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Middle East Fertility Society Journal
Middle East Fertility Society
ISSN: 1110-5690
Vol. 10, Num. 2, 2005, pp. 110-111

Middle East Fertility Society Journal, Vol. 10, No. 2, 2005, pp. 110-111


Prevention of multiple pregnancy in ART

Comment by:

Karl Nygren. M.D.


Stockholm, Sweden

Code Number: mf05019

Since several years back now, we have seen very convincing evidence from many studies to show that triplets or more after ART carries with them a very substantial increase of perinatal mortality and of short and long term morbidity. In addition we also know that the psycho-social consequences often are huge.

Twins carry with them similar problems at a significant but somewhat lower scale. The mothers suffer from a large increase of obstetrical complications.

At the recent ESHRE Annual Meeting in Copenhagen, two additional strong reasons to avoid at least high order of multiple pregnancy after ART were presented.

First, the economy. Two reports, one from the Nordic countries and one from France clearly demonstrated that the total cost, including cost for deliveries and post-natal complications, were very much higher with a clinical policy leading to high proportions of multiples. The myth, therefore, that multiples would help reducing cost is totally false because it does not include cost for complications.

Second, national statistics showing the feasibility of a national policy of a high proportion of elective single embryo transfers (e-SET). National data from Finland and Sweden and also from Belgium now show, with treatments during 2004, that a high proportion of e-SET (over 50%) is proven to be compatible with a continuously high pregnancy rate per embryo transfer in fresh cycles (over 30%) leading to a substantial decrease of multiple deliveries to now below 10% of twins and virtually no triplets.

The conclusion is, that high order of multiple pregnancy after ART, can no longer be defended by economical evidence or evidence of low effectiveness.

A shift over to a clinical policy to avoid high order of multiple deliveries and to at least to decrease the proportion of twins is therefore only logical.

How can that be achieved, in clinical practice? Several suggestions put forward may be summarized as follows:

  1. Select, for e-SET, women under 38 years of age, during their first (and possibly second) IVF cycle.
  2. Select, for e-SET, women with an obstetrical increased risk with multiple gestation.
  3. Stimulate for 10-12 eggs, at aspiration.
  4. Transfer the best embryo and freeze the other suitable embryos one by one. Transfer them one by one.
  5. Use high quality freezing equipment and monitor transfer cycles closely.
  6. To present success, use combined fresh and frozen delivery rates, i.e. delivery rates by aspiration procedure.
  7. Transfer 2 embryos otherwise, but never three.
  8. Convince your staff and your patients that such a policy is founded on very sound evidence, and is in the best interest of all parties involved, and that it is not counter productive for efficacy or cost.

Are there any negative sides to such a policy?

1. Q: Is it more cost-effective with multiples?

A: No, it is not. It may appear so, in the ultra-short term,  if only direct treatment cost is included, but in a longer perspective that is not at all true.

2. Q: Do multiples save time for the couple to achieve their reproductive goal for a larger family?    

A: Only marginally so. And it saves quality of life for children and families alike.

So, all evidence available on

 a/ medical risks,

 b/ psycho-social problems,

 c/ economy and

 d/ feasibility for effectiveness

all speak the same language: A shift in clinical policy to avoid, totally, high order of multiple pregnancy (triplets or more) and to decrease the proportion of twins is logical, rational and beneficial to all parties involved.


  1. Granberg M, Nygren KG, Wikland M. Cost of IVF in the Nordic countries. Hum Reprod Vol 20, Suppl 1 2005: Abstract book. ESHRE 21st Annual Meeting, Copenhagen O-269, i100. 
  2. J. de Mouzon, J.L.Pouly, Mourouvin, A.Bachelot: Multiple pregnancies. How much they cost for a nation? Hum Reprod Vol 20, Suppl 1 2005: Abstract book. ESHRE 21st Annual Meeting, Copenhagen 0-270, I 100.
  3. K.Erb, A Nyboe Andersen, J.M. Gissler, A. Tiitinen, J.Hazekamp, P.O. Karlstrom: A shift towards single embryo transfer in ART. National data from the Nordic Countries 2002 and 2003. Hum Reprod Vol 20, Suppl 1 2005: Abstract book. ESHRE 21st Annual Meeting, Copenhagen 0-152, i 56.

Karl Nygren, MD
IVF-clinic at Sophiahemmet Hospital,

© Copyright 2005 - Middle East Fertility Society

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