Multifetal pregnancy reduction in Sweden. Utilization rate and pregnancy outcome (1986-1992)

Maternal and perinatal outcomes of multiple pregnancy following IVF-ET

OBJECTIVE

To analyze the course of pregnancy and perinatal outcome in 31 twins, 22 sets of triplets and five quadruplet clinical pregnancies following conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedures and in relation to 58 singleton pregnancy following the same procedure.

METHODS

Retrospective analysis of maternal and neonatal medical records of 58 singleton, 31 twin, 22 triplet and five quadruplet pregnancies diagnosed at 7-8 weeks gestation following 561 embryo transfer procedures in 628 oocyte collections at the IVF Center in the Maternity Hospital, Kuwait from July 1994 to December 1996.

RESULTS

The clinical pregnancy rate in 628 cycles proceeding to oocyte collection was 32.6%, there being 58 singletons (50.6%), 31 twins (33.5%), 22 triplets (10.8%) and five quadruplets (2.5%). Early complicated outcomes included 47 miscarriages (23.7%), four ectopic pregnancies (1.9%) and one hydatidiform mole. The spontaneous fetal reduction rate was 20.6% in twin, 45.5% in triplet and 40% in quadruplet pregnancies. There was a significantly higher maternal and neonatal complication rate in the triplet group compared to singletons and twins, including threatened miscarriage, pre-eclampsia, antepartum hemorrhage, longer hospital stay and preterm labor. The chance of operative delivery was higher in high-order multiple pregnancy (HOMP). The major neonatal complications were related to prematurity. Neonatal morbidity and mortality were significantly higher in the triplet group. The need for admission to the Special Care Baby Unit (SCBU) and the Neonatal Intensive Care Unit (NICU) was significantly higher in HOMP. However, there were no statistically significant differences in the perinatal mortality in relation to the degree of HOMP.

CONCLUSION

Maternal complications, perinatal and neonatal morbidity after 2 years activities in the IVF Center have been reviewed leading to changes in policies of management, notably a reduction in the number of embryos transferred.

Multifetal pregnancy reduction: a review of the world results for the period 1993-1996

The objective of this work was to evaluate the outcome of multifetal pregnancy reduction and to provide an analysis of the ethical dilemmas associated with its application. The study design was based on data on over 1400 completed pregnancies that underwent multifetal pregnancy reduction as reported in the world literature during 1993-1996. The results were: A total of 1453 completed cases of multifetal pregnancy reduction are presented. The total survival rate was estimated to be 87.7%, resulting in a total pregnancy loss rate of 12.3%. The lowest survival rate is found to be in higher-order pregnancies of five or more fetuses (75.2%), whereas pregnancy loss rate seems to be similar for quadruplets, triplets and twins that underwent reduction (11.3%, 8.3% and 13.6%, respectively). A 33.3% of the total pregnancy loss rate occurred within four weeks from the procedure, whereas 66.7% occurred after the four weeks but at 24 weeks of gestation or earlier. The mean gestational age at delivery was estimated to be 33 weeks for pregnancies reduced to triplets, 35.8 weeks for those reduced to twins and 36.9 weeks for singletons, with 5% delivering at less than 28 weeks and 9.6% at 29-32 weeks. We conclude that multifetal pregnancy reduction has been established as an efficient and safe way to improve outcome of multifetal gestations, especially those with four or more fetuses and likely of triplets. As the experience from the procedure increases, it seems that reduction of triplets to twins can be offered to patients with satisfactory results. The reduction to singletons has not yet been established and is being performed only when medical indications exist. Prenatal genetic diagnosis should become an integral part of counselling on multiple pregnancy. Physicians should take whenever possible measures designed to prevent high multiple birth pregnancies. We also note that although multifetal pregnancy reduction improves significantly the outcome of multiple pregnancies, several ethical dilemmas arising from its application are still under dispute.

A triplet pregnancy after in vitro fertilization is a procedure-related complication that should be prevented by replacement of two embryos only

OBJECTIVE

To investigate whether the incidence and obstetric outcome of triplet pregnancies after IVF treatment justify strict limitation of the number of embryos to be replaced to two.

DESIGN

Retrospective analysis.

SETTING

A transport IVF program.

PATIENT(S)

All patients who had more than one embryo replaced.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Obstetric outcome, pregnancy.

RESULT(S)

High-order pregnancies occurred in 24 cases (23 triplets and 1 quadruplet). Three patients opted for selective embryo reduction (12.5%). Three triplet pregnancies spontaneously reduced to twins. Comparison of 18 triplets, reaching at least 20 weeks' gestation, with 54 twin pregnancies shows a higher perinatal mortality in the triplet group, causing 6 out of 18 patients to be confronted with at least one perinatal death. Triplets were born at a lower gestational age, had a lower birth weight, and a higher hospital admission rate of longer duration. Replacement of two, three, or four embryos did not lead to differences in pregnancy rates in the population studied. When a pregnancy occurred after replacement of three embryos, the risk of having a triplet pregnancy was 7.5%.

CONCLUSION(S)

The obstetric outcome of triplet pregnancies in our population indicates that triplet pregnancies after IVF treatment have to be prevented. Selective embryo reduction is acceptable for few patients only and can therefore not be seen as a solution. Replacement of three embryos results in triplet pregnancy in an unacceptably high percentage. Replacement of two embryos only gives acceptable IVF results and is the method chosen in the IVF program in Rotterdam to prevent triplet pregnancies.

Complex genetic counseling and exclusion of Duchenne muscular dystrophy in a twin pregnancy after in vitro fertilization (IVF)

A twin pregnancy following in vitro fertilization-embryo transfer coincidentally at risk for the X-linked recessive Duchenne muscular dystrophy is described. First-trimester prenatal diagnosis by transabdominal chorionic villus samplings on the dichorionic placentae and molecular linkage analysis could exclude the disorder in both fetuses. Genetic counseling and prenatal diagnosis were particularly complex due to the twin pregnancy, the need for linkage analysis, and confined placental mosaicism 45,X/46XX in one of the fetuses. All parties should be aware that additional invasive diagnostic procedures in the second trimester might be required. It is proposed that, in similar situations, only one, arguably two, fertilized egg be transferred at a time to facilitate prenatal diagnosis and decision making for these rare couples. This problem, however, may be increasingly overcome by preimplantation diagnosis.