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Multiple Pregnancy Prevention - 2001-08-06

On July 12, 2001 a woman, who had been treated with fertility drugs, gave birth to septuplets at a Washington D.C. hospital. But the great risks associated with multiple pregnancies and deliveries raise some health-related questions.

Almost two decades ago, doctors first began to give fertility drugs to women who had difficulty conceiving. The injected hormones help a woman's ovaries release eggs. Often, there are three, four or more eggs which, when fertilized, can yield multiple pregnancies. As a result, since the early eighties, the number of triplets, quadruplets and quintuplets born each year in the U.S. has increased dramatically. Obstetricians are not happy with this outcome. They warn that multiple pregnancies can pose a serious danger to the pregnant mothers and can lead to developmental problems for the babies.

But, Dr. Craig Winkel, chairman of the Department of Obstetrics and Gynecology at Georgetown University Hospital says that such multiple pregnancies can be avoided if the fertility drugs are administered correctly. "I think in general, most reproductive endocrinologists would agree that ovulation induction needs to be carefully monitored, so that you can know how many eggs are likely to be fertilizable," he says. "If there are more than an acceptable number, you would stop the infertility treatment, let things calm down and then restart at a different dose or different medication."

Dr. Winkel says that the whole process is more of an art than a science in the sense that the medical experts who perform the treatment have to choose drugs and dosages that fit the particular patient. During this process they have to perform serial sonograms - visual scans of the uterus - to monitor the ovulation process, that is, to see how many ovarian sacs are developing. These sacs, called follicles, contain fertilizable eggs.

"You cannot actually see the egg, but you can see the follicle, which is the fluid-filled sac in which the egg is maturing," he explains. "You can see the size; and in general, a follicle that's about two centimeters in diameter, should likely contain a mature egg."

Dr. Winkel says if the patient produces a large number of eggs, the physician has to reduce the dosage of the fertility drugs before conception. "What we would do ordinarily, we would recognize that fact," he says. "We would tell the woman that there is a whole bunch of eggs, that that's risky business. We would like to stop the medicine. We would like to not give her the medicine to release the eggs, and we would send her husband to Argentina and her to Alaska. So, they couldn't get together by mistake."

According to Dr. Winkel most reputable fertility specialists are not in favor of creating medically induced multiple pregnancies and believe they can be avoided with proper monitoring. But, he says, if the eggs are fertilized, there is still time to avert a multiple birth, by performing fetal reduction, a form of abortion. Dr. Winkel says this is an invasive procedure. Potassium chloride is injected into the sac where the embryo is growing and terminates the life of the developing fetus.

Dr. Winkel says selective reduction improves the chances of the remaining fetuses to be born healthy and reduces the possibility of a future miscarriage. Still, he says, this is a risky enterprise because it can terminate the whole pregnancy. Also, it is emotionally taxing on the future parents. That's why, Dr. Winkel urges, before the fertility treatment starts, the doctor should discuss these issues with his patients, and be aware of their convictions regarding selective reduction.

"The physician should be aware of the couple's feelings and desires," he says. "If you have a couple that feels they cannot do reduction, you don't put them in a position where they have to go through the potential pain and heartache of caring a multiple pregnancy and then losing all of the babies."

Although monitoring the ovulation process can reduce the danger of a high-order multiple pregnancy, it cannot eliminate it. Dr. Winkel says there are women who can produce a large number of eggs with a very small dose of medication. Some of these patients, he says, may find in-vitro fertilization, fertilization of a set number of eggs outside the uterus, more predictable. "If you put back fewer embryos there would be a less incidence or less likelihood I should say of greater numbers of babies," he says.

In-vitro fertilization costs more than hormone therapy and is more painful. But regardless of the choice of treatment, the key to success, according to Dr. Craig Winkel of Georgetown University, is good communication between the doctor and the patient.