Mind Matters

Patients undergoing fertility treatments often express a desire for twins so they can “get it over with” and create their family all at once without having to access fertility treatments and draw out the emotional ordeal. Older women especially may hope to complete their families in one go, before their reproductive capacity wanes. Couples with financial struggles often wish to have twins; they may want more than one child but cannot afford more than one IVF cycle.

 

If you are experiencing infertility, your dream of having even one baby can feel elusive. Often, part of the loss of infertility is the possibility that if you conceive or adopt, that baby may be your only child. People who conceive through fertility treatments are, of course, thrilled and relieved to become parents at all, but they may still grieve the loss of the family they envisioned, which may have included two, three, or more children.

 

Medical, emotional, social, and financial risks posed by multiple births are well documented. Studies have shown that twins are associated with a three- to five-fold increase in rates of fetal death, gestational diabetes, pre-eclampsia, preterm delivery, and cerebral palsy.¹ One study reports the incidence of cerebral palsy is three to seven times greater in twins than singletons, and ten times greater in triplets.² Caring for six-month-old triplets requires 197.5 hours per week – but there are only 168 hours in a week!³ Research showed 22% of IVF mothers of twins or triplets had “abnormally high” stress levels, compared to 5% of IVF mothers of a singleton and 9% of mothers who had conceived spontaneously.⁴

 

Psychological demands are also high for parents of multiples. One study stated, “these parents are more likely to be exhausted, depressed, or anxious after the birth of the babies,” and parents of multiples may feel isolated from friends, family, and each other, and are at higher risk for divorce.⁵ In another study, 100% of mothers with triplets reported fatigue, emotional distress, and difficult relationships with their children at age four. These difficulties had not decreased since the children were two years old.⁶

 

Clearly, multiple births pose a risk to parents and children medically, financially, and psychologically. Yet even if their physician outlines the medical risks, infertility patients often downplay or underestimate them. It has even been suggested that a couple’s distress at their inability to conceive may affect their ability to make a truly informed decision about multiple births.

 

Infertile patients are clearly aware of the risks of multiple pregnancy, but many choose to accept them on behalf of themselves and their potential children. It is debatable whether patients may be considered fully capable of an objective view upon this point as their perception of multiple pregnancy may be affected by their personal situation.⁷

 

A number of studies indicate that the majority of infertility patients are open or eager to conceive more than one baby at a time.^1,7,8,9,10 My colleagues at the Centre for Reproductive Care (CRC) in Hamilton state:

 

Due to their infertility, they feel that they would be blessed by having more than one baby at a time. “Instant family,” as some call it … older patients see multiple births as a practical solution to their race against time. Patients in this ‘the more the merrier’ mode rarely think that MGP [multiple gestation pregnancy] is, by definition, a high risk pregnancy.⁹

 

While multiples are generally desired, twins are more coveted than triplets. Up to 90% of patients in one study wished to have twins, while 50% would be happy with triplets. In the CRC study, 87% of women and 85% of men were “very open” or “somewhat open” to conceiving twins. Not one respondent indicated they were “not at all open” to conceiving twins; no women and only 5% of men said they were “not very open” to twins. In the same study, 59% of women and 62% of men were “somewhat” or “very” open to conceiving triplets. Less than 10% of men and women were “not at all open” to conceiving triplets.

 

Why do patients tend to underestimate the risks of multiple births? Some suggest that media representations of multiple births affects the perception of the public and of infertility patients. The McCaughey septuplets conceived through intrauterine insemination with fertility medications, born in Iowa on November 19, 1997, engaged public awareness and sympathy. Though two of the seven children have cerebral palsy, they all survived, which was seen as “a miracle” in the media. The family received massive support in the way of donations: diapers, formula, shoes until age ten, a minivan, education scholarships, and even a new house. Ladies Home Journal features the children on their cover and the TV show Dateline throws a party for them each year on their birthday.

 

However, parents of most multiples, especially twins, do not get the public and corporate support the McCaugheys have received, and not all children born from multiple gestations thrive. A U.S. columnist noted, “The last American woman [before Bobbi McCaughey] to have septuplets lost one at birth, three died agonizingly over a few days, and the remaining three have severe problems. Haven't seen them on TV, have you?”¹¹Recently, Canadians were both astounded and surprised by the birth of sextuplets in B.C., and saddened by the deaths of two of the babies. The media does not often portray the agonizing health, or the emotional and financial burden some families of multiples endure.

 

Infertility patients don’t often hear personal stories of families of multiples. In fact, parents of multiples conceived from infertility treatment may be reluctant to let anyone know how distressed and overwhelmed they are once the babies arrive. They may feel that they got what they asked for, and they should shoulder the burden without complaint. They may also feel that acknowledging the difficulties and expressing dissatisfaction of parenting more than one baby would be ungrateful or disrespectful to the children. A British father of triplets conceived via infertility treatment states:

 

I remember the pain of infertility and feel deeply for anyone who is going through it. You have the right to call us self-indulgent whiners who got lucky and must live with the consequences. And that is what makes the bewildering first year of triplet parenthood all the harder. You feel guilty for struggling and guilty for not being able to cope, because wasn’t this what you hoped and prayed for, and nearly bankrupted yourself for? So you keep your mouth shut, don’t tell anyone your nerves are frayed, your patience exhausted, your temper explosive. And when you find yourself squeezing that crying baby too hard, or thinking – just for a moment – about throwing it across the room, you remember that it’s all your fault, you’re the failure, the one who can’t cope, the one who gets weepy every time someone says congratulations.¹²

 

In order for infertility patients to make truly informed decisions, they need to hear personal accounts from families who have had twins or higher order multiples. Referrals to multiple birth support groups (in Canada, Multiple Births Canada, www.multiplebirthscanada.org) could be provided. It is difficult to dismiss this father’s statement:

 

I have IVF triplets. I have been knackered, angry, and depressed. And yes, I have resented them. Sleep is the new crack cocaine. It’s the new wine, the new tobacco. Sleep, sadly, is the new sex. It’s what you think about and talk about and crave when you are the new parents of one, two, three beautiful, bouncing, crying, shitting, screaming babies.¹²

 

While most infertility patients say they would eagerly welcome multiples, a growing minority of clients I see are very clear that they do not wish to have twins or higher-order multiples. Nonetheless, many patients consent to fertility procedures that result in the conception of multiples. Sometimes, the patient is worried that their chance of conceiving at all is less if they transfer only one or two embryos.

 

When a twin pregnancy is conceived through fertility treatment, two babies on the way is not always seen as a wonderful turn of events. Some expectant parents of twins are afraid and anxious, but they are likely aware that other infertility patients might be thrilled to have twins, and that their distress at a twin conception may not be understood or supported. This lack of understanding complicates their distress even further. For patients adamant about not wishing to have twins, single embryo transfer in IVF should be presented as a reasonable and sound medical decision.

 

While medical professionals may well inform patients about the likelihood of multiple births from infertility treatment, much more should be done to ensure that patients gain a clear understanding of the impact parenting multiples has on families. If they are more aware of the medical, financial, and emotional hardships, patients will likely make a truly informed consent to their treatment.

 

Sherry Dale (formerly Sherry Franz) specializes in counselling for infertility and pregnancy loss. She works full-time at the LifeQuest Centre for Reproductive Medicine. Clients can see her at LifeQuest even if they are not patients there (e-mail sdale@lifequestivf.com or call 416-506-0804). Sherry also has a private counselling practice, where she can be reached at sherry.dale@pathcom.com or 416-410-8904. Sherry lives in Toronto with her two sons, both conceived through assisted reproductive technologies.

 

1. Child, T.J., Henderson, A.M., & Tan, S.L. (2004). The desire for multiple pregnancy in male and female infertility patients. Human Reproduction, 19(3), 558-561.

 

2. Petterson, B., Stanle, F., & Henderson, D. (1990). Cerebral palsy in multiple births in Western Australia. American Journal of Medical Genetics, 37, 346-351.

 

3. Australian Multiple Births Association (1984). Proposal Submitted to the Federal Government Concerning ‘Act of Grace’ Payments for Triplet and Quadruplet Families. Coogee, Australia: Australian Multiple Births Association.

 

4. Glazebrook, C., Sheard, C., Cox, S., Oates, M., & Ndukwe, G. (2004). Parenting stress in first-time mothers of twins and triplets conceived after in vitro fertilization. Fertility and Sterility, 81(3), 505-511.

 

5. Elster, N., & The Institute for Science, Law, and Technology Working Group on Reproductive Technology (2000). Less is more. The risks of multiple births. Fertility and Sterility, 74(4), 617-623.

6. Garel, M., Salobir, C., & Blondel, B. (1997). Psychological consequences of having triplets: A 4-year follow-up study. Fertility and Sterility, 67(6), 1162-1165.

 

7. Hartshorne, G.M., & Lilford, R.J. (2002). Different perspectives of patients and health care professionals on the potential benefits and risks of blastocyst culture and multiple embryo transfer. Human Reproduction, 17(3), 1023-1030.

 

8. Gleicher, N., Campbell, D.P., Chan, C.L., Karande, V., Rao, R., Balin, M., & Pratt, D. (1995). The desire for multiple births in couples with infertility problems contradicts present practice pattern. Human Reproduction, 10, 1079-1084.

 

9. Hahn, S.A., Neal, M.S., Franz, S., Cowan, L., & Hughes, E. (2003). The Cost of Multiple Gestation Pregnancies (MGP) From Assisted Reproductive Technology. Abstract: Canadian Fertility and Andrology Society.

 

10. Ryan, G.L., Zhang, S.H., Dokras, A., Syrop, C.H., & Van Voorhis, B.J. (2004). The desire of infertile patients for multiple births. Fertility and Sterility, 81(3), 500-504.

 

11. Lessenberry, J., (1997). Pick of the litters. Politics and Prejudices. Accessed October 28, 2006. Available: http://www.metrotimes.com/news/columns/18/jl/10.html

 

12. Moreton, C., (2003). I have IVF triplets. I have been knackered, angry, and depressed. And yes, I have resented them. The Independent, October 19, 2003. Accessed October 22, 2003. Available: http://news.independent.co.uk/uk/health/story.jsp?story=454810.