of their lives." Perhaps doctors who are passionately invested in helping people to become parents find that notion just too difficult to think about, let alone discuss. The birth of a healthy infant or infants is always a reason for great joy. But educating women about the reproductive possibilities open to them — explaining both the possible rewards and risks — is the responsible thing to do, allowing a knowledgeable patient to happily partner with her health care provider so she can make her dream of becoming a mother a reality. And that is a happy ending after all.

Photo caption: Fertility treatments frequently lead to multiple births. If babies are born small, and early, their chance of having developmental lags are increased dramatically. Are fertility doctors placing too much emphasis on conception, without adequately informing parents of the risks?